Subjective Memory Complaints in Relation to Anxiety and Test Performance of Patients Recovering from Severe Acute Respiratory Syndrome in Hong Kong.
 
Alma Au1
 Iris Chan2
Patrick Li2
Chan Yiu Han 2
 Johnny Chan2

 
 
1  Department of Applied Social Science, Hong Kong Polytechnic University, Hong Kong, China.
2 Department of Medicine, Queen Elizabeth Hospital, Hong Kong, China.
 
 

Citation:
Au A., Chan, I,., Li  P, Han C.Y., & Chan, J.  (2006). Subjective Memory Complaints in Relation to Anxiety and Test Performance of Patients
 Recovering from Severe Acute Respiratory Syndrome in Hong Kong.
   International Journal of Psychosocial Rehabilitation.  10 (1)
 
 
 
Reprint requests and correspondence should be sent to
Alma Au. Ph.D.
Department of Applied Social Science
Hong Kong Polytechnic University
Hung Hom
Hong Kong
China
Email: ssalma@inet.polyu.edu.hk


Abstract
Memory problems have been reported during steroid administration. The existing literature suggests that many of these effects are transient and reversible. The purpose of the study was to explore the associations of subjective memory complaint with objective test performance and emotional state in recovering SARS patients.
Method:
Twenty-three patients aged between 20 to 34 were divided into 2 groups: those who reported trouble with their memory and those who did not. Cognitive functioning including general intelligence and memory was assessed using subtests of the Wechsler Adult Intelligence and Memory Scales and the Hong Kong List Learning Test. Mood was assessed using the Hospital Anxiety and Depression Scale.
Results: 
No significant difference was identified between the two groups in cognitive test performance. Furthermore, results obtained did not suggest the presence of any systematic cognitive impairment in both groups. However, the group reporting memory trouble was found to significantly score higher on an anxiety scale.
Conclusion:
Results suggested the possibility of a relationship between anxiety and subjective memory complaint. Results also suggest that subjective memory complaints need to be assessed and treated in the context of the overall adjustment in individuals trying to recover from a sudden and severe illness. Specifically, psychological intervention may be needed to help patients to overcome their anxiety about their functional competence in the process of psychosocial rehabilitation.
 
Key Words: SARS, memory, subjective complaint, test performance, anxiety
  


Introduction
Severe Acute Respiratory Syndrome (SARS) is an acute atypical pneumonia believed to be caused by a previously unknown coronavirus and is responsible for the first pandemic of the 21st century (Peiris et al., 2003). Hong Kong, China, remains one of the most severely affected areas. With the infectious nature of this new disease, SARS can have many behavioral and emotional implications for recovering patients. After recovering initially in the physical sense, other challenges begin to surface. These include uncertainties about side effects of medication, longer-term effects of the illness, the ability to return to previous occupation and to handle interpersonal relationships. Uncertainty and stigmatization are prominent themes in the longer-term emotional adjustment in SARS (Maunder et al., 2003; Gorodzinsky, 2003, Au et al., 2004).
 
A treatment protocol including a combination of ribavirin and systemic steroids was adopted from the beginning of the epidemic and the protocol is currently being reviewed (Chan et al., 2003; So et al., 2003; Yuji, 2003). Memory problems have been reported during steroid administration. This ranges from mild problems in verbal memory to severe dementia. The existing literature suggests that many of these effects are transient and reversible (Brown & Chandler, 2003; Newcomer et al., 1999). However, some recovering SARS patients receiving outpatient follow-up care in our specialist clinic have continued to report a subjective sense of memory difficulties. So far, there is no published data on the cognitive functioning of recovering Severe Acute Respiratory Syndrome (SARS) patients who have received steroid therapy in Hong Kong. Thus, the purpose of the study was to explore the relationships between subjective memory complaint, objective cognitive test performance and emotional state for these patients.
 
 
Method
Subjects and Procedure
Twenty-three discharged SARS patients (aged between 20-34) were recruited from the Outpatient Clinic of Queen Elizabeth Hospital. The age group chosen was based primarily on the availability of local test norms for that particular age group which is also the primary reference group of the established Wechsler scales (Wechsler, 1981). At the time of their regularly scheduled appointments at the clinic, all patients of this age range were invited to an interview with the clinical psychologist. After briefly outlining the purpose of the assessment and obtaining written consent, patients were invited to complete self-administered questionnaires. All consenting patients were seen about 1 to 2 months after discharge from hospital. One patient did not turn up for the scheduled appointment stating that there was no need for assessment.
 
Demographic characteristics were collected through the questionnaire. Illness and treatment related information including medication was obtained from the medical record. For the subjective memory complaint, each subject was asked “Do you have trouble with your memory?” The answer “yes” or “no” was recorded. This one question has been previously proven to be a sensitive and valid method to assess memory complaint in Chinese-speaking population (Wang et al., 2000). Based on the response to this question, 12 patients were allocated to the group with subjective memory complaint (SMC+) and 11 were allocated to the group without subjective memory complaint (SMC-).
 
Measures
The Chinese translation of the Wechsler Adult Intelligence Scale-Revised (WAIS-R) was used to assess general intellectual functioning (Wechsler, 1981; Chan et al., 2000). As for testing of memory, the Hong Kong List Learning Test (HKLTT) was used to assess verbal memory (Chan & Kwok, 1999; Au et al., 2003) and the Visual Reproduction (VR) subtest of the Wechsler Memory Scale-Revised (WMS-R) was used to assess to visual memory (Wechsler, 1987).
 
The WAIS-R subtests administered included Digit Span, Arithmetic, Similarities, Picture Completion, Block Design and Digit Symbol. The selection of subtests was based on the seven-subtest short form version of WAIS-R that has generally been found to be a cost-effective and accurate method to estimate overall intellectual functioning (Axelrod & Paolo, 1998).  However, the Information subtest was omitted as the questions in the original American version were judged to be not representative enough for the local culture. In terms of the dimensions of the underlying abilities measured, Similarities has been found to load on the “verbal” factor. Block Design, Picture Completion and Digit Symbol loaded on the “perceptual” factor. Finally, Digit Span and Arithmetic loaded on the third factor termed “freedom-from-distractibility” of “attention/concentration” (Leckliter et al., 1986). The HKLTT yields measures of immediate recall of the auditory-verbal learning of a 16-word list over three trials. It also involves a delayed recall of the list after 30 minutes. Local norms are available for the chosen WAIS-R subtests and the HKLTT. Requiring the drawing from memory simple geometric designs that are each exposed for ten seconds, the WMS-R (VR) produced a score for immediate recall and a score for delayed recall after 30 minutes. There are no local norms for the WMS-R (VR). However, with its primarily non-verbal content, the culture loading is considered minimized. 
 
Emotional state was monitored using the 14-item Hospital Anxiety and Depression Scale (HADS) to provide measures of anxiety and depression (Zigmond & Snaith, 1983). Each item is scored from 0 to 3. Total scores range from 0 to 21 for the Anxiety subscale and also for the Depression subscale. The HADS has been widely used to monitor mood changes in medical and neurological patients in Hong Kong (Au et al., 2002).
 
Data analysis
The WAIS-R yielded six raw scores, one for each subtest. The VR of the WMS-R yielded two measures: immediate recall and 30-minute delayed recall. For the HKLTT, learning over three trials was added up to form a total learning score. The HKLTT delayed recall was based on the number of words recalled after 30 minutes. The raw scores of the WAIS-R and the HKLTT were converted into percentiles according to the available Hong Kong Chinese norms (Chan et al., 2000, Chan & Kwok, 1999).  The scores for the WMS-R (VR) were converted into percentiles according to the norms given in the manual. The HADS yielded scores for 14-items from which two independent subscale scores was calculated for Anxiety and Depression. Subjects were divided into two subgroups according to the presence or absence of subjective memory complaint. T-tests were performed to investigate group differences on emotional state and objective measures of cognitive functioning. The SPSS programs for Windows, Release 7.0, was used for all analysis.
 
 
RESULTS
Demographic characteristics and medical information of the two groups are summarized in Table 1. The 2 groups are largely comparable in the variables described. However, the age was higher in the group with subjective memory complaint than the group without [t(22) = -2.80, p < 0.05]. Results on the WAIS-R, HKLTT and WMS-R (VR) are summarized in Table 2. Results on the HADS are summarized in Table 3. No significant differences between the 2 groups were identified in the objective test performance. Furthermore, the test scores for both groups are all in the normal range.  As for the HADS, there were also no significant in terms of the Anxiety and Depression subscale scores. Again, the scores for both groups are in the normal range. However, the group with subjective memory complaint was found to score significantly higher in Item 3 [t(22) = -2.35, p < 0.05]. For this item, patients were asked to rate in what degree they “got a sort of frightened feeling as if something awful is about to happen”. Higher scores on the item indicated greater anxiety. 

Table 1. Demographic characteristics and medical information of the two groups: patients with subjective memory complaint (SMC+) versus those without (SMC-)
___________________________________________________________________________
                                                                                    SMC+ Group (n=12)              SMC- Group (n=11)
                                                                                    Mean (SD)                                          Mean (SD)
___________________________________________________________________________
Age                                                                              30.92 (2.07)                                          26.92 (4.30)*
Sex
            Male                                                                     3                                                                      7         
            Female                                                                  9                                                                      4
Education                                                                      13.83 (2.79)                                          13.73 (2.61)
Employment
            Employed                                                              1                                                                      1
            Unemployed                                                         11                                                                    10
Marital status
            Single                                                                    5                                                                      6
            Married                                                                 6                                                                      5
            Widowed                                                               1         
Time since onset (days)                                             71.00 (12.64)                                                86.00 (21.95)
Time since discharge (days)                                       43.67 (16.85)                                                 56.10 (21.31)
Period of hospitalization (days)                                   27.18 (12.24)                                                 27.80 (17.00)
Need for Admission into                        
            Intensive Care Unit
            Yes                                                                       2                                                                      2
            No                                                                       10                                                                      9
Need for Intubation
            Yes                                                                       3                                                                      2
            No                                                                         9                                                                      9
 
Prenisolone equivalence (mg)                                     2059.08 (1045.13)                                  1840.86 (1006.50)
___________________________________________________________________________________
*p < 0.05
 

Table 2. Objective test performance of the two groups: patients with subjective memory complaint (SMC+) versus those without (SMC-)
<>                                                                                    SMC+ Group (n=12)  SMC- Group (n=11)
                                                                                    Mean (SD)                              Mean (SD)
<>___________________________________________________________________________
<>Wechsler Adult Intelligence Scale-Revised
<>(In percentile)
<>Digit Span                                                                 83.82 (28.03)                             96.85 ( 7.41)
<>Arithmetic                                                                 47.50 (28.09)                             50.55 (27.92)
<>Similarities                                                                47.00 (28.08)                             41.27 (26.05)
<>Picture Completion                                                    43.68 (22.06)                             50.55 (29.62)
<>Block Design                                                            49.17 (27.89)                             59.45 (27.70)
<>Digit Symbol                                                             59.50 (29.44)                             54.91 (33.50)
<>Hong Kong List Learning Test
<>(In percentile)
<>Total Learning                                                           58.61 (16.48)                             55.90 (23.64)
<>Delayed Recall                                                          59.17 (26.20)                             62.00 (24.20)
<>Wechsler Memory Scale-Revised (Visual Reproduction)
<> (In percentile)
<>Immediate Recall                                                       83.08 (15.79)                             90.91 (11.36)
<>Delayed Recall                                                          80.75 (21.62)                             87.73 (17.41)
<>___________________________________________________________________________
<>
<>____________________________________________________________________________________________________________
<>Table 3. Emotional state profile of the two groups: patients with subjective memory complaint (SMC+) versus those without (SMC-)
<>
_____________________________________________________________________________________________________________
                                                                    SMC+ Group (n=12)       SMC- Group (n=11)

                                                                           Mean (SD)                              Mean (SD)
___________________________________________________________________________
Hospital Anxiety and Depression Scale
(Raw scores)
Anxiety                                                             5.42 (3.00)                                3.45 (2.73)
Depression                                                        3.50 (3.85)                                2.18 (2.40)
            Item 1                                                   0.92 (0.67)                                0.45 (0.69)
            Item 2                                                   0.67 (0.89)                                0.45 (0.52)
            Item 3                                                   1.08 (0.79)                                0.36 (0.67)*
            Item 4                                                   0.08 (0.29)                                0.18 (0.40)
Item 5                                                               0.75 (0.75)                                0.81 (0.60)
Item 6                                                               0.58 (0.90)                                0.45 (0.52)
Item 7                                                               0.83 (0.72)                                0.64 (0.50)
Item 8                                                               1.08 (0.51)                                0.82 (0.75)
Item 9                                                               0.75 (0.45)                                0.45 (0.52)
Item 10                                                             0.25 (0.45)                                0.18 (0.40)
Item 11                                                             0.42 (0.51)                                0.27(0.47)
Item 12                                                             0.67 (0.98)                                0.18 (0.40)
Item 13                                                             0.75 (0.75)                                0.64 (0.67)
Item 14                                                             0.17 (0.39)                                0.00 (0.00)
___________________________________________________________________________
*p < 0.05

Conclusion
The study explored the relationships of subjective memory complaint with objective test performance and emotional state in 23 recovering SARS patients aged between 20 to 34. Comparing a group with subjective memory complaint and a group without the complaint, results did not reveal any significant differences in the objective test performance in terms of intellectual functioning and memory. The cognitive test scores and the mood scores for both groups are all in the normal range. However, the group with subjective memory complaint scored significantly higher on an anxiety item that described “a sort of frightened feeling as if something awful is about to happen.” This is a rather interesting finding as apprehensive expectation is the cardinal feature of anxiety according to the Diagnostic and Statistical Manual of Mental Disorders. These results would suggest the subjective memory complaint could be related to anxiety (APA, 1994).
 
Discrepancies between subjective memory complaint and cognitive test performance in neurological patients have been frequently reported (Piazzini et al., 2001). The present study is perhaps the first to document this discrepancy in recovering SARS patients. Findings suggest that subjective memory complaint in these patients may be related to anxiety. However, the present study has certain limitations. The subject number was relatively small and the age group was confined to younger patients. The choice of the age range was initially based on the availability of local test norms and the relative lack of other possible neurological complications in older adults.   
 
To conclude, the present study highlighted the possibility of the relationship between emotional factors and the subjective sense of memory competence. A severe illness like SARS can cause major disruptions to activities in daily living. Furthermore SARS patients are also faced with social prejudice causing them difficulties in getting the support when they need them most. The subjective sense of frailty and fatigue can lower the sense of personal control to return to the previous functioning and lifestyle. Levels of anxiety and depression have been found to correlate with the subjective sense of mastery in local epilepsy patients (Au et al., 2002).  Although future studies need to clarify the relationship between emotions and subjective memory, the findings of the present study reinforced the need to take into account the emotional state in the recovery in SARS patients. Results of the present study suggest that subjective memory complaints need to be assessed and treated in the context of the overall adjustment in individuals trying to recover from a sudden and severe illness. Specifically, psychological intervention may be needed to help patients to overcome their anxiety about their functional competence in psychosocial rehabilitation.




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