ORIGINAL ARTICLE

A Comparison Study of Mild Cognitive Impairment With

3 Memory Tests Among Chinese Individuals
Qihao Guo, MD, Qianhua Zhao, MD, Meirong Chen, MD,
Ding Ding, MD, MPH, and Zhen Hong, MD

Objective: To examine whether 3 common memory tests dier

statistically in terms of mild cognitive impairment (MCI) discrimination rates and conversion rates to Alzheimer disease.
Methods: A sample of 329 Chinese patients who consulted our
memory clinic in Shanghai were tested using tasks including the
auditory verbal learning test (AVLT), the logical memory (LM)
test, the Rey-Osterrieth complex gure test, and other neuropsychologic tasks. One hundred and forty-nine of these patients were
tested again using the identical tests 2 years later. The diagnose
standard of probable Alzheimer disease is the same as the standard
of the National Institute of Neurological and Communicative
Diseases and Stroke-Alzheimer Disease and Related Disorders
Association.
Results: The results of the MCI discrimination rates are as follows:
AVLT-II (51%) >AVLT-I (31%) > complex gure test-II (27%)
>LM-I (21%) = LM-II (21%) (Iimmediate recall; IIdelayed
recall). The MCI group categorized based on LM-II cuto has a
higher conversion rate per year (24%), but also a higher reversal
rate and missed diagnosis rate, whereas the group based on AVLT-II
cuto has a lower conversion rate per year (12%), but also a lower
reversal rate and missed diagnosis rate.
Conclusions: The MCI discrimination rate and the conversion rate
among dierent episodic memory tests are dier considerably.
Key Words: neuropsychologic tests, auditory verbal learning test,
logical memory test, mild cognitive impairment

proposed by Peterson et al,4 which includes subjective

memory complaints, objective evidence of memory deterioration, normal general cognitive function, normal
capacity to perform daily activities, and the absence of a
dementia syndrome is currently the preferred denition.
This denition, is, however, not without limitations.5,6 For
example, various measures of objective evidence of
memory deterioration are used, including the Wechsler
memory scale (WMS), logical memory (LM) test, and
verbal memory test.7,8 Given that neuropsychologic test
performance is inuenced by language and culture, it
remains an unsettled question as to which test is the most
sensitive and specic for Chinese patients.
It is recognized that performance across episodic
memory, semantic memory, and implicit memory tasks
vary in MCI discrimination rates, and manifest dierently
in MCI and AD, but the sensitivity and specicity to group
dierences and likelihood of conversion from MCI to
dementia using dierent episodic memory tests with
dierent material and under dierent modalities has not
been studied extensively. For this study, we examined
performance characteristics of 3 common episodic memory
tests to identify the most sensitive and specic indicator of
MCI and the task that had the strongest predictive power
for conversion to dementia.

(Alzheimer Dis Assoc Disord 2009;23:253259)

PARTICIPANTS AND METHODS

hina is a country with a rapidly increasing elderly

population, and a consequent risk for incident
dementia. As such, Alzheimer disease (AD) has become
the main neurologic disorder that threatens the health and
quality of life of the elderly.1 Mild cognitive impairment
(MCI) is a recognized transition state between normal
aging and dementia. Individuals with MCI are more likely
to convert to AD than cognitively normal elders. Eective
identication of MCI is therefore critical to the early
diagnosis of AD and institution of treatment.2 The
diagnostic standard of probable AD conformed to that of
the National Institute. There is, however, no consistent
operational diagnostic standard for MCI.3 The standard
Received for publication March 5, 2008; accepted October 27, 2008.
From the Department of Neurology, Huashan Hospital aliated to
Fudan University, China.
Supported by the Natural Science Foundation of China (number:
30570601).
Reprints: Qihao Guo, MD, Department of Neurology, Huashan
Hospital, Fudan University, Shanghai 200040, China (e-mail:
guoqihao@hotmail.com).
Copyright r 2009 by Lippincott Williams & Wilkins

Alzheimer Dis Assoc Disord

Participants
Seven hundred and twelve outpatients of the Memory
Clinic at Huashan hospital presenting with memory
complaints lasting more than 3 months were screened
consecutively between January 5, 2004 and January 5, 2006.
All were native Chinese speakers. Among subjects presenting to the clinic, 329 who met the following criteria were
selected for this study: (1) aged 50 to 80 years old, (2)
achieved between 8 and 15 years of education, (3) scored
greater than or equal to 24 on the Mini-Mental State
Examination-Chinese version (MMSE),9 (4) had no history
of cerebrovascular accident, (5) had no serious physical
disease (eg, myocardial infarction or history of congestive
heart failure), (6) had no chronic mental illness (eg,
schizophrenia), (7) had no visual or auditory decit, and
(8) did not meet the criteria for probable AD of the
National Institute of Neurological and Communicative
Disorders and Stroke and Alzheimer Disease and Related
Disorders Association (NINCDS-ADRDA).10
The average age of the selected group was 67.6 8.1
years. One hundred and eighty-eight were males, and 141
were females. The level of educational achievement

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Guo et al

included junior high school (N = 68), senior high school

(N = 123), and college (N = 138).
All patients received detailed questions regarding
history of brain disease, physical disease, and mental state
such as anxiety and depression. In addition, all patients
underwent thorough neurologic examination, thyroid
function testing (FT3, FT4, and TSH), and folic acid and
vitamin B12 measurements. All participants were examined
by brain computed tomography or magnetic resonance
imagining scan to exclude vascular factors (including
lacunar infarctions or pathy or diuse white matter
ischemic changes).
As shown in Figure 1, 149 of the 161 patients who had
come to our hospital between January 5, 2004 and January
5, 2005 were available for repeat testing 2 years later. For
the other 12 patients, 4 lost contact, 3 rejected our visits, 3
moved to other countries or cities, 1 died of physical
disease, and 1 was hospitalized owing to cerebral infarction.
Medication use during this time was limited to Aniracetam
and Ginkgo biloba, primarily owing to economic reasons.
Among the 149 patients in follow-up, 21 developed
dementia, 19 of whom were diagnosed with AD. Clinical

Volume 23, Number 3, July-September 2009

diagnosis of dementia for the other 2 patients was viral

encephalitis and presumed vascular dementia after cerebral
infarction. Brain imaging of the 19 patients diagnosed with
AD revealed only atrophy. The MMSE score for the
incident dementia group declined from 25.5 0.9 at
baseline to 21.1 1.8 at year 2.19. AD individuals averaged
66.1 years of age, among whom 8 were males and 11 were
females. With regard to educational achievement, 7 had
completed middle school, 8 high school, and 6 college.

Assessment Methods
Three separate memory tasks were studied: the
auditory verbal learning test (AVLT), the LM test, and
the ReyOsterrieth complex gure test (CFT). Each of
these tasks is discussed in detail in this section.

AVLT11
The AVLT adopts the rationale and methods of the
California verbal learning test and the Hong Kong verbal
learning test. The following testing procedure is used: the
examiner reads out dierent semantic categories with 4 in
each type. The words of dierent categories are presented

Total 712 subjects

Excluding 65 subjects due to age < 50ys or age > 80ys
647 subjects
Excluding 81 subjects due to illiteracy or elementary school
( 7 ys education)
566 subjects
Excluding 167 subjects due to MMSE total score < 24
399 subjects

354 subjects

Excluding 45 subjects due to other cerebral organic causes

and severe physical disease, such as vascular dementia,
frontotemporal dementia and dementia with Lewy bodies,
cerebral trauma and CO intoxication
Excluding 9 subjects due to major depression or psychiatric
disorder

345 subjects
Excluding 9 subjects due to hearing impairment
(unable to complete AVLT)
336 subjects
Excluding 7 subjects due to visual impairment
(unable to complete testing)
329 subjects
Number of individuals at least 2 years from initial evaluation

161 subjects
12 lost to follow-up
149 subjects
FIGURE 1. Flow chart for clinical evaluation.

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randomly, with 1-second between-word intervals. Right

after the presentation of the whole list, the participant
recalls these words. This learning phase and recalling phase
are repeated 3 times. The participant then takes a 5-minute
nonverbal test. He or she then recalls the 12 words again for
the fourth time. Another 20-minute nonverbal task is then
carried out, after which the participant recalls the list for a
fth time. Finally, the participant is asked to recognize the
word list. The indicators we measure are as follows:
(1) AVLT short-term memory (AVLT-I): the sum score
of free recall accuracy of the rst 3 repetitions, with a full
mark of 36 and (2) AVLT delayed recall (AVLT-II): the
recall score of the fth time, with a full mark of 12.

LM Test12
A story from the LM test of the Chinese version of
WMS is used. The short simple story is printed in large font
(20  30 cm), and is visually presented to the participant.
The participant is asked to read the story for 2 minutes and
then recall it immediately (LM-I). The participant then
performs a nonverbal test, 25 minutes after the completion
of which the participant recalls the story again (delayed
recall, LM-II). There are 20 scoring points in the story, one
grade for each point. The full mark is 20.
An English translation of the story is given here (the
underlined contents are the scoring points): Long long
ago, there was a youth/who was taking a long journey/.
When he was crossing a river/, he sat along the side of the
boat/and suddenly lost his sword in the river/. The boater
felt sorry for him/, and anchored the boat/for the youth to
look for his sword in the river. The youth said, /Dont
worry/. I have already marked at the side of the boat/.
When the boat pulls into the shore/ I can dive into the river
at the mark/, and my sword must be there/.

Rey-Osterrieth CFT13
The participant copies a gure, and then draws
the gure from memory after about 25 minutes (CFT-II).
The time for copying the gure is limited to 10 minutes. The
scoring standard established by Taylor14 is used, with a full
mark of 36. Rey gure is used in both rst and second
assessments.
The cuto scores of the 3 tests are obtained by
surveying a large sample of middle-aged and elderly
cognitively normal individuals in Shanghai. We grouped
the patients according to age, education levels, and sexes.
The cuto scores are 1.5 SD below the mean scores of the
matching group (Mean 1.5 SD).

A Comparison Study of Mild Cognitive Impairment

a color word is written in various colored inks. The

participant is to name the ink colors. We use reaction time
and accuracy for items with inconsistent color words and
ink colors; (6) Trial making test (TMT)17: in TMT-A, the
participant connects the Arabic numbers 1 to 25 in
the proper numerical sequence; in the Chinese version of
TMT-B, the Arabic digits are surrounded by either squares
or circles, and the participant is asked to connect the digits
in sequence while alternating the 2 surrounding shapes. The
time consumed in TMT-A and TMT-B is analyzed;
(7) Clinical dementia rating (CDR)18: the examiner interviews the family members of the participant to complete
ratings of function and cognition of the participant to
complete the ratings and the CDR score is the sum score of
6 items; (8) Center for Epidemiologic Studies Depression
Scale (CESD): a patient is diagnosed as having denite
depression if he or she scores higher than 19. The validity
and reliability for all the tests mentioned above have been
examined before this study.

Diagnosis of MCI
In this paper, MCI is referred to as amnesic MCI (both
aMCI-single domain and aMCI-multidomain). The operational diagnostic criteria for MCI required (1) memory
complaints and memory diculties, which are veried by
an informant; (2) MMSE score between 24 and 30
(inclusive) (the education level of all the patients ranged
from 8 to 15 y); (3) preserved basic activities of daily living/
minimal impairment in complex instrumental functions;
(4) objective evidence of episodic memory impairment.
Abnormal memory function documented by scoring below
the age and education adjusted cuto on the memory test.
The episodic memory impairment can be isolated or
associated with other cognitive function (language, visuospatial, and executive domains) changes; and (5) exclusion of
other medical disorders severe enough to account for
memory impairment, such as major depression, cerebrovascular disease, toxic and metabolic abnormalities, etc.

Method of Statistical Analysis

Chi-square analysis was adopted for ordinal data.
Overall dierences among the 3 groups were assessed with
analysis of variance, with an a level of 0.05 used as the
cuto for signicance. Post hoc pairwise comparisons
between each group were assessed by using the least
signicant dierence test.

RESULTS

Other Assessment Methods

MCI Discrimination Rates of Different Memory

Indicators

To maximize the diagnostic reliability and validity,

and comprehensively test as many cognitive domains as
possible, the following tests were added to the cognitive
assessment at each time point: (1) MMSE: the modied
version (Zhang9) with a maximum score of 30 was adopted;
(2) Clock drawing test: we developed our own scoring
standard, with a maximum score of 30; (3) Figural uency
test (5-point test): in this test, the participant is asked to
connect 5 points with 4 arbitrary lines within 3 minutes.
The score consists of the total number of correct
responses15; (4) Verbal uency test: we asked the participant to name as many animals as possible in 1 minute. The
score consists of the number of unique responses; (5)
Stroop color-word test16: the test involves 3 cards, on which

The cuto scores of the 3 tests were obtained based on

sampling 400 middle age and elderly cognitively normal
individuals in the Shanghai region whose education levels
were around 8 to 16 years. The cutos for each test by age
group are shown in Table 1.
The MCI discrimination rates of various memory tests
are shown in Table 2. They are ordered according to
number of MCI patients identied: AVLT-II >AVLT-I
>CFT-II >LM-I = LM-II. The discrimination rates of
each indicator among the age groups were comparable
(P>0.05), but the 5 indicators were signicantly dierent
from each other (P<0.01). The dierence between LM-II
and CFT-II did not reach signicance level (w2 = 2.99,
P = 0.08).

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51-60
61-70
71-80

Volume 23, Number 3, July-September 2009

incongruent group can be viewed as another MCI group

with relatively milder cognitive decit.

TABLE 1. The Cutoffs of the Indicators in the 3 Tests

Age (y)

AVLT-I

AVLT-II

LM-I

LM-II

CFT-II

12
11
10

4
3
2

5
5
5

4
4
4

9
6
3

Education: 8 to 15 years.
AVLT indicates auditory verbal learning test; CFT, complex gure test;
LM, logical memory test.

Results of the Follow-up Visit

The MCI group that is identied by the AVLT-II
cuto is labeled MCI-I, the group identied by the LM-II
cuto is labeled MCI-II, and the group identied by the
CFT-II cuto is labeled MCI-III (Table 5).

Reversal Rate
The reversal rate is the rate of conversion from MCI
back to SCI. The MCI-III group has the highest reversal
rate (55%) and the MCI-I group has the lowest (11%).

Grouping According to Different Memory

Indicators

Stability

We divided the 329 patients into 3 groups. If an

individuals scores on the AVLT-II and the LM-II were
both higher than the cuto, this individual was identied as
having Subjective Cognitive Impairment (SCI). This
group of patients complained that they suered from
cognition decline, but we did not nd any objective memory
decit using neuropsychologic tests. There were 155
patients in this group, or 47% of the total number. An
individual was identied as having denite MCI (dMCI)
if both his AVLT-II and LM-II scored below the cuto.
This group consisted of 63 patients, or 19% of the 329
individuals screened. The nal group consisted of individuals with impairment either in AVLT-II or in LM-II, but
not both. These were identied as the incongruent group.
One hundred and four patients (32% of the 329 screened)
scored below the AVLT-II cuto while above the LM-II
cuto; 7 patients (2%) showed the reverse pattern.
There was no signicant dierence among the 3 groups
in the distribution of age, sex, or educational achievement
(P>0.05). They also did not dier in terms of history of
high blood pressure, diabetes, smoking, alcohol consumption, or cerebral trauma (P>0.05).

The Categorization of the Incongruent Group

When comparing the SCI and dMCI groups with the
incongruent group, we obtained the following results. The
SCI group and the incongruent group diered signicantly
on executive function, general cognitive function, and the
CDR scale. The incongruent group and the dMCI group
diered in MMSE total scores, animal category uency,
and TMT, but not for the clock-drawing test, gural
uency test, color-word test, and CDR (Tables 3 and 4).
Generally, compared with the SCI group, the incongruent
group declined in overall cognitive function, whereas it
showed no signicant dierence with the dMCI group in
language, executive function, and CDR. Therefore, the
incongruent group departs greatly from the SCI group,
whereas it resembles the dMCI group. In some aspects, the

Stability is an estimate of an individual retaining the

same classication (eg, AVLT-IIbased MCI) at baseline
and follow-up assessment 2 years later. Individuals
identied as being in the MCI-I group were the most stable
(67% remained with the same grouping after 2 y).

Conversion Rate
The conversion rate from MCI to AD reects the
predictability power of a particular test. We found a 2-year
conversion rate of 43% in the MCI-II group, the highest
among the 3 groups (MCI-I, MCI-II, and MCI-III).
Assuming that the conversion rate of MCI to AD remained
the same in the rst year and the second year, we therefore
mathematically calculated a 1-year conversion rate of 24%
for the MCI-II group. Conversely, the MCI-I group had the
lowest conversion rate: 2-year, 22% and 1-year, 12%.

Missed Diagnosis Cases

Missed diagnosis cases refer to those patients who did
not satisfy the criteria of MCI according to dierent
neuropsychologic tests at baseline assessment, while meeting AD criteria at the 2-year follow-up visit. The numbers
of AD patients that did convert from MCI to dementia
were also compared. Three patients failed to be classied
into MCI-I (according to AVLT-II score), but converted to
dementia at the 2-year follow-up. Among these, 2 were
from the SCI group and 1 was from the MCI-II group. The
MCI-II and MCI-III groups together missed 7 patients, of
whom 2 were from the SCI group and 5 were from the
MCI-I group.

DISCUSSION
To make meaningful comparisons across dierent
MCI studies, it is critical to select an appropriate objective
memory test to determine the memory decit. Our research
showed that dierent episodic memory indicators dier as
to the ability to discriminate MCI patients from cognitively
normal patients, the stability of maintaining an MCI

TABLE 2. MCI Discrimination Rate of Different Memory Indicators

Group (y)
51-60
61-70
71-80
Recognized number

No. MCI
70
108
151
329

AVLT-I (%)
21
34
49
104

(30)
(31)
(32)
(31)

AVLT-II (%)
36
57
74
167

(51)
(53)
(49)
(51)

LM-I (%)
14
26
31
71

(20)
(24)
(21)
(21)

LM-II (%)
15
23
32
70

(21)
(21)
(21)
(21)

CFT-II (%)
16
35
38
89

(22)
(32)
(25)
(27)

AVLT indicates auditory verbal learning test; CFT, complex gure test; LM, logical memory test; MCI, mild cognitive impairment.

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A Comparison Study of Mild Cognitive Impairment

TABLE 3. The Comparison of Performance of Neuropsychologic Tests Among the 3 Groups (Mean SD)

Tests
MMSE score
Clock drawing test
CFT copying
Animal uency test
Figural uency test
TMT-A time (s)
TMT-B time (s)
CWT time (s)
CWT score

SCI Group (n = 155)

28.3
22.4
33.3
16.3
8.3
59.5
175.9
88.9
43.1

Incongruent Group (n = 111)

(1.4)*
(4.8)*
(3.9)
(4.2)*
(4.3)*
(22.7)*
(74.3)*
(29.0)*
(6.0)*

27.3
20.5
32.9
13.9
6.1
70.0
197.8
105.3
40.1

dMCI Group (n = 63)

(1.7)w
(6.1)
(4.2)w
(3.9)w
(3.8)
(30.6)w
(84.6)w
(67.3)
(8.9)

26.0
19.8
30.0
12.2
5.9
80.3
227.6
109.6
38.4

(1.4)z
(6.4)
(8.8)z
(3.6)z
(3.6)z
(49.4)z
(94.7)z
(35.8)z
(9.5)z

F
49.95**
5.99**
8.47**
22.31**
5.27**
10.01**
8.64**
6.29**
9.39**

*SCI mean diered signicantly from incongruent MCI mean at P<0.01.

wIncongruent MCI mean diered signicantly from dMCI mean at P<0.01.
zSCI mean diered signicantly from dMCI mean at P<0.01.
**P<0.01.
CFT, indicates complex gure test; CWT, color-word test; dMCI, denite mild cognitive impairment; MCI, mild cognitive impairment; MMSE, MiniMental State Examination; SCI, subjective cognitive impairment; TMT, trial making test.

diagnosis, and the rate of conversion from MCI to

dementia. Compared with LM-II and CFT-II, AVLT-II
identied the largest number of MCI cases and had the
most stable diagnostic accuracy. Conversely, the impaired
performance on the AVLT-II was associated with the
lowest conversion rate to dementia. Despite this limitation,
we conclude that AVLT-II is superior to LM-II and CFT-II
and is the most suitable to serve as objective verication of
memory impairment in MCI.
Earlier studies showed a conversion rate of 16% from
MCI to AD in AVLT by Devanand et al,19 13% by Tian
et al,20 and 20% by Lehrner et al.21 In our study, the
annually conversion rate of MCI to AD is 24% using LMII cuto for MCI diagnosis, and 12% using AVLT-II, both
much higher than the conversion rate of the cognitively
intact healthy elderly (1% to 2% per year).22 The 12%
annual and 24% 2-year conversion rate for this group is
similar to the conversion rates identied in earlier longitudinal MCI studies (eg, Petersen et al23). The reason for
the lower conversion rate seems to be that the AVLT
identied a higher number of MCI patients than the other
memory tests earlier in the course of the disorder. Only
additional follow-up will verify whether this is indeed the
case.
The reversal from MCI to SCI could be attributed to
various factors: medication treatment, practice eect, the
psychologic state uctuation, the instability of the neuropsychologic tests, or a combination. Both doctors and
patients may stop intervention owing to improvement of

the participants score. In fact, the participant may still be

categorized as having MCI if classifying according to a
dierent test. The reversal rate of CFT-II being so high
means that it is not an ideal indicator of MCI. Changing the
cuto might increase its discriminative ability, but the rate
of reversal would increase accordingly. As CFT is a
nonlinguistic test and is comparable across dierent
educational levels or cultural backgrounds, we chose
CFT-II as a discriminator of MCI. Nevertheless, our
results yielded a reversal rate of more than 50%, which
would therefore misled us in early intervention. Thus,
further utilization of CFT in MCI was hampered by this
fatal disadvantage.
Compared with LM-II and CFT-II, AVLT-II has a
much higher discrimination rate. Does this mean that the
ADhigh-risk group identied by AVLT-II will contain
more false alarms? The result of the follow-up visit revealed
that AVLT-II generated the lowest MCI reversal rate. If we
lengthen the follow-up visit, it is likely that the rate of
conversion to AD will increase similarly. The stricter the
MCI diagnosing standard, the higher the conversion rate to
AD, and the higher the missed diagnosis rate.24
The Chinese version of AVLT and LM dier in
manner of presentation: AVLT is auditorily presented and
LM is visually presented. In addition, AVLT is made up of
12 isolated words, whereas LM uses a coherent story. We
believe that LM uses tasks resembling daily memory
function (eg, daily dialogs, newspaper-reading, and TVwatching). The visual presentation of the stimuli in LM

TABLE 4. The Comparison of Performance of CDR Among the 3 Groups (Mean SD)

CDR Item

SCI Group (n = 155)

Memory
Orientation
Judge and solve problem
Work and sociality
Family life and hobbies
Ability of leading and independent life
CDR total score

0.9
0.2
0.2
0.3
0.3
0.1
2.0

(0.5)w
(0.4)z
(0.3)
(0.3)w
(0.5)w
(0.3)w
(1.3)w

Incongruent Group (n = 111)

1.2
0.3
0.3
0.5
0.8
0.3
3.3

(0.7)
(0.4)
(0.4)
(0.5)
(0.8)
(0.4)
(2.1)

dMCI Group (n = 63)

1.3
0.4
0.3
0.4
0.9
0.3
3.6

(0.7)y
(0.4)y
(0.3)
(0.4)
(0.9)y
(0.5)y
(2.0)y

F
16.2**
3.57*
1.73
4.67*
18.77**
6.04**
21.57**

wSCI mean diered signicantly from incongruent MCI mean at P<0.05.

zSCI mean diered signicantly from incongruent MCI mean at P<0.01.
yIncongruent MCI mean diered signicantly from dMCI mean at P<0.01.
*P<0.05; **P<0.01.
CDR indicates clinical dementia rating; dMCI, denite mild cognitive impairment; MCI, mild cognitive impairment; SCI, subjective cognitive impairment.

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TABLE 5. The Distribution of 149 Participants Based on Different Memory Indicators After 2 Years

The Distribution After 2 Years

Baseline
SCI (n = 74)
MCI-I (based on AVLT-I, n = 73)
MCI-II (based on LM-II, n = 28)
MCI-III (based on CFT-II, n = 33)

SCI (%)
63
8
6
18

(85)
(11)
(21)
(55)

MCI (%)
9
49
10
3

AD (%)

(12)*
(67)
(36)
(9)

2
16
12
12

(3)
(22)
(43)
(36)

Missed Number

3
7
7

*Met criterion of MCI-I.

AD indicates Alzheimer disease; AVLT, auditory verbal learning test; CFT, complex gure test; LM, logical memory test; MCI, mild cognitive impairment;
SCI, subjective cognitive impairment.

lessens the attention load, and the meaningfulness of the

story allows easier usage of semantic knowledge. However,
MCI patients suer mainly from episodic memory decit
arising from pathologic changes in the entorhinal cortex
and the hippocampus area. As in its broadest sense
semantic memory includes all our knowledge of the world
not related to specic episodic memories, one could argue
that it resides in multiple cortical areas. Thus, it is usually
preserved in these patients. The observed MCI discrimination rates determined by both LM-I and LM-II were
comparable, suggesting that the story presented visually
was more easily retained in the memory.25 Chinese is a
logographic language. Material presented visually might
therefore be easier to store through double encoding both
as imaging codes and as linguistic codes. Both LM and
CFT presented visually have the picture superiority eect
compared when with AVLT.26
The LM and AVLT are the most common tests used to
identify objective memory impairment in Western countries.27 There are various versions of AVLT that dier by
details, such as the verbal memory and recognition test of
Consortium to Establish a Registry for Alzheimers
Disease, the California verbal learning test, the Rey
AVLT,28 and the Buschke selective reminding test.15
Nordlund et al29 compared the delayed recall performances
between cognitively normal elders and MCI individuals
using both AVLT and LM, and the t values were very close
(3.43 and 3.50, respectively). Alladi et al30 studied 124
patients with memory decit who were nondemented and
nondepressive by using both AVLT and CFT, and found
that the MCI discrimination rate of AVLT delayed recall
was 58% and of CFT delayed recall was 72%. Generally,
the cognitive-processing and the cognitive-aging patterns of
Chinese elders might dier from western elders owing to the
dierent characteristics of the languages they speak.31
In summary, our study revealed some distinguishing
characteristics of various neuropsychologic tests such as
AVLT, MCI, and LM in MCI diagnosis and follow-up.
The poor score in AVLT was helpful in early detection,
which might indicate the early stage of MCI, whereas the
poor score in LM or CFT might correlate more with high
risk of converting to dementia. Thus, we should choose a
comprehensive test or indicator such as delayed recall
factor in WMS-III, which satised both sensitivity and
specicity. However, the time-consuming shortage of
WMS-III prevented its extensive use in the early discrimination and intervention of MCI in the elderly. Considering
the clinical practicality, we should adopt the most sensitive
indicator AVLT-II as the objective index for memory
impairment in MCI discrimination.

258 | www.alzheimerjournal.com

The operational MCI diagnosing standard we advocate takes the score of auditory word delayed recall as the
objective evidence of memory deterioration. An MMSE
score higher than (or equal to) 24 is required, which should
exclude impairment of general cognitive functions other
than memory deterioration. The self-report and memory
function state is obtained through CDR with the patients
and/or their family members.32 In the future, we plan to
more comprehensively examine the sensitivity and specicity of dierent episodic memory indicators and to
construct the most appropriate objective memory impairment indicator, by enlarging the sample size, shortening the
between-visit interval, and lengthening the follow-up
period. We will include those patients with lower education
as well. As for the many studies in imaging, molecular
biology, and medical intervention that are conducted
relating to MCI, we strongly suggest clearly specifying the
particular neuropsychologic tests that are used. Only by
doing so can readers make meaningful comparisons of the
results across the dierent studies.
ACKNOWLEDGMENT
The authors thank Prof Agnes Chan of the Psychology
Department of the Chinese University of Hong Kong for
providing the Hong Kong verbal learning test.
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