Journal of Geriatric

Psychiatry and Neurology

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Significance of Subjective Memory Complaints in the Clinical Setting

Dina Silva, Manuela Guerreiro, Catarina Faria, Joo Maroco, Ben A. Schmand and Alexandre de Mendona
J Geriatr Psychiatry Neurol published online 24 April 2014
DOI: 10.1177/0891988714532018
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Research Investigation

Significance of Subjective Memory

Complaints in the Clinical Setting

Journal of Geriatric Psychiatry

and Neurology
1-7
The Author(s) 2014
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0891988714532018
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Dina Silva, PhD1, Manuela Guerreiro, PhD1, Catarina Faria, MS2,

Joao Maroco, PhD3, Ben A. Schmand, PhD4,
and Alexandre de Mendonca, MD, PhD1,5

Abstract
Objective: The clinical significance of subjective memory complaints in the elderly participants, particularly regarding liability of
subsequent progression to dementia, has been controversial. In the present study, we tested the hypothesis that severity or type
of subjective memory complaints reported by patients in a clinical setting may predict future conversion to dementia. Methods:
A cohort of nondemented patients with cognitive complaints, followed up for at least 2 years or until conversion to dementia,
underwent a neuropsychological evaluation and detailed assessment of memory difficulties with the Subjective Memory
Complaints (SMC) Scale. Results: At baseline, patients who converted to dementia (36.8%) had less years of formal education
and generally a worse performance in the neuropsychological assessment. There were no differences in the total SMC score
between nonconverters (9.5 + 4.2) and converters (8.9 + 4.0, a nonsignificant difference), but nonconverters scored higher in
several items of the scale. Conclusion: For patients with cognitive complaints observed in a memory clinic setting, the severity of
subjective memory complaints is not useful to predict future conversion to dementia.
Keywords
memory complaints, memory impairment, Subjective Memory Complaints Scale, clinical setting, Alzheimer disease, mild cognitive
impairment

Introduction
The clinical significance of subjective memory complaints in
the elderly participants, particularly regarding liability of subsequent progression to dementia, has been controversial. On
one hand, memory complaints certainly represent an important
symptom in clinical practice. The report of memory decline by
patients or informants is part of the core diagnostic features for
mild cognitive impairment (MCI) and Alzheimer disease.1-3
On the other hand, memory complaints are very common in the
general population. For instance, using a formal scale, the Subjective Memory Complaints (SMC) Scale4 as much as 75.9% of
people in the community report at least minor complaints when
answering to the question Do you have any complaints concerning your memory?5 Studies with other populations (eg,
Dutch population) have reported a lower percentage of memory
complaints,6 possibly because of a social acquiescence bias of
Portuguese to complain more about their memory.5
It appears that the clinical significance of subjective memory complaints in the elderly participants might depend, among
other factors, upon the characteristics of participants and the
settings where they are recruited. There might be an important
difference between agreeing that one has some memory difficulties when directly questioned and actively seeking help for
memory problems.7 In a recent study, participants in a clinical

setting had more severe memory complaints and reported more

often forgetting names of family members or friends than those
in the community.8
Regarding participants in the community, a meta-analysis of
cross-sectional studies found that the presence of memory complaints was more frequent in patients with cognitive impairment
than in cognitively normal elderly participants,9 although memory complaints had modest diagnostic value to establish the presence of MCI or dementia. Furthermore, subjective memory
complaints may predict future cognitive decline as suggested
by a systematic review of longitudinal studies performed in

Dementia Clinics, Institute of Molecular Medicine and Faculty of Medicine,

University of Lisbon, Portugal
2
Universidade Lusofona de Humanidades e Tecnologias, Lisbon, Portugal
3
Health and Psychology Research Unit, ISPA-IU, Lisbon, Portugal
4
Faculty of Social and Behavioural Sciences, University of Amsterdam, the
Netherlands
5
Laboratory of Neurosciences, Institute of Molecular Medicine and Faculty of
Medicine, University of Lisbon, Portugal
Corresponding Author:
Dina Silva, Laboratory of Neurosciences, Institute of Molecular Medicine,
Av Prof Egas Moniz, 1649-028 Lisboa, Portugal.
Email: dinasilva@fm.ul.pt

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Journal of Geriatric Psychiatry and Neurology

participants with normal baseline cognitive status.10 A recent

community-based study found that participants with subjective
memory complaints had a high risk of progression to dementia
even if they had normal performance in memory tests.11
In the clinical setting, it is not clear whether the severity or
type of subjective memory complaints in nondemented patients
might be associated with subsequent progression to dementia.
Most longitudinal studies performed in patients with MCI just
considered the presence of memory complaints at baseline as
an entry criterion and did not analyze the severity or the type
of memory complaints as a predictive factor for future conversion to dementia. In fact, in many of these studies, a single general question about memory difficulties and not a detailed
formal scale was used.12 Several studies that analyzed in more
detail, using appropriate scales, the memory complaints in
patients with MCI as a predictive factor for future conversion
to dementia generally found that the severity of memory complaints was not predictive.13-15
It could be that specific memory complaints have different
values as predictors of cognitive decline in the clinical setting.
If true, then the type of complaints characterized in a self-report
scale such as SMC would be determinant to identify high-risk
patients and offer them a vigilant follow-up. One study performed in patients with MCI reported that a scale focused on
the current level of cognitive function relative to the past function could predict future decline.16 In this regard, the report of
slower thinking than before (item 8 of SMC Scale) in our study
could as well be prognostic of future decline. Likewise, general
complaint about memory (item 1 of SMC Scale), which in previous studies was shown to be more frequently reported in
older people,5 might have a higher score in converters as a sign
of patients insight about their cognitive difficulties.
In the present study, we tested the hypothesis that the
severity of subjective memory complaints or the presence of
specific types of complaints may predict future conversion
to dementia in a clinical setting. For this purpose, a detailed
scale concerning difficulties in daily-life memory tasks, the
SMC Scale, was used.

establishment was already published.17 The study was

approved by the local ethics committee.

Inclusion Criteria
1.
2.

3.

Exclusion Criteria
1.

2.

3.
4.

Participants were selected from the Cognitive Complaints

Cohort (CCC), established in a prospective study conducted
at the Institute of Molecular Medicine, Lisbon, to investigate
the cognitive stability or evolution to dementia in patients with
cognitive complaints, based on a comprehensive neuropsychological evaluation and other biomarkers. The CCC is constituted of nondemented patients with cognitive complaints
severe enough to be referred for a comprehensive neuropsychological assessment during the period 1999 to 2007, at the participating institutions (Laboratory of Language, Faculty of
Medicine of Lisbon; Memoclnica, a private memory clinic
in Lisbon; and the Dementia Clinics, Hospitais da Universidade
de Coimbra). More detailed information concerning CCC

Patients with neurological (stroke, brain tumor, significant head trauma, and epilepsy) or psychiatric disorders
that may induce cognitive deficits and patients with
major depression according to Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text
Revision), DSM-IV-TR,18 were excluded;
systemic illness with cerebral impact (uncontrolled
hypertension, metabolic, endocrine, toxic or infectious
diseases);
history of alcohol abuse, recurrent substance abuse or
dependence;
presence of dementia according to DSM-IV-TR.18

From the CCC of nondemented patients with cognitive

complaints referred for neuropsychological examination,
134 patients were selected according to the inclusion criteria,
and from these 1 was excluded (severe head trauma previous
to subjective memory complaints).

Procedures
The baseline comprehensive neuropsychological assessment
was carried out by the same team of trained neuropsychologists, supervised by MG, following a standard protocol and
comprised several tests and scales:
1.

Methods
Research Participants

Subjective cognitive complaints;

cognitive assessment with a comprehensive neuropsychological battery (including assessment of subjective
memory complaints);
follow-up 2 years (or less if conversion to dementia
occurred sooner).

Battery of Lisbon for the Assessment of Dementia

(BLAD)19,20: the BLAD is a comprehensive neuropsychological battery evaluating multiple cognitive
domains. The results were standardized according to the
age and education norms for the Portuguese population
and z scores were calculated. This battery includes tests
for the following cognitive domains: attention (Cancellation Task); verbal(Semantic Fluency), motor, and graphomotor initiatives; verbal comprehension (a modified
version of the Token Test); verbal and nonverbal
abstraction (Interpretation of Proverbs and the Raven
Progressive MatricesAb series B); orientation (personal, spatial, and temporal); visuoconstructional abilities (Cube Copy); planning and visuospatial/praxis
abilities (Clock Draw); calculation (Basic Written Calculation); immediate memory (Digit Span forward;

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Silva et al

2.

3.

4.

5.

Wechsler Memory Scale [WMS]); visual memory

(Visual Reproduction test; WMS); working memory
(Digit Span backward; WMS); and learning and verbal
memory (Verbal Paired-associate Learning, Logical
Memory and Word Recall; WMS).
Trail Making Test (TMT)21,22: The TMT part A measures psychomotor speed and attention and part B
assesses the ability to shift strategy, executive functions, and visual spatial working memory.
Blessed Dementia Rating Scale (BDRS)23,24: the BDRS
is a brief behavioral scale based on the interview of a
close informant; the first part of the scale refers to daily
life activities, the second part to habits, and the third
part to changes in personality.
Geriatric Depression Scale (GDS)25-27: the GDS is a
self-report assessment used specifically to identify
depression in the elderly individuals. For this study, a
short form (15 items) of the self-report instrument was
used.
Subjective Memory Complaints Scale4,28 for the assessment of subjective memory complaints. Participants
were required to answer 10 individual items concerning
difficulties in daily life memory tasks, with total scores
ranging from 0 (absence of complaints) to 21 (maximal
complaints score). These items are considered representative of common memory complaints.4

In the present study, no alternative forms of neuropsychological tests were used, since the interval between assessments
was long (approximately one year), minimizing any learning
effects.

Outcome
Patients were assessed after a follow-up of at least 2 years or at
time of conversion to dementia. Patients from CCC have
annual clinical consultations at the participating institutions
so it was therefore easier to schedule the reassessments.
Patients who did not attend clinical consultations were contacted by telephone and invited to come to one of the participating institutions to perform the same neuropsychological battery
of baseline assessment.
Whenever it was not possible to reevaluate the patient in
person, an assessment was performed by a telephone call using
2 validated telephone questionnaires to identify mild cognitive
impairment (MCI) or dementia. We used the Telephone Interview for Cognitive Status that gathers information in the
domains of orientation, concentration, short-term memory,
mathematical skills, praxis, and language. The cutoff used for
dementia was less than 31.29-31 The Dementia Questionnaire
(DQ) was also used in cases of severe cognitive decline or
died patients. The DQ is applied by telephone to caregivers
allowing the diagnosis of dementia using the Diagnostic and
Statistical Manual of Mental Disorders (Fourth Edition, Text
Revision) criteria, and in some cases even to suggest the
dementia subtype (Teixeira J, oral communication, GEECD,

June 3, 2011).32,33 The diagnosis of dementia and Alzheimer

disease was established according to the DSM-IV-TR18 criteria, in a consensus meeting with the neurologist and the
neuropsychologists.

Statistical Analysis
Statistical analyses were performed using IBM SPSS Statistics
19 for Windows (SPSS Inc, An IBM Company, Chicago, Illinois). Comparison of demographic and neuropsychological
data in participants who were clinically stable or converted to
dementia was done using Student t-test on quantitative variables and the Fisher exact test on the qualitative nominal variables. Comparison of the SMC total scores between converters
and nonconverters was also performed with the Student t-test.
A multivariate analysis of variance (MANOVA) using Pillais
trace, which is robust to moderate departure of MANOVA
assumptions, was used to test differences in SMC individual
item scores between converters and nonconverters. A Logistic
Regression (LR) analysis (Forward LR method) was also performed to evaluate the effects of age, formal education, depressive symptoms, and SMC on the risk of future conversion
versus nonconversion to dementia. A P value  .05 was
assumed as statistically significant.

Results
One hundred and thirty three participants (mean age 68.2 + 9.1)
were followed for at least 2 years or until conversion to dementia
(2.6 + 1.5 years for converters and 4.1 + 2.0 for nonconverters,
a significant difference, Table 1). During the follow-up period,
49 (36.8%) patients progressed to dementia and 84 (63.2%) did
not. Most patients who progressed to dementia were diagnosed
as Alzheimer disease (80%). The converters had less years of
formal education (Student t test, Table 1) and generally performed worse than nonconverters in the neuropsychological tests
administered, with the exception of Cancellation Task, Clock
Drawing Test, Trail Making Test (A and B), Motor and Graphomotor Initiatives, Basic Written Calculation, Token Test, and
Digit Span Forward (Student t test, Table 2). There were no statistically significant differences in the total SMC score between
nonconverters (9.5 + 4.2 [0-21]) and converters (8.9 + 4.0 [017]) at the baseline assessment (Student t test, Table 3). A Binary
Logistic Regression analysis was performed to evaluate the
effect of age, formal education, depressive symptoms, and SMC
on the risk of future conversion to dementia. Higher education
was associated with a lower risk of future conversion to dementia, b 0.0961; w2wald (1) 4.242; P 0.040; odds ratio (OR)
0.908, 95% confidence interval (CI) 0.829-0.995. Age,
depressive symptoms, and SMC did not predict future conversion to dementia.
Differences in individual SMC items between nonconverters and converters were analyzed with MANOVA, as reported
in Table 3. The Pillai trace test indicated that there are overall
significant differences in the converters versus nonconverters
SMC individual items. (Pillai trace 0.17; F10 2.52;

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Journal of Geriatric Psychiatry and Neurology

Table 1. Baseline Demographic and Clinical Characterization Data.a

Age, years, mean (SD)

Gender, female/male, n
Formal education, years, mean (SD)
Follow-up time, years, mean (SD)
Geriatric Depression Scale, mean (SD)
Blessed Dementia Scale, mean (SD)

Converters (n 49)

Nonconverters (n 84)

P Value

69.9 (8.4)
34/15
8.1 (4.2)
2.6 (1.5)
4.6 (2.9)
4.0 (1.7)

67.3 (9.4)
44/40
10.6 (4.8)
4.1 (2.0)
4.6 (3.1)
3.3 (2.0)

.11
.07b
<.01c
<.01c
.93
.11

Abbreviation: SD, standard deviation.

a
Please see Results section.
b
Group comparisons were performed with independent samples t tests (or Pearson chi-square test).
c
Statistically Significant.

Table 2. Baseline Neuropsychological Performances of Converters and Nonconverters to Dementia.a,b

Cognitive Domain
Neuropsychological Tests
Attention and Executive Functions
Cancellation Task
Digit Span Backward
Clock Draw
Trail Making Test A
Trail Making Test B
Initiative
Verbal Semantic Fluency
Motor Initiative
Graphomotor Initiative
Conceptual Thinking
Raven Progressive Matrices
Interpretation of Proverbs
Orientation
Personal, spatial and temporal
Calculation
Basic Written Calculation
Visuoconstructional Abilities
Cube Copy
Language
Token Test
Memory and Learning
Visual Reproduction
Digit Span Forward
Word Recall
Logical Memory (immediate recall)
Logical Memory (delayed recall)
d
Forgetting Index
Verbal Paired-Associate Learning

Converters (n 49), Mean (SD)

Nonconverters (n 84), Mean (SD)

P Value

0.18 (0.97)
0.04 (1.11)
0.75 (0.64)
1.32 (1.56)
1.89 (2.32)

0.15 (1.26)
0.32 (1.00)
0.58 (1.01)
0.72 (1.51)
1.23 (2.10)

.13
.03c
.76
.07
.19

0.78 (1.42)
0.19 (1.54)
0.03 (0.79)

0.22 (1.55)
0.11 (1.01)
0.13 (0.70)

<.01c
.90
.28

0.35 (1.04)
0.50 (1.18)

0.44 (1.04)
0.95 (1.22)

<.01c
.02c

2.57 (2.42)

0.43 (1.64)

<.01c

0.63 (1.60)

0.003 (0.67)

.09

0.46 (0.98)

0.92 (0.85)

<.01c

0.18 (1.36)

0.03 (1.21)

.51

0.28 (1.01)
0.41 (0.68)
1.59 (1.44)
1.64 (1.43)
2.42 (1.37)
1.44 (3.32)
1.64 (1.00)

0.82 (1.23)
0.28 (0.53)
0.70 (1.21)
0.85 (1.35)
1.11 (1.17)
1.15 (5.85)
0.77 (1.23)

<.01b
.61
<.01c
<.01c
<.01c
<.01c
<.01c

Abbreviations: LM, Logical Memory; SD, standard deviation.

a
Please see Results section.
b
Means of z scores, calculated according to the equation (z [x  mean]/SD); group comparisons were performed with independent samples t tests.
c
Statistically significant.
d
Forgetting Index ([LM delayed recall  LM immediate]/LM immediate])  100.

P 0.009). Nonconverters scored higher than converters in

several SMC items, namely, item 5 (Do you often use notes
to avoid forgetting things?), item 6 (Do you ever have difficulties in finding particular words?), and also tended to
score higher in item 3 (Do you ever forget names of family
members or friends?; Table 3).

Discussion
In the present study, performed in a clinical setting, we
hypothesized that the severity or type of memory complaints
could predict future conversion to dementia. The results
showed that the severity of cognitive complaints was not

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Silva et al

Table 3. Subjective Memory Complaints in Converters and Nonconverters to Dementia.a,b,c,d,e

1. Do you have any complaints concerning your memory?

2. Do other people find you forgetful?
3. Do you ever forget names of family members or friends?
4. Do you often forget where things are left?
5. Do you often use notes to avoid forgetting things?
6. Do you ever have difficulties in finding particular words?
7. Did you ever lose your way in neighborhood?
8. Do you think more slowly than you used to?
9. Do your thoughts ever become confused?
10. Do you have concentration problems?
Total SMC score

Converters
(n 49)
Mean (SD)

Nonconverters
(n 84)
Mean (SD)

Statistical
Testf
F

Statistical
Significancef
P Value

2.00 (0.82)
0.98 (0.63)
0.76 (0.88)
1.53 (0.89)
0.98 (0.78)
0.35 (0.48)
0.06 (0.24)
0.71 (0.65)
0.76 (0.72)
0.78 (0.65)
8.9 (4.0)

2.00 (0.71)
0.92 (0.68)
1.05 (0.96)
1.42 (0.93)
1.25 (0.74)
0.58 (0.50)
0.07 (0.26)
0.79 (0.56)
0.57 (0.61)
0.83 (0.67)
9.5 (4.2)

<0.01
0.28
3.07
0.48
3.97
7.19
0.05
0.45
2.46
0.23
0.77h

1.00
.60
.08
.49
.045g
<.01g
.82
.50
.12
.63
.44h

Abbreviations: MANOVA, multivariate analysis of variance; SMC, Subjective Memory Complaints Scale; SD, standard deviation.
a
Please see Results section.
b
Scoring of items 1, 3, and 4: 0 no; 1 yes, but no problem; 2 yes, problem; 3 yes, serious problem.
c
Scoring of items 2 and 5: 0 no; 1 yes, sometimes; 2 yes, often.
d
Scoring of items 6 and 7: 0 no; 1 yes.
e
Scoring of items 8, 9 and 10: 0 no; 1 yes; 2 yes, serious problem.
f
MANOVA of SMC item scores.
g
Statistically significant (P < 0.05).
h
Student t test.

predictive. This observation is in agreement with several studies performed in a memory clinic setting.13-15
In contrast to the initial hypothesis, patients who did not
convert to dementia actually had higher scores on several
items of SMC Scale (items 5 and 6, and also tended to score
higher in item 3). It could be that memory complaints were
more likely associated with depression than with an early
stage of AD. However, converters and nonconverters did not
differ at baseline regarding the presence of depressive symptoms. On the other hand, converters showed more deficits in
several areas of neuropsychological assessment, particularly
learning and memory, although they did not differ from nonconverters functionally at the baseline (as assessed by the
BDRS). Patients with more pronounced cognitive deficits
would be in a more advanced stage of the neurodegenerative
disease and thus closer to a decline in functional status and
conversion to dementia.34 Along the disease process, the
insight that a patient has on his or her cognitive impairment
is hindered.35,36 Probably patients deemed to convert tended
to have less subjective complaints just because they already
presented more alteration in insight.
An important aspect is that converters and nonconverters
did not differ at the baseline for important factors that could
influence both conversion to dementia and perception of
memory difficulties. Several longitudinal studies on progression to dementia found that converters are older than nonconverters at baseline,37-39 but in the present study, both groups
were not significantly different. Depressive symptoms can
be associated with subjective memory complaints;40,41 however, as mentioned earlier, they were not significantly different in converters and nonconverters and were correlated with
SMC both in converters and nonconverters (results not

shown). In the present study, converters had less years of formal education. More educated patients were shown to decline
less at early stages of MCI and to decline more at late stages of
MCI as could be anticipated from the cognitive reserve theory.42 It is not clear at the moment whether education could
influence the way patients recognize and report specific memory complaints, an issue that should be addressed in future
research. It should also be noted that the analysis of subjective
memory complaints in the present study relied on the SMC
Scale, and the results might not be generalizable to other
instruments of memory complaints assessment. However, the
SMC items were selected in such a way to be representative of
common memory complaints.4
A few other aspects deserve comment. A cohort of patients
with cognitive complaints was established irrespective of having formal criteria for the diagnosis of MCI. This decision of
not restricting the sample to patients with MCI was taken
because several studies have shown that people with cognitive
complaints and no alterations in the standard neuropsychological assessment might also be at risk of future conversion to
dementia.43-45 In a previous longitudinal study from our
group, some patients with cognitive complaints and no alterations in the standard neuropsychological assessment progressed to dementia and interestingly, as a group, had a
decline in hippocampal volumes.46 Anyway, most (82%) of
the patients recruited in the present longitudinal study would
fulfill the criteria for MCI,1 and the observed annualized conversion rate (14%) fits quite well the values previously
reported for patients with MCI.47
The clinical significance of subjective memory complaints
in the elderly individuals likely depends upon the characteristics of participants and the settings where they are recruited.

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Journal of Geriatric Psychiatry and Neurology

In healthy people living in the community, subjective memory

complaints may help predict future cognitive decline.10 Likewise, in a general practice consultation population, the presence of memory complaints was reported to be a significant
independent predictor for subsequent hospital-based dementia
diagnosis.48 On the other hand, the present study shows that
in a memory clinic setting, where patients with cognitive complaints have a higher risk of future conversion to dementia, the
severity of subjective memory complaints is no longer useful to
predict outcome. Even so, the use of scales to assess subjective
cognitive complaints may be important for the characterization
of the perceived difficulties and the planning of a comprehensive rehabilitation strategy.
Acknowledgments
The authors thank Memoclnica for the facilities provided.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This work was
supported by Fundacao para a Ciencia e Tecnologia (grant number:
PTDC/EIA-EIA/111239/2009).

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