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Bosnes et al. BMC Psychology(2020) ARCH ARTICLEOpen AccessSubjective working memory predictsobjective memory in cognitively normalaging: a HUNT studyOle Bosnes1* , Ove Almkvist2, Ingunn Bosnes1,3 and Eystein Stordal1,4AbstractBackground: Recent studies have shown that subjective memory is multi-, rather than uni-dimensional, in line withthe results of objective memory tests. The purpose of this study was to investigate whether there is an associationbetween aspects of memory measured by the subjective Meta-Memory Questionnaire (MMQ) and aspects ofmemory measured by the objective Wechsler Memory Scale-III (WMS-III) and Wechsler Adult Intelligence Scale-III(WAIS-III) tests in cognitively normal older adults.Method: The study subjects (n 106) were cognitively normal, were aged 57–89 years and had participated in thethird wave of the North-Trøndelag Health survey (HUNT3). All subjects had completed the MMQ, the WMS-III andthe WAIS-III. Previous results from the MMQ (measured as the total MMQ score; the Component I score, related tolong-term explicit declarative memory; and the Component II score, related to working/short-term memory) werecompared with objective results from WMS-III (Logical Memory) and WAIS-III (Vocabulary and Letter-NumberSequencing) subtests. We conducted linear regression analyses with each objective memory test result as thedependent variable, and subjective memory measures and demographics as independent variables, as well asanalyses of MMQ items vs. objective memory.Results: Subjective working memory impairment (Component II) was significant related to poor performance inobjective episodic memory, according to correlation and regression analyses with demographic covariates. Incontrast, ratings of impaired subjective declarative memory (Component I) were not related to poor objectivememory performance.Conclusions: Specific aspects of subjective memory related differentially to performance in specific objectivememory tests. Clinicians and researchers might consider targeting working memory aspects of subjective memorytests, when seeking an estimate of objective memory performance.Keywords: Subjective memory tests, Objective memory tests* Correspondence: obosnes@broadpark.no1Namsos Hospital, Nord-Trøndelag Hospital Trust, Namsos, NorwayFull list of author information is available at the end of the article The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver ) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

Bosnes et al. BMC Psychology(2020) 8:77BackgroundSelf-reported memory complaints are common in olderadults [1] and the prevalence increases with age, according to population- [2–4] and community-based studies[5, 6]. Previous research has demonstrated that the relationship between subjective memory test results and objective memory performance is complex and unclear [7].Individuals complaining of memory problems may haveno objective signs of memory impairment [8, 9]. On theother hand, memory complaints may be a preclinicalsign of dementia in individuals with verified cognitivedecline and memory impairment, exemplified by mildcognitive impairment (MCI) [10]. Many of those withclinically diagnosed dementia and objective memory impairment do not complain of memory loss, presumablybecause they lack insight into their serious impairment[11, 12]. Previous research has suggested that the lack ofa consistent relationship between subjective and objective memory performance may be related to non-memoryfactors such as depression [1], neuroticism [13, 14], poorsomatic health [15] and health status (healthy or nothealthy individuals). There are other important reasonsfor the seeming lack of relationship between subjectiveand objective memory performance, including use of different sample populations [16], limitations of the cognitive tests used [17], and the measurement of differentaspects of cognitive ability by the subjective and objective memory tests [18]. At a personal level the authorshave often met older adults claiming about memoryproblems, but who perform well on objective memorytests, while perhaps showing some problems with attention. To summarize, although a meta-study [11] concluded that it is a small positive correlation (r 0.15)between subjective and objective memory performance,the association between subjective and objective memoryperformance are only partly understood.Furthermore, research in the field is seriously hampered by the lack of a commonly accepted definition ofmemory from a subjective point of view and the poorquality of subjective memory testing methods [19, 20].An extensive review of subjective memory questionnaires, which listed a total of 34 self-reported measuresused in 19 studies in different countries, stated that themajority of instruments did not document satisfactorystatistically assessable characteristics (e. g. reliability, validity and factor structure), which questions the use ofthe instruments in research and clinical practice [17]. Inaddition, the questionnaires differed widely in type, content and number of items, which makes it hard to compare the results. This may indicate that tests ofsubjective memory have more than one dimension andthat single sum scores from such tests therefor may beoversimplifying and partly be the cause of divergentfindings.Page 2 of 8The Meta-Memory Questionnaire (MMQ) was chosenas a test of subjective memory in the present study, because it has been used previously in the Nordic countries[21–25], the internal structure has been investigated andfound to be multi-dimensional [20], because there is nointernational standard of subjective memory test to relyon [17], and because this nine item questionnaire wasused in the third wave of the North-Trøndelag Healthsurvey (HUNT3) [26]. Interestingly, six among the nineitems in the MMQ are included in the list of the 10most common items in other questionnaires that assesssubjective memory as reported by Rabin and associates[17]. Three items in MMQ (recent events, conversationand intention) related to working memory (componentII) and three items in MMQ (general memory, memorychange and names) related to declarative memory (component I) were common in other subjective memory instrument. This commonality makes it possible togeneralize the present findings to subjective memoryquestionnaires in general.The HUNT study (an acronym for the Norwegianname: Helseundersøkelsen iNord-Trøndelag), which bynow has been completed four times from 1984 to 2018,is a large population based study, covering a wide rangeof medical, social and health related data of all inhabitants in the county of Nord-Trøndelag in Norway (about125,000). The surveys have a high participation rate anddata drawn from samples in the surveys may thereforebe generalizable to the population in Norway. Detailedinformation about the surveys is found at the HUNThomepage [26]. A previous study of subjective memoryperformance based on the total MMQ score in HUNT3found that approximately 45% of the participants reported minor memory problems and 1.5% reportedmajor memory problems, and that men reported morememory impairment than women [22]. That studyassessed subjective memory performance using a singlemeasure (total score).In the present study subjective memory performancewas assessed also using the two components of theMMQ detected in a previous study [20]: one namedComponent I, associated with long term declarativememory (5 items about memory problems, changedmemories, remembering names, dates and events fromyears ago), and another factor named Component II, associated with working/short-term memory and linked toattention (4 items about events from minutes or daysago, planned activities, and keeping track in a conversation). The reliability, in terms of PCA structure, showedselectively high associations (r 0.80) between 5 itemsand Component I, and 4 items and Component II [20].Whether the MMQ total score or either of its components is valid indicators of objective memory performance has not previously been studied, although this

Bosnes et al. BMC Psychology(2020) 8:77Page 3 of 8knowledge would enhance the utility of the instrumentsignificantly and be of great interest, both to cliniciansand researchers using the MMQ and similar questionnaires. This explorative study aims to fill this gap.We investigated the relationships between subjectivememory performance, expressed as the total score, thecomponent scores and scores on single items of theMMQ, and performance on objective memory tests in asample of cognitively normal older adults, while alsoconsidering the effects of demographics (age, gender andlevel of education) as covariates, because it is wellknown they are important factors for cognition in general and for memory in particular. As an exploratorystudy no precise hypothesis were stated, but we anticipated that the three scores derived from the MMQ (thetotal score and the scores of Components I and II) weredifferentially related to objective memory performance.If so, this would have important implications on how tomake empirically based interpretations of scores on theMMQ, which is the main reason for this study.MethodsParticipantsParticipants in the present study (n 106) were extracted from a sample of community-dwelling olderadults who had participated in a study of memory andintelligence conducted in 2009 and 2010 [27], and hadcomplete MMQ data in HUNT3, conducted in 2006–2008 [26]. Inclusion criteria in the study of memory andintelligence were (i) age 55–89 years, (ii) self-reportedgood health and daily functioning according to twoquestionnaires in HUNT3 (Q1 and Q2, [26]), (iii) livingnear the city of Namsos in middle Norway (the examination site), and (iv) confirmed unchanged cognition sinceHUNT3 by a structured clinical interview before testing.Two individuals were excluded because their health waschanged. Health was checked by using a similar procedure as used in the standardization study of the WechslerAdult Intelligence Scale-III and the Wechsler MemoryScale-III (WAIS-III/WMS-III), for details see [27].Table 1 Demographic characteristics of the study sample andof eligible participants from HUNT3Study sampleHUNT3N10617,247Age (Mean SD), y73.4 8.466.6 8.7Range, yGender, frequency of females (%)57–8955–10153 (50)8968 (52)EducationElementary school, n (%)47 (44)7029 (41)High school, n (%)34 (32)6086 (40)College/university, n (%)25 (24)3332 (19)Education data were divided into three levels: elementaryschool, high school, and college/university. The demographic characteristics of the study sample and eligibleparticipants are presented in Table 1, which shows thatthe mean age of the study sample was significantlyhigher than that of the comparable group in HUNT3(t 8.36 df 105, p 0.001), while the education levelsand gender distributions were comparable (p’s 0.1).The comparison of the study sample and the populationwill help facilitate generalization of results.Subjective and objective memory assessmentMemory was assessed subjectively in HUNT3 [26] usingthe MMQ, which contains nine items for assessingmemory problems. Each item is scored out of 3 (1 noproblems, 2 sometimes problems, and 3 often problems). The usual approach is to sum the individual itemscores to obtain the total score (range 9–27), where ascore of 9 means no problems and a score of 27 meanssevere impairment. An earlier principal component analysis showed that the nine items of the MMQ can be described by two largely independent componentscovering explicit, long-term declarative memory andworking/short-term memory related to attention (as discussed in the introduction; see [20] for details). We included the scores from the two MMQ components inthis study, in addition to the commonly reported totalscore, as possible predictors of objective memoryperformance.Data on objective memory performance andintelligence were collected in a study of the psychometric characteristics of the Norwegian versions of theWMS-III and WAIS-III [27, 28]. We used the scoresfrom three subtests of memory: Logical Memory I (LM)in the WMS-III to study new auditory verbal learningand recall (episodic memory), Vocabulary (Voc) in theWAIS-III to study recall of overlearned verbal material(semantic memory) and Letter-Number Sequencing(LNS) in the WAIS-III to study auditory working memory. These subtests were chosen because they representdifferent aspects of objective memory performance according to theories about memory [29]. Because researchon the factor structure of the WMS-III has demonstrated that the immediate (LM I) and delayed recall(LM II) tests from the WMS-III are associated to thesame factor [28, 30], LM II was not included in thepresent study.Statistical analysesDescriptive statistics and correlation analyses (Pearsonand Kendall’s tau) was used to characterize the sampleand associations. To analyze the relationship betweeneach objective memory test and subjective memory variables (Component I, Component II and demographic

Bosnes et al. BMC Psychology(2020) 8:77Page 4 of 8variables), multiple regression analyses was used by entering predictors simultaneously. This procedure was repeated with MMQ total score and demographics aspredictors. There was no problem with multicollinearityin the regression analyses as tolerance values were closeto 1 for variables in the analyses. Health status was notincluded in the analyses, because the inclusion criteriaensured that the sample included older adults who hadgood daily functioning and were free of major diseasesand disabilities. To check for the influence of the varyingtime interval between HUNT3 and cognitive testing,age-adjusted results for objective memory were calculated and used in regression analyses. The outcome ofthese analyses did not differ from those presented inTable 5 (based on un-adjusted test scores) and the accompanied text: significant predictors were the same aswell as multiple r’s and beta weights (second decimal differed sometimes).ResultsThe analyses of subjective memory performance focusedon the total MMQ score, the scores of the MMQ components, and the single item MMQ scores.Objective memory performanceThe mean raw scores for the WMS-III LM subtest (episodic memory), and the WAIS-III Voc (semantic memory) and LNS (working memory) subtests across the sixage groups are presented in Table 3. The LM scores inthe study sample were higher than the norms publishedin the WAIS-III and WMS-III manuals, but not significantly higher [30], whereas the Voc and LNS scores weresimilar to the norms.The mean scaled scores for the study sample werenormally distributed (Means SD: LM 10.7 3.3, Voc9.7 2.5 and LNS 9.5 2.4) and close to the US normsin the WAIS-III and WMS-III manuals [28].The Pearson correlation coefficients for the associationbetween age and the three objective memory tests wereclearly significant (LM r 0.39, Voc r .049 and LNSr .041; all p 0.001). The associations between levelof education and the three objective memory tests werealso clearly significant (LM r 0.37, Voc r 0.75 andLNS r 0.50; all p 0.001). There was no significant association between gender and the three objective memory tests.Subjective memory performanceAssociation between subjective and objective memoryperformanceThe mean MMQ total and Component II scores werelower than in the corresponding HUNT3 population,but not significantly so, see Table 2.The MMQ scores for the six studied age groups arepresented in Table 2, along with the MMQ scores fromthe HUNT3 population. The cognitively normal olderadult group, the oldest members in particular, reportedfewer memory problems than the HUNT3 population.The correlation coefficients between age and MMQmeasures, gender and MMQ measures, and level of education and MMQ measures were not significant for anyassociation (all p’s 0.1).The correlations between the MMQ total and component scores and the objective memory scores are presented in Table 4. The correlations between subjectiveand objective memory scores were analyzed using thePearson correlation coefficient and the t-test with 104degrees of freedom. The total MMQ score was significantly associated with the LM score. Component I wasnot significantly associated with any of the three objective memory measures, whereas Component II was significantly negatively correlated with all three measures.Because there was a varying time interval between theMMQ assessments and the objective memory tests, theTable 2 Total raw score MMQ and z scores of Components I and II (means SD) of the study sample and the HUNT3 population(across six age groups)Age groupMMQ score55–64n 1765–69n 1970–74n 1975–79n 2180–84n 1885–89n 12Total12.7 1.914.2 2.514.7 1.914.2 2.715.1 3.613.3 2.6Component I 0.04 0.91 0.10 0.630.48 0.570.11 0.870.26 1.24 0.1 0.85Component II 0.67 0.61 0.08 1.04 0.24 0.71 0.08 1.120.17 0.90 0.22 0.8314.3 3.014.8 2.914.7 3.015.2 3.115.3 3.315.8 3.9Normally aging adultsHUNT populationTotalComponent I0.12 0.960.27 0.920.20 0.910.30 0.940.26 0.950.26 1.07Component II 0.04 1.000.01 1.040.07 1.060.20 1.110.28 1.16 0.52 1.28

Bosnes et al. BMC Psychology(2020) 8:77Page 5 of 8Table 3 Raw scores (means SD) on LM, Voc and LNS across age groups in cognitively normal participantsAge groupTest55–64n 1765–69n 1970–74n 1975–79n 2180–84n 1885–89n 12LM I42.6 8.439.2 10.535.3 12.831.1 11.532.4 9.728.5 9.5Voc45.4 9.340.5 8.442.1 11.935.0 10.033.7 10.026.8 7.9LNS9.1 2.27.7 2.28.1 2.77.1 1.67.1 1.55.5 1.9correlation analyses were repeated to control for thetime interval. The same pattern of results remained.Predictors of objective memory performanceWe conducted a number of linear regression analysesfor each objective test, see Table 5.Firstly, LM performance was used as the dependentvariable in relation to the following independent variables: age, gender, level of education, and the two MMQcomponents. This model was significant (F 7.83 (5,100), p 0.001, multiple r 0.53, r2 0.28) and explained25% (adjusted r2) of the variance in LM with three significant predictors: age, education and Component II(negative beta). Component I and gender were not significant predictors.Next, the analysis was repeated with Voc as thedependent variable, and the same independent variablesas above. The model was significant (F 35.57 (5, 100),p 0.001, multiple r 0.80, r2 0.64), with age, education, Component I (positive beta) and II (negative beta)as significant predictors. This model accounted for 62%(adjusted r2) of the total variance in Voc.A corresponding analysis was performed with LNS asthe dependent variable and the same predictors as above.The model was significant (F 10.72 (5, 99), 0.001,multiple r 0.59, r2 0.35) with three significant predictors: age, education and Component I (positive beta), accounting for 32% (adjusted r 2) of the variance in LNS.Then the analyses were repeated with each objectivememory test score as the dependent variable and the totalMMQ score, age, gender and level of education as independent variables. The total MMQ score was a significantpredictor of LM (F 8.73 (4, 101), p 0.001; multiple r 0.51, r2 0.26) together with age and education as significant predictors (β 0.24, p 0.013; β 0.20, p 0.025;age and education, respectively) accounting for 23% of theTable 4 Correlation coefficients for MMQ total and componentscores, versus LM, Voc and LNS raw scoresTestMMQ totalComponent IComponent IILM 0.27** 0.05 0.33***Voc 0.060.12 0.21*LNS 0.010.18 0.22*** p 0.05; ** p 0.01; *** p 0.001. Significant results are boldedvariance (adjusted r 2). In contrast, the total MMQ scorewas not a significant predictor for the two other objectivememory tests in the regression analyses (p 0.937 andp 0.553; Voc and LNS, respectively).Sensitive items in subjective memory measurementTable 6 shows the Pearson partial correlations betweenthe single MMQ items and the age-adjusted objectivememory test scores at HUNT3, controlling for age, gender and education level. Three MMQ items (3, 7 and 9)linked to Component II were significantly associatedwith LM performance and item 9 (“Do you have problems keeping track of a conversation?”) was linked toVoc performance. In addition, item 3 (“Do you haveproblems remembering what happened a few minutesgo?”) was significantly associated with LNS performance.In contrast, no item was significantly linked with Component I. The positive correlation between item 8 (“Doyou have problems remembering events years ago?”) andTable 5 Multiple regression analyses on LM, Voc and LNS withcomponents, age, gender and education as predictorsBSE BβpAge .321.11 .220.022Gender 1.922.08 .090.348Education4.061.410.280.005Component I 0.671.11 .0.050.560Component II 3.251.11 0.260.004Age 0.230.09 .66 0.001Independent variablesLogical MemoryVocabularyComponent I1.690.770.130.031Component II 1.830.77 0.150.019Age .150.270.41 0.001Letter-Number SequencingComponent I0.480.210.180.026Component II 0.360.21 0.150.085

Bosnes et al. BMC Psychology(2020) 8:77Page 6 of 8Table 6 Pearson correlation coefficients for MMQ items tappingComponents I and II versus LM, Voc and LNSComponent ItemLMVocLNSI1 Memory problems 0.18 0.020.00I2 Changed memory0.030.160.10I4 Remembering names 0.070.150.12I5 Remembering dates 0.090.070.03I8 Events from years ago 0.160.110.19*II3 Events from minutes ago 0.19* 0.10 0.20*II6 Planned activities 0.16 0.12 0.12II7 Events from days ago 0.22* 0.020.03II9 Keeping track 0.23** 0.23** 0.00* p 0.05; ** p 0.01 one-tailed statistical significance. Significant resultsare boldedLNS was unreasonable because of the direction (themore impairment the better the performance).DiscussionThere are three main findings in this study of subjectivememory assessment (MMQ total, components anditems) and its relationship with objective memory performance, age, education and gender in a sample ofolder adults. In discussing the findings, we deal primarilywith empirical associations between subjective and objective memory in relation to demographics in olderadults.Firstly, as shown in Table 4, the results of a specificpart of the MMQ, i.e., Component II (related to subjective ratings of impairments in attention and working/short-term memory), were significantly correlated withall three objective memory test scores i.e. objective episodic, semantic and working/short-term memory. Thispattern was observed for three Component II items related to current or recent events (see Table 6), but notfor any Component I item. It could be speculated thatattention is a common factor to Component II and LM,as attention is an integral part of both Component IIand theories of learning and memory [27]. The relationship between working memory (Component II) and LMindicates that subjective working memory (ComponentII) is more strongly related than subjective declarativememory (Component I) to objective memory performance. To the best of our knowledge, this pattern has notbeen shown previously.Secondly, Component I (ratings related to long term/declarative memory of events, dates and names) was not significantly correlated with objective tests of episodic,semantic and working/short-term memory performanceaccording to standard clinical memory tests (see Table 4).The regression analyses reported in Table 5, showed thatsubjective long-term/declarative memory (Component I)was positively associated with two objective tests (Voc andLNS); however, these findings are considered as spurious,because of unreasonable direction (the more impairmentthe better results). In fact, as Table 6 shows, none of thefive items linked to subjective long-term/declarative memory (Component I) was significantly associated with objective memory performance. This means that a clear-cutpattern emerged from our correlations and regressionanalyses, indicating that subjective long-term/declarativememory (Component I), as well as items associated withComponent I (e.g. memory problems, rememberingdates), which at face value may seem to correlate with objective episodic and semantic memory tests, do not in factdo so, at least not in this sample of healthy older adults. Asimilar conclusion has been reported by other researchers[7]. Consequently, subjective memory assessment will givedifferent outcomes from those attained with objectivememory assessment and therefore both types of assessment may be needed. A second implication would be thatto learn about a person’s episodic/semantic memory, youshould ask about the person’s ratings of present activityand most recent events. In an earlier paper [23], for example, we showed that MMQ outcomes could be used todifferentiate between demented and healthy olderindividuals.Thirdly, education was a strong, significant predictorof all three objective memory tests (see Table 5). Severalstudies have reported that education is a significantmoderating factor in objective cognitive function testingin older adults [31]. In this study, the power of educationas a predictor was greater than the power of ComponentII. The effects of education have often been related tocognitive reserve [32], and research findings support thesuggestion that education is one of the key factors preventing cognitive decline and dementia [33]. Regardless,because education is such a powerful moderator of several aspects of objective memory performance, it shouldbe considered in clinical subjective and objective memory assessments.In addition, age was a strong significant predictor ofall three objective memory measures (see Table 5). Thisfinding is well known in normal aging, as well as in clinical studies of patients with brain diseases. Interestingly,there is a paradoxical difference between age-relatedchanges in objective memory tests, while there were nosignificant age-related changes in subjective memorymeasures in the present study (see results on correlations with demographics). A similar pattern of associations was observed for education, namely significantcorrelation between objective, but not subjective memory measures and education.Furthermore, no association was found between gender and objective memory performance in the studysample, in contrast to the findings of Holmen et al. [22]that there were more subjective memory complaints in

Bosnes et al. BMC Psychology(2020) 8:77men than in women in the HUNT3 population. Thesedivergent findings may be because Holmen et al. [22]based their study on the total HUNT3 population andonly used the MMQ total score to subjectively assessmemory. There were no significant associations betweenage and subjective memory performance, despite astrong, significant association between age and all objective memory test outcomes. This may be because, insubjective assessments of memory, one compares oneselfwith neighbors and friends of approximately the sameage, where some have poor memory and some havegood memory. In objective tests, however, memory performance is compared with that of the total populationof various ages rather than with closely relatedindividuals.The MMQ total score together with age and educationsignificantly predicted the LM, but not the VOC andLNS performance according to the multiple regressionanalyses, see results. The explanation for these complexassociations may depend on the fact that three items related to Component II (3, 7 and 9) were significantlycorrelated to LM and one item (3) to LNS, see Table 6.Older adults frequently worry about their memories. Itis therefore essential that the subjective questionnairesused to assess memory also allow the documentation ofthe statistical characteristics associated with the resultsat hand, to ensure that health personnel can understandwhat the results of those questionnaires really mean, sothey can convey the outcomes to the worried patients.This study showed that certain items in the MMQ aremore informative of objective memory test outcomesthan others, while other MMQ items may be moreclosely linked to aspects of ordinary life, such as emotions, personal stress, etc. [17]. This pattern of complexresults indicates a differential relationship between specific items in component II (working/short-term memory) and performance in objective memory, whichillustrates that objective memory tests may not be exclusively uni-dimensional. Previously it was shown that theMMQ is a multi-dimensional measure of subjectivememory [20].Strengths and weaknessesThe primary advantage of this study is that the scores ofdifferent MMQ components, rather than a single subjective memory score, were compared to objective memory performance. A second advantage was that thedomain-specific objective memory performance wasassess

the association between subjective and objective memory performance are only partly understood. Furthermore, research in the field is seriously ham-pered by the lack of a commonly accepted definition of memory from a subjective point of view and the poor quality of subjective memory testing methods [19, 20].

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