Cognitive Complaints in Memory Clinic Patients and in Depressive Patients: An Interpretative Phenomenological Analysis

Cognitive Complaints in Memory Clinic Patients and in Depressive Patients: An Interpretative... Abstract Background and Objectives Cognitive complaints are discussed as early signs of Alzheimer’s disease (AD). However, they are also very common in cognitively normal older adults and in patients with depression. Qualitative, interview-based approaches might be useful to identify those features of cognitive complaints specific for the experiences of cognitive decline in preclinical or prodromal AD versus those complaints typically reported by depressed patients. Research Design and Methods A semi-structured interview was administered to 21 cognitively normal older adults (HC), 18 nondemented memory clinic patients (MC), and 11 patients with a major depression (MD), all above 55 years. Interpretative phenomenological analysis (IPA) was applied to the interview transcripts to develop emerging complaint themes in each group. To identify thematic correspondence and possibly novel, hitherto unappreciated themes, the extracted complaint categories were compared with the neurocognitive domains in the DSM-5 and the content of the Everyday Cognition questionnaire (E-Cog). Results IPA yielded 18 cognitive complaint categories in MC, 10 in depressive patients, and 10 categories in the HC group. Several themes were common across groups, but some were group-specific, for example, spatial disorientation was only reported in MC patients. Some of these MC-specific themes were neither represented by DSM-5 domains nor by the E-Cog. Discussion and Implications We report a comprehensive qualitative description of cognitive complaints in old age which could help to develop questionnaires or structured interviews to better assess AD-related subjective cognitive decline. This may help to increase specificity in selecting high-risk subjects in research settings and improve clinical judgment of diverse cognitive complaints types mentioned by their patients. Subjective cognitive decline (SCD), Qualitative research methods, Alzheimer’s dementia (AD), Cognition Mounting evidence suggests that cognitive complaints are a sensitive early behavioral marker of Alzheimer’s disease (AD) (Jessen et al., 2014; Mitchell, Beaumont, Ferguson, Yadegarfar, & Stubbs, 2014). Many studies associated subjective cognitive complaints with an increased risk of future cognitive decline (Koppara et al., 2015) and an increased likelihood of abnormal AD biomarkers (Amariglio et al., 2012; Chételat et al., 2010; Perrotin, Mormino, Madison, Hayenga, & Jagust, 2012; Saykin et al., 2006; Wolfsgruber et al., 2015). Other findings suggest associations between memory complaints and depressive symptoms (Balash et al., 2013; Balash, Mordechovich, Shabtai, Merims, & Giladi, 2010; Schmand, Jonker, Geerlings, & Lindeboom, 1997). Based on current findings, attention is now turning to the issue of sensitivity and specificity of cognitive complaints with regard to AD (Rabin et al., 2015). A particularly salient issue relates to the notion of what components of complaints are “AD-like” and which may be more representative of a mood disorder or of aging in general. Primarily, subjective cognitive decline (SCD) has been defined as the “subjective experience of worsening cognitive function in comparison with earlier performance” (Jessen et al., 2014). The SCD Initiative (SCD-I) recently published criteria for the implementation of SCD in research studies (Molinuevo et al., 2016). With regard to the core clinical criteria of mild cognitive impairment (MCI) proposed by the NIA-AA diagnostic framework, evidence of concerns should relate to decline in cognition (Albert et al., 2011). However, much of the early literature has focused only on concerns related to memory. Current methods of measurement of cognitive complaints are as heterogeneous as the different criteria (Abdulrab & Heun, 2008; Jessen et al., 2014; Jonker, Geerlings, & Schmand, 2000; Rabin et al., 2015). There is a lack of well evaluated measures for SCD and the theoretical and empirical development of the existing scales is mostly not well documented. Common instruments such as the Cognitive Failures Questionnaire (CFQ; Broadbent, Cooper, FitzGerald, & Parkes, 1982), the Cognitive Function Instrument (CFI; Amariglio et al., 2015), the Everyday Cognition Scale (E-Cog; Farias et al., 2008) or the Assessment of memory complaint in age-associated memory impairment (MAC-Q; Crook, Feher, & Larrabee, 1992) are based on expert knowledge, theoretical considerations, statistical methods or diagnostic criteria. Importantly, neither of these instruments was developed by a systematic qualitative study of cognitive complaints. This raises the possibility that some complaint themes reflecting cognitive decline due to neurodegenerative processes are not well represented in current instruments. Qualitative methods are advantageous as they address highly nuanced and contextualized aspects of subjective experiences (Smith, Flowers, & Larkin, 2009). Investigations of MCI patients’ self-awareness and experience of their diagnosis have revealed that qualitative approaches may well lead to a more in-depth view than a quantitative measurement (Lingler et al., 2006; Roberts & Clare, 2013). There is already a substantial literature dealing with the qualitative exploration of the lived experience of people with dementia (Clare, Roth, Pratt, & Clare, 2005; Clare, Rowlands, Bruce, Surr, & Downs, 2008; Harman & Clare, 2006; Johansson, Marcusson, & Wressle, 2015; Sabat & Harré, 1992). However, the approach of a qualitative description of the experiences underlying cognitive complaints has only recently been pursued with patients with MCI or SCD. Buckley and colleagues (2015) first examined the subjective experience of memory change in cognitively normal older adults and MCI patients. Using an inductive thematic approach, 12 themes were extracted (Buckley et al., 2015). Many themes were more commonly expressed in MCI patients, and some were also sensitive to β-amyloid (Aβ) load. While the memory complaint categories derived in this study address the different ways of “how” different people express their complaints, the aspect of “what type of” complaints they have is a different one. Quantitative studies dealing with this question are dependent on current measurements and thus suffer from the inherent operationalization problem mentioned above (La Joie et al., 2016). The aim of the current study was to take a “fresh look” at the range of cognitive complaints in older adults. We explored these complaints in cognitively normal older adults (HC), memory clinic patients (MC), and patients with major depressive disorder (MD) using a qualitative method called interpretative phenomenological analysis (IPA). IPA is particularly suited to capture subjective experiences associated with a given phenomenon (Smith et al., 2009). Complaint themes extracted with IPA were compared between the three groups to determine common and group-specific cognitive complaint symptomatology. Themes specific for the MC group (i.e., for potential preclinical/prodromal AD) were also qualitatively compared with established SCD measurements, to determine whether these fully reflect the subjective cognitive complaint experience in nondemented patients at risk for AD. Design and Methods Design The study is a qualitative study, involving a semi-structured interview, with additional quantitative clinical and neuropsychological assessment. Here, quantitative data are only reported for sample description purposes. Participants The total sample of this study includes 21 memory clinic patients, 11 psychiatric inpatients with a diagnosis of MD and 21 healthy controls. All participants were above the age of 55 and spoke German proficiently. MC patients initially sought diagnostic work-up in the Clinical Treatment and Research Center for Neurodegenerative Disorders (KBFZ), Department for Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn. Diagnosis of AD dementia or MCI was made according to the core clinical criteria of the NIA-AA (Albert et al., 2011; McKhann et al., 1984). The diagnostic procedure included a cognitive assessment, detailed medical history, and a neurological examination. Three patients were excluded as they received a diagnosis of AD dementia. Of the remaining 18 subjects, 10 fulfilled the core clinical criteria of MCI according to the NIA-AA criteria (Albert et al., 2011), as they reported cognitive concerns and had an impairment (score of <−1.5 SD below age-, gender-, and education adjusted norms) in at least one test of one or more cognitive domains. The remaining eight patients had subjective concerns without objective impairment, and were classified as SCD patients in line with recently published recommendations for defining SCD in clinical studies (Jessen et al., 2013; Molinuevo et al., 2016). While no biomarker information was available for this study, a high prevalence of AD pathology (~45% with abnormal Abeta42/Tau ratio) has been reported in similar memory clinic samples (Wolfsgruber et al., 2017). MD patients were recruited from the Clinic of Psychiatry and Psychotherapy, University of Bonn. All patients fulfilled a diagnosis of a unipolar, major depressive disorder according to ICD-10 criteria (World Health Organization, 1993). At the time of the interview the MD patients were on stable antidepressive and/or neuroleptic medication for at least 3 weeks and were not in an acute suicidal crisis. The HC group was recruited from a healthy volunteer subject pool of the German Center for Neurodegenerative Diseases (DZNE), Bonn. Exclusion criteria for HC were (a) report of concerns about mental abilities/memory; (b) psychological, psychiatric, or neurological treatment within the last 6 months; (c) severe or chronic disease (e.g., diabetes or MS); (d) experience of head injury with a loss of consciousness; (e) a diagnosis of neurological disease (e.g., AD or Parkinson); or (f) report of a neurodegenerative disease in a first-degree relative. Data Collection: Interview Procedure All participants were interviewed by a clinical psychologist (LM). Interviews were digitally recorded, transcribed verbatim, and pseudonymized by replacement of patient names with a random number and deletion of personal information throughout the whole transcripts. The interview procedure followed a semi-structured format and lasted between 8 and 31 min. The process started with an open question asking whether the interviewee had noticed any changes in memory or thinking during the last years. Each interview had an unstructured beginning, which allowed patients to determine the initial focus of the conversation. If cognitive changes were reported, the participants were asked to give an example of their everyday life. Then the patient was asked whether he/she has noticed further cognitive problems followed by the request to give an everyday example. This process was repeated until the participant did not mention further complaints. He/she was then asked to name the most concerning symptom which was selected for further detailed questioning, that is, 10 detailed questions about the phenomenological experience of the reported cognitive changes/difficulties. Questions were designed to cover all aspects of cognitive complaints proposed by Buckley et al. (2015), Table 1. The interview was tested in a pilot phase on a small number of patients (not included in the present report) with in between iterative discussion in a panel of experienced clinicians and researchers which lead to further amendments and the final version of the interview. Table 1. Semi-structured Interview Questions in the interview 1st Question: Have you noticed any changes in memory or thinking during the last years? When and where was the last time (cognitive complaint) occurred? How common is (…)? Is (…) only in special/ specific situations or is this a general problem? Is (…) in situations where you are distracted or in which you are distracted by others? Is (…) only in situations where you feel burdened emotionally? Do you feel that (…) has increased? / Do you believe that this change isn’t normal for your age? What was your first emotional reaction when you noticed (…) for the first time? Are you worried about (…)? How do you help yourself if (…) occurs? Are you successful with this strategy? Are you looking for help? Questions in the interview 1st Question: Have you noticed any changes in memory or thinking during the last years? When and where was the last time (cognitive complaint) occurred? How common is (…)? Is (…) only in special/ specific situations or is this a general problem? Is (…) in situations where you are distracted or in which you are distracted by others? Is (…) only in situations where you feel burdened emotionally? Do you feel that (…) has increased? / Do you believe that this change isn’t normal for your age? What was your first emotional reaction when you noticed (…) for the first time? Are you worried about (…)? How do you help yourself if (…) occurs? Are you successful with this strategy? Are you looking for help? View Large Table 1. Semi-structured Interview Questions in the interview 1st Question: Have you noticed any changes in memory or thinking during the last years? When and where was the last time (cognitive complaint) occurred? How common is (…)? Is (…) only in special/ specific situations or is this a general problem? Is (…) in situations where you are distracted or in which you are distracted by others? Is (…) only in situations where you feel burdened emotionally? Do you feel that (…) has increased? / Do you believe that this change isn’t normal for your age? What was your first emotional reaction when you noticed (…) for the first time? Are you worried about (…)? How do you help yourself if (…) occurs? Are you successful with this strategy? Are you looking for help? Questions in the interview 1st Question: Have you noticed any changes in memory or thinking during the last years? When and where was the last time (cognitive complaint) occurred? How common is (…)? Is (…) only in special/ specific situations or is this a general problem? Is (…) in situations where you are distracted or in which you are distracted by others? Is (…) only in situations where you feel burdened emotionally? Do you feel that (…) has increased? / Do you believe that this change isn’t normal for your age? What was your first emotional reaction when you noticed (…) for the first time? Are you worried about (…)? How do you help yourself if (…) occurs? Are you successful with this strategy? Are you looking for help? View Large Neuropsychological Assessment Neuropsychological assessment included the German version of the Consortium to Establish a Registry for Alzheimer’s disease (CERAD; Morris, Mohs, Rogers, Fillenbaum, & Heyman, 1988; Schmid, Ehrensperger, Berres, Beck, & Monsch, 2014) and the E-Cog (Farias et al., 2008). Depressive symptoms were assessed with the 15-item version of the Geriatric Depression Scale (GDS; Yesavage et al., 1983) and the PHQ-9 (Kroenke, Spitzer, & Williams, 2001). Qualitative Data Analysis With IPA The transcribed interview material was subjected to qualitative data analysis using the method of IPA as an inductive qualitative approach combining psychological, idiographic, and interpretative components (Smith et al., 2009). The IPA is a systematic phenomenological approach to reduce qualitative information, describe, and search for essences or structures underlying a given phenomenon (Finlay, 2012). The phenomenological perspective of the IPA influenced by Husserl’s philosophy tries to make sense of a personal experience. Therefore, we choose this approach because IPA allows an exploration of an experience with personal significance for example, such as an illness phenomenon (the experience of cognitive complaints questioned in this study; Smith et al., 2009; 1997). First, each transcript was analyzed separately to enable an extraction of themes unique to each individual. The main goal at this step is to derive expressions general enough to allow for thematic connections within and across the groups, but which also express the individual experiences of cognitive complaints. For example, the statement “I’ve lost my key” was interpreted as the subtheme “Losing” and thematically classified under the category “action monitoring.” The first part of the analysis process was an inductive approach which was close to the text itself by using the patient’s own words (Smith et al., 2009). To incorporate the experiences of the patients with an underlying theoretical framework of cognitive complaints, themes were in a second step connected in a deductive way which leads to complaint categories described with text examples. By repeated reading, clustering, and summarizing of themes, categories were integrated across participants in each group to generate a list that captured participant’s shared experiences of cognitive complaints. The themes which are initially described by a participant’s own words (e.g., “I was suddenly absent-minded”) were then labelled with abstract categories (e.g., “blank mind”). The results were discussed and restructured several times by expert consensus (MW, SW, IF, CW, KF, SR, AP, LM), then restructured and aggregated until the group found agreement about category assignment. We gradually refined themes through a cyclical process of reading until we elicited categories that resonated across the data set. We also compiled a glossary with a detailed description of all categories together with example quotations (Supplementary Data). Quantitative Data Analysis Quantitative data are presented for descriptive characterization of the sample. All analyses were performed using IBM SPSS for Windows. Group differences were examined with analysis of variance (ANOVA) for demographical, and analysis of covariance (ANCOVA; controlled for age, gender, and education) for clinical and neuropsychological variables, respectively, all followed by Bonferroni corrected post hoc test for pairwise comparison. For categorical variables, chi-square tests were used. Two-sided p values of less than .05 were considered significant. Results Sample Descriptive Statistics: Demographic, Clinical, and Cognitive Data Characteristics of the total study sample and the specific diagnostic groups are presented in Table 2. Memory clinic patients were older and had a lower MMSE score than controls. The MD group exhibited elevated levels of depressive symptomatology, with most subjects scoring above the GDS cut-off for depression and the PHQ-9 cut-off for moderate depression. Table 2. Sample Description for All Groups Total sample, N = 50 HC group, n = 21 HC vs MC Memory clinic patients, n = 18 MC vs MD Major depressive patients, n = 11 MD vs HC Group comparison n (%) n (%) p n (%) p n (%) p Chi2 p-Value Sex (female) 27 (54) 12 (57.1) n.s. 5 (27.8) ** 10 (90.9) n.s. 11.10 .004** M (SD) M (SD) p M (SD) p M (SD) p F-value p-Value Age 70.52 (7.56) 67.48 (7.20) * 74.06 (6.82) n.s. 70.55 (7.46) n.s. 4.14 .022* Educationa 14.82 (3.43) 15.10 (3.08) n.s. 16.11 (3.38) ** 12.18 (2.92) n.s. 5.42 .008** Interview duration (in min) 16:35 (06:55) 14:32 (06:18) * 20:44 (06:18) * 13:43 (06:12) n.s. 6.26 .004** CERAD-total score 80.90 (11.82) 89.29 (6.68) ** 75.83 (12.56) n.s. 73.18 (8.27) ** 13.02 <.001*** MMSE 28.30 (1.79) 29 (1.22) n.s. 27.10 (3.03) n.s. 27.64 (2.20) n.s. 2.28 .075 E-Cog sum 1.46 (.44) 1.21 (0.16) ** 1.73 (0.52) n.s. 1.52 (0.45) n.s 8.81 .001** E-Cog memory 1.83 (.69) 1.48 (.366) ** 2.24 (.776) n.s. 2.04 (.755) n.s. 7.66 .001** E-Cog language 1.43 (.48) 1.21 (.285) * 1.64 (.570) n.s. 1.58 (.507) n.s. 4.88 .012* E-Cog visuospatial 1.28 (.428) 1.05 (.082) ** 1.54 (.516) n.s. 1.35 (.522) n.s. 7.79 .011* E-Cog planning 1.22 (.386) 1.03 (.072) ** 1.47 (.510) n.s. 1.28 (.337) n.s. 7.72 .001** E-Cog divided attention 1.65 (.652) 1.37 (.365) ** 2.03 (.769) n.s. 1.69 (.726) n.s. 5.51 .007** E-Cog organization 1.35 (.483) 1.11 (2.63) n.s. 1.48 (.601) n.s. 1.64 (.449) * 5.25 .009** GDS 2.63 (3.63) 0.62 (1.80) n.s. 2.53 (2.88) ** 6.64 (4.18) ** 13.00 <.001*** PHQ-9 4.53 (4.82) 2.29 (2.17) n.s. 3.94 (2.94) ** 10.30 (6.91) ** 15.77 <.001*** Total sample, N = 50 HC group, n = 21 HC vs MC Memory clinic patients, n = 18 MC vs MD Major depressive patients, n = 11 MD vs HC Group comparison n (%) n (%) p n (%) p n (%) p Chi2 p-Value Sex (female) 27 (54) 12 (57.1) n.s. 5 (27.8) ** 10 (90.9) n.s. 11.10 .004** M (SD) M (SD) p M (SD) p M (SD) p F-value p-Value Age 70.52 (7.56) 67.48 (7.20) * 74.06 (6.82) n.s. 70.55 (7.46) n.s. 4.14 .022* Educationa 14.82 (3.43) 15.10 (3.08) n.s. 16.11 (3.38) ** 12.18 (2.92) n.s. 5.42 .008** Interview duration (in min) 16:35 (06:55) 14:32 (06:18) * 20:44 (06:18) * 13:43 (06:12) n.s. 6.26 .004** CERAD-total score 80.90 (11.82) 89.29 (6.68) ** 75.83 (12.56) n.s. 73.18 (8.27) ** 13.02 <.001*** MMSE 28.30 (1.79) 29 (1.22) n.s. 27.10 (3.03) n.s. 27.64 (2.20) n.s. 2.28 .075 E-Cog sum 1.46 (.44) 1.21 (0.16) ** 1.73 (0.52) n.s. 1.52 (0.45) n.s 8.81 .001** E-Cog memory 1.83 (.69) 1.48 (.366) ** 2.24 (.776) n.s. 2.04 (.755) n.s. 7.66 .001** E-Cog language 1.43 (.48) 1.21 (.285) * 1.64 (.570) n.s. 1.58 (.507) n.s. 4.88 .012* E-Cog visuospatial 1.28 (.428) 1.05 (.082) ** 1.54 (.516) n.s. 1.35 (.522) n.s. 7.79 .011* E-Cog planning 1.22 (.386) 1.03 (.072) ** 1.47 (.510) n.s. 1.28 (.337) n.s. 7.72 .001** E-Cog divided attention 1.65 (.652) 1.37 (.365) ** 2.03 (.769) n.s. 1.69 (.726) n.s. 5.51 .007** E-Cog organization 1.35 (.483) 1.11 (2.63) n.s. 1.48 (.601) n.s. 1.64 (.449) * 5.25 .009** GDS 2.63 (3.63) 0.62 (1.80) n.s. 2.53 (2.88) ** 6.64 (4.18) ** 13.00 <.001*** PHQ-9 4.53 (4.82) 2.29 (2.17) n.s. 3.94 (2.94) ** 10.30 (6.91) ** 15.77 <.001*** Note: SD = standard deviation; MMSE = Mini-mental state examination; CERAD = Consortium to Establish a Registry for Alzheimer’s disease; GDS = Geriatric Depression Scale. aEducation in years. *Indicates significant results on the α < .05 level. **Indicates significant results on the α < .01 level; ***indicates significant results on the α < .001 level. p-values are adjusted for age, gender, and education; Bonferroni adjusted p-values. View Large Table 2. Sample Description for All Groups Total sample, N = 50 HC group, n = 21 HC vs MC Memory clinic patients, n = 18 MC vs MD Major depressive patients, n = 11 MD vs HC Group comparison n (%) n (%) p n (%) p n (%) p Chi2 p-Value Sex (female) 27 (54) 12 (57.1) n.s. 5 (27.8) ** 10 (90.9) n.s. 11.10 .004** M (SD) M (SD) p M (SD) p M (SD) p F-value p-Value Age 70.52 (7.56) 67.48 (7.20) * 74.06 (6.82) n.s. 70.55 (7.46) n.s. 4.14 .022* Educationa 14.82 (3.43) 15.10 (3.08) n.s. 16.11 (3.38) ** 12.18 (2.92) n.s. 5.42 .008** Interview duration (in min) 16:35 (06:55) 14:32 (06:18) * 20:44 (06:18) * 13:43 (06:12) n.s. 6.26 .004** CERAD-total score 80.90 (11.82) 89.29 (6.68) ** 75.83 (12.56) n.s. 73.18 (8.27) ** 13.02 <.001*** MMSE 28.30 (1.79) 29 (1.22) n.s. 27.10 (3.03) n.s. 27.64 (2.20) n.s. 2.28 .075 E-Cog sum 1.46 (.44) 1.21 (0.16) ** 1.73 (0.52) n.s. 1.52 (0.45) n.s 8.81 .001** E-Cog memory 1.83 (.69) 1.48 (.366) ** 2.24 (.776) n.s. 2.04 (.755) n.s. 7.66 .001** E-Cog language 1.43 (.48) 1.21 (.285) * 1.64 (.570) n.s. 1.58 (.507) n.s. 4.88 .012* E-Cog visuospatial 1.28 (.428) 1.05 (.082) ** 1.54 (.516) n.s. 1.35 (.522) n.s. 7.79 .011* E-Cog planning 1.22 (.386) 1.03 (.072) ** 1.47 (.510) n.s. 1.28 (.337) n.s. 7.72 .001** E-Cog divided attention 1.65 (.652) 1.37 (.365) ** 2.03 (.769) n.s. 1.69 (.726) n.s. 5.51 .007** E-Cog organization 1.35 (.483) 1.11 (2.63) n.s. 1.48 (.601) n.s. 1.64 (.449) * 5.25 .009** GDS 2.63 (3.63) 0.62 (1.80) n.s. 2.53 (2.88) ** 6.64 (4.18) ** 13.00 <.001*** PHQ-9 4.53 (4.82) 2.29 (2.17) n.s. 3.94 (2.94) ** 10.30 (6.91) ** 15.77 <.001*** Total sample, N = 50 HC group, n = 21 HC vs MC Memory clinic patients, n = 18 MC vs MD Major depressive patients, n = 11 MD vs HC Group comparison n (%) n (%) p n (%) p n (%) p Chi2 p-Value Sex (female) 27 (54) 12 (57.1) n.s. 5 (27.8) ** 10 (90.9) n.s. 11.10 .004** M (SD) M (SD) p M (SD) p M (SD) p F-value p-Value Age 70.52 (7.56) 67.48 (7.20) * 74.06 (6.82) n.s. 70.55 (7.46) n.s. 4.14 .022* Educationa 14.82 (3.43) 15.10 (3.08) n.s. 16.11 (3.38) ** 12.18 (2.92) n.s. 5.42 .008** Interview duration (in min) 16:35 (06:55) 14:32 (06:18) * 20:44 (06:18) * 13:43 (06:12) n.s. 6.26 .004** CERAD-total score 80.90 (11.82) 89.29 (6.68) ** 75.83 (12.56) n.s. 73.18 (8.27) ** 13.02 <.001*** MMSE 28.30 (1.79) 29 (1.22) n.s. 27.10 (3.03) n.s. 27.64 (2.20) n.s. 2.28 .075 E-Cog sum 1.46 (.44) 1.21 (0.16) ** 1.73 (0.52) n.s. 1.52 (0.45) n.s 8.81 .001** E-Cog memory 1.83 (.69) 1.48 (.366) ** 2.24 (.776) n.s. 2.04 (.755) n.s. 7.66 .001** E-Cog language 1.43 (.48) 1.21 (.285) * 1.64 (.570) n.s. 1.58 (.507) n.s. 4.88 .012* E-Cog visuospatial 1.28 (.428) 1.05 (.082) ** 1.54 (.516) n.s. 1.35 (.522) n.s. 7.79 .011* E-Cog planning 1.22 (.386) 1.03 (.072) ** 1.47 (.510) n.s. 1.28 (.337) n.s. 7.72 .001** E-Cog divided attention 1.65 (.652) 1.37 (.365) ** 2.03 (.769) n.s. 1.69 (.726) n.s. 5.51 .007** E-Cog organization 1.35 (.483) 1.11 (2.63) n.s. 1.48 (.601) n.s. 1.64 (.449) * 5.25 .009** GDS 2.63 (3.63) 0.62 (1.80) n.s. 2.53 (2.88) ** 6.64 (4.18) ** 13.00 <.001*** PHQ-9 4.53 (4.82) 2.29 (2.17) n.s. 3.94 (2.94) ** 10.30 (6.91) ** 15.77 <.001*** Note: SD = standard deviation; MMSE = Mini-mental state examination; CERAD = Consortium to Establish a Registry for Alzheimer’s disease; GDS = Geriatric Depression Scale. aEducation in years. *Indicates significant results on the α < .05 level. **Indicates significant results on the α < .01 level; ***indicates significant results on the α < .001 level. p-values are adjusted for age, gender, and education; Bonferroni adjusted p-values. View Large Phenomenology of Cognitive Complaints: IPA Results The IPA yielded 18 categories in MC patients and 10 categories each in MD patients and the HC group. To deliver as concise an account as possible, we here focus on themes unique for each group. Overlapping complaint categories are shown in Table 3 and are described in more detail in our glossary (Supplementary Data). In addition, we have chosen to discuss themes on the upper category level rather than breaking them into their constituting subthemes. The presented themes were the most salient across all participants’ accounts and provide a first-person insight into the experience of cognitive complaints (Table 4). Table 4. Nonoverlapping Complaint Categories Per Group With Example From the Interview HC group n (%) Memory clinic patients n (%) Major depressive patients n (%) No changes in cognitive function 7 (33.3) General decline 7 (38.9) Nonspecific overwork 7 (63.6) “I don’t feel a change. I feel fit. I mean, not necessarily physically but mentally at least.” “I perform only with great effort and no longer neatly” “I even don’t get a book, I can’t bring myself to do (read) it, and I think I couldn’t manage that anymore.” Increased distractibility 5 (23.8) Slowing of cognitive processing speed 6 (33.3) Formal though disorder 3 (27.3) “For example when I want to watch the news. I watch them and someone else in the room is singing. I have to say “stop singing please”, otherwise I couldn’t listen to the TV” “I have the feeling it is slowed down, like delayed” “sometimes it feels like I cannot think” Learning 3 (14.3) Planning 6 (33.3) Initiating actions 2 (18.2) “I have problems in remembering new vocabularies” “when I want to order things, I want to build up categories and then everything gets in a muddle” “in the evening I have to think what I have to do for the next morning” Blank mind 4 (22.2) “complete conversations are simply lost” Visual spatial orientation 4 (22.2) “I have problems to find the shortest route” Deceleration 3 (16.7) “everything goes slow…even thinking” Cognitive flexibility 3 (16.7) “it always happens when I have to do multi-tasking” Derealization 2 (11.1) “I have the feeling that I am disconnected from the reality” Dyscalculia 1 (5.6) “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched”. Loss of control experience 1 (5.6) “I don’t have the control anymore and I couldn’t control the things the way as I would like to” HC group n (%) Memory clinic patients n (%) Major depressive patients n (%) No changes in cognitive function 7 (33.3) General decline 7 (38.9) Nonspecific overwork 7 (63.6) “I don’t feel a change. I feel fit. I mean, not necessarily physically but mentally at least.” “I perform only with great effort and no longer neatly” “I even don’t get a book, I can’t bring myself to do (read) it, and I think I couldn’t manage that anymore.” Increased distractibility 5 (23.8) Slowing of cognitive processing speed 6 (33.3) Formal though disorder 3 (27.3) “For example when I want to watch the news. I watch them and someone else in the room is singing. I have to say “stop singing please”, otherwise I couldn’t listen to the TV” “I have the feeling it is slowed down, like delayed” “sometimes it feels like I cannot think” Learning 3 (14.3) Planning 6 (33.3) Initiating actions 2 (18.2) “I have problems in remembering new vocabularies” “when I want to order things, I want to build up categories and then everything gets in a muddle” “in the evening I have to think what I have to do for the next morning” Blank mind 4 (22.2) “complete conversations are simply lost” Visual spatial orientation 4 (22.2) “I have problems to find the shortest route” Deceleration 3 (16.7) “everything goes slow…even thinking” Cognitive flexibility 3 (16.7) “it always happens when I have to do multi-tasking” Derealization 2 (11.1) “I have the feeling that I am disconnected from the reality” Dyscalculia 1 (5.6) “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched”. Loss of control experience 1 (5.6) “I don’t have the control anymore and I couldn’t control the things the way as I would like to” View Large Table 4. Nonoverlapping Complaint Categories Per Group With Example From the Interview HC group n (%) Memory clinic patients n (%) Major depressive patients n (%) No changes in cognitive function 7 (33.3) General decline 7 (38.9) Nonspecific overwork 7 (63.6) “I don’t feel a change. I feel fit. I mean, not necessarily physically but mentally at least.” “I perform only with great effort and no longer neatly” “I even don’t get a book, I can’t bring myself to do (read) it, and I think I couldn’t manage that anymore.” Increased distractibility 5 (23.8) Slowing of cognitive processing speed 6 (33.3) Formal though disorder 3 (27.3) “For example when I want to watch the news. I watch them and someone else in the room is singing. I have to say “stop singing please”, otherwise I couldn’t listen to the TV” “I have the feeling it is slowed down, like delayed” “sometimes it feels like I cannot think” Learning 3 (14.3) Planning 6 (33.3) Initiating actions 2 (18.2) “I have problems in remembering new vocabularies” “when I want to order things, I want to build up categories and then everything gets in a muddle” “in the evening I have to think what I have to do for the next morning” Blank mind 4 (22.2) “complete conversations are simply lost” Visual spatial orientation 4 (22.2) “I have problems to find the shortest route” Deceleration 3 (16.7) “everything goes slow…even thinking” Cognitive flexibility 3 (16.7) “it always happens when I have to do multi-tasking” Derealization 2 (11.1) “I have the feeling that I am disconnected from the reality” Dyscalculia 1 (5.6) “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched”. Loss of control experience 1 (5.6) “I don’t have the control anymore and I couldn’t control the things the way as I would like to” HC group n (%) Memory clinic patients n (%) Major depressive patients n (%) No changes in cognitive function 7 (33.3) General decline 7 (38.9) Nonspecific overwork 7 (63.6) “I don’t feel a change. I feel fit. I mean, not necessarily physically but mentally at least.” “I perform only with great effort and no longer neatly” “I even don’t get a book, I can’t bring myself to do (read) it, and I think I couldn’t manage that anymore.” Increased distractibility 5 (23.8) Slowing of cognitive processing speed 6 (33.3) Formal though disorder 3 (27.3) “For example when I want to watch the news. I watch them and someone else in the room is singing. I have to say “stop singing please”, otherwise I couldn’t listen to the TV” “I have the feeling it is slowed down, like delayed” “sometimes it feels like I cannot think” Learning 3 (14.3) Planning 6 (33.3) Initiating actions 2 (18.2) “I have problems in remembering new vocabularies” “when I want to order things, I want to build up categories and then everything gets in a muddle” “in the evening I have to think what I have to do for the next morning” Blank mind 4 (22.2) “complete conversations are simply lost” Visual spatial orientation 4 (22.2) “I have problems to find the shortest route” Deceleration 3 (16.7) “everything goes slow…even thinking” Cognitive flexibility 3 (16.7) “it always happens when I have to do multi-tasking” Derealization 2 (11.1) “I have the feeling that I am disconnected from the reality” Dyscalculia 1 (5.6) “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched”. Loss of control experience 1 (5.6) “I don’t have the control anymore and I couldn’t control the things the way as I would like to” View Large Healthy Control Group For some individuals, aging was not associated with subjective cognitive changes, while others reported difficulties in prospective memory. A number of subthemes emerged within this key theme. Many participants mentioned situations like: “You are going from one room to another and don’t know what you actually wanted,” “I have to write down all my appointments,” or “Nowadays, I have to make a plan.” Overall the HC group reported a notion of cognitive changes but it was common to refer to these as processes of normal aging. Some did not experience any cognitive changes at all. Learning —This category comprises the experience that learning seems more difficult. This involves examples like: “it’s more difficult to hold new words,” “you are just living from the saved memory more than from the new ones,” “I couldn’t remember numbers like in old times.” Increased Distractibility —Increased distractibility is exemplified by accounts such as “you have to listen clearer to understand and to remember.” Alternatively, increased distractibility involves expressions such as the “background noise is disturbing me nowadays” or “… that I have to force myself to concentrate on the book and not on other things. But I often digress.” Memory Clinic Group Self-experienced cognitive changes in MC patients were mostly described in rich detail and with common examples from everyday life. Some patients reported to perceive their experience of impaired cognition as annoying and as causing worries, sadness, and anger. Visual Spatial Orientation —Problems with visuospatial orientation are exemplified by accounts such as: “Problems to find the shortest route” or “I find the destination but always with great detours.” Others experience failures like: “I start to upset things. If I take something, I grab something but do not notice that there is something beneath and so I upset it.” Cognitive Flexibility —There were also subjectively experienced changes in cognitive flexibility. Cognitive flexibility includes phrases like “It always happens when doing multitasking! It’s hard for me.” Some patients describe problems with “switch(ing)” between different tasks. Planning —While for some patients aging brings problems in scheduling, others experience problems in organizing. For example, “When I order something. And forget about how I ordered it.” Slowing of Cognitive Processing Speed —Many experience a slowing of cognitive processing speed by accounts such as: “I am no longer able to conceive complicated texts that fast. And … eh … likely also not to keep them (in mind).” Deceleration —Deceleration is apparent in phrases such as “that everything is a bit slower, so that I have to search for it even when it’s just a second or a minute.” The theme is also expressed through accounts such as “I have the feeling that everything is slowed down, delayed.” Blank Mind —This category reflects smaller memory lapses up to complete memory “black-outs.” This involves examples like “I was just reading a small part and then suddenly I totally blacked-out,” “complete conversations are simply lost” or “that bothers me at most … I have these … eh memory lapses.” Dyscalculia —Participants also experienced problems in dealing with numbers. This category reflects reports such as “dealing with numbers is becoming worse” or “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched.” Loss of Control Experience —Loss of control experience is exemplified by accounts such as: “so I haven’t had the control and (...) to control the things I wanted to” or “I know that what happened was wrong but I was not able to manage the things the way that everything goes the right way.” Derealization —This category defines experiences in which participants felt disconnected from reality. This involves statements like: “I have the feeling that I am disconnected from reality” or “there are things where I tell someone that they happened in a certain way but that isn’t the truth … and that isn’t meant as a lie by me … it’s just … I have the wrong memory about it. My memory is kind of deformed.” General Decline —Many experience a decline in physical and mental fitness. Participants mention “a lot of things are getting more difficult” and that they “perform only with great effort and no longer neatly.” Major Depressive Group Participants with major depression complained frequently about memory difficulties. In comparison to MC patients, reports of complaints were more abstract, that is, the participants had difficulties in verbalizing and contextualizing specific examples for the experienced difficulties. The expressions were often less detailed as compared to the MC group, and many complaints seemed to emerge from depressive symptoms (i.e., complaints were more related to a lack of drive and a psychical state of exhaustion), rather than from cognitive decline. Formal Thought Disorder —“It feels like I cannot think” illustrates the experiences of formal thought disorder. Common reports include “dull feelings,” “sometimes, tugging and plucking in the brain,” or expressions such as “cannot think.” Initiating actions —People with depression expressed difficulties in initiating actions and in this regard a dependency on auxiliary means (e.g., a structured activity plan). For example, “I have to think about what I can do the next day so that I am not without tasks for the next day.” Unspecific Overwork —Depressive participants expressed feelings of unspecific overwork. A number of subthemes contributed to this upper category. These were experiences like “everything is so hard for me,” “Everything doesn’t work the way it should,” “That something isn’t right,” or “Everything is a bit difficult.” Summary of Results: Similarities and Differences of Cognitive Complaints Across Groups Looking at the similarities of cognitive complaints across groups, it is important to note that even the healthy controls without cognitive impairment recognize subjective cognitive changes and where moreover able to give examples from daily living. Across all groups, participants reported problems in “action monitoring.” This means that actions which were intended by the person cannot be actively recalled in the specific situation or are completely forgotten. Alternatively, routine processes are not fully monitored, that is, the patient is not sure whether he has turned off the stove or not. A majority of participants from every group describe themselves as forgetful and use terms like “forgetfulness.” All participants frequently complained about problems remembering names and content memory, and reported word finding difficulties. As these complaints seem to be rather general in old age, they may contain little diagnostic information. Complaints in the MD group were generally more abstract, containing little detail or context. MD patients described memory problems that were emotionally incriminating and they tended to complain bitterly, however, they were largely unable to provide detailed descriptions compared to other groups. Their complaints were consistent with depressive symptoms, comprising concentration difficulties, a feeling of nonspecific overwork, and problems with initiation actions. Another unique symptom in the depressive group was a formal thought disorder. In the HC group, participants appraised memory changes largely as part of a normal, nonalarming aging process. This was one reason why some HC participants mentioned no marked changes in cognition. However, other participants talked about cognitive failures comprising increased distractibility or problems in learning vocabulary, without being anxious or worried about it. Most unique complaint themes were derived in MC patients. Besides reporting extensive memory problems, they were the only group experiencing executive functioning deficits, for example, in planning and cognitive flexibility. In addition, visuospatial orientation difficulties and dyscalculia were only mentioned by MC patients. Complaints also comprised reports about general physical/mental decline, loss of control experience and derealization. Importantly, these latter categories, although uniquely reported in the MC group, are normally not subsumed under the term “cognitive decline.” The fact that MC patients reported these symptoms suggests that the phenomenological experience of cognitive decline in this group is not confined to memory problems. In addition, they were the only group describing memory lapses drastically as “complete memory lapses,” that is, not only reporting a retrieval difficulty but a total loss of information from memory. They further reported changes in “short-term memory.” However, this term was often used in reports about working memory problems which is why it was summarized into the category “General complaints about increasing memory problems.” Lastly, only MC patients reported experiences of slowing cognitive processing speed. Subjective Cognitive Complaints Compared to Quantitative Assessment and Common Diagnostic Criteria To examine whether common instruments for assessment of subjective cognitive complaints capture all themes reported in our interview, we compared IPA-derived cognitive complaints of MC patients with the item content of the E-Cog (Farias et al., 2008) (Table 5). We found that the E-Cog does not capture all subjective complaints reported by the MC patients. Specifically, the categories “loss of control experience,” “derealization,” and “general decline” were neither found to be represented in the E-Cog nor in the examples provided for the neurocognitive domains enlisted in the DSM-5 neurocognitive disorder section (Table 5). Further, the categories “blank mind” and “action monitoring” could not be assigned to these domains unambiguously. Table 5. Comparison of Memory Clinic Patient’s IPA-derived SCD Themes With the DSM-5 (American Psychiatric Association, 2013) Neurocognitive Domains and the E-Cog (Farias et al., 2008)) SCD themes of memory clinic patients Neurocognitive domains DSM-5 (American Psychiatric Association, 2013) E-Cog domains (Farias et al., 2008) Deceleration Complex alertness — Word finding difficulties speech Language Memory for names speech Language Action monitoring Executive function (Organization) Slowing of cognitive processing speed Complex alertness — Concentration difficulties Complex alertness Divided attention Visual spatial disorientation Visuo-constructive Visuospatial abilities General complaints about increasing memory problems Learning and memory Memory Cognitive flexibility Complex alertness Divided attention Planning Executive function Organization Blank mind (Learning and memory) (memory) Dyscalculia Complex alertness Divided attention Loss of control experience — — Derealization — — General decline — — Forgetfulness Learning and memory Memory Content memory Learning and memory Memory Prospective memory (Executive function) (Planning) — Social cognition — SCD themes of memory clinic patients Neurocognitive domains DSM-5 (American Psychiatric Association, 2013) E-Cog domains (Farias et al., 2008) Deceleration Complex alertness — Word finding difficulties speech Language Memory for names speech Language Action monitoring Executive function (Organization) Slowing of cognitive processing speed Complex alertness — Concentration difficulties Complex alertness Divided attention Visual spatial disorientation Visuo-constructive Visuospatial abilities General complaints about increasing memory problems Learning and memory Memory Cognitive flexibility Complex alertness Divided attention Planning Executive function Organization Blank mind (Learning and memory) (memory) Dyscalculia Complex alertness Divided attention Loss of control experience — — Derealization — — General decline — — Forgetfulness Learning and memory Memory Content memory Learning and memory Memory Prospective memory (Executive function) (Planning) — Social cognition — Note. The table shows a comparison of memory clinic patient’s IPA-derived complaint themes with the DSM-5 neurocognitive domains and the subscales of the E-Cog as a representative quantitative assessment instrument; domains in brackets reflect unclear domain assignment. View Large Table 5. Comparison of Memory Clinic Patient’s IPA-derived SCD Themes With the DSM-5 (American Psychiatric Association, 2013) Neurocognitive Domains and the E-Cog (Farias et al., 2008)) SCD themes of memory clinic patients Neurocognitive domains DSM-5 (American Psychiatric Association, 2013) E-Cog domains (Farias et al., 2008) Deceleration Complex alertness — Word finding difficulties speech Language Memory for names speech Language Action monitoring Executive function (Organization) Slowing of cognitive processing speed Complex alertness — Concentration difficulties Complex alertness Divided attention Visual spatial disorientation Visuo-constructive Visuospatial abilities General complaints about increasing memory problems Learning and memory Memory Cognitive flexibility Complex alertness Divided attention Planning Executive function Organization Blank mind (Learning and memory) (memory) Dyscalculia Complex alertness Divided attention Loss of control experience — — Derealization — — General decline — — Forgetfulness Learning and memory Memory Content memory Learning and memory Memory Prospective memory (Executive function) (Planning) — Social cognition — SCD themes of memory clinic patients Neurocognitive domains DSM-5 (American Psychiatric Association, 2013) E-Cog domains (Farias et al., 2008) Deceleration Complex alertness — Word finding difficulties speech Language Memory for names speech Language Action monitoring Executive function (Organization) Slowing of cognitive processing speed Complex alertness — Concentration difficulties Complex alertness Divided attention Visual spatial disorientation Visuo-constructive Visuospatial abilities General complaints about increasing memory problems Learning and memory Memory Cognitive flexibility Complex alertness Divided attention Planning Executive function Organization Blank mind (Learning and memory) (memory) Dyscalculia Complex alertness Divided attention Loss of control experience — — Derealization — — General decline — — Forgetfulness Learning and memory Memory Content memory Learning and memory Memory Prospective memory (Executive function) (Planning) — Social cognition — Note. The table shows a comparison of memory clinic patient’s IPA-derived complaint themes with the DSM-5 neurocognitive domains and the subscales of the E-Cog as a representative quantitative assessment instrument; domains in brackets reflect unclear domain assignment. View Large Discussion and Implications Summary While a number of qualitative studies have provided insights into the phenomenological experience of living with MCI or receiving a diagnosis of moderate to severe dementia (Clare et al., 2005, 2008; De Boer et al., 2007; Harman & Clare, 2006; Vernooij-Dassen, Derksen, Scheltens, & Moniz-Cook, 2006), the phenomenological (i.e., first person) experience of cognitive complaints has so far only been described in Parkinson’s disease (Kudlicka, Hindle, Spencer, & Clare, 2017). The present study is the first to undertake a detailed description of the experience and components of cognitive complaints in three different diagnostic groups (Finlay, 2012). Our findings provide evidence that common, quantitative SCD instruments do not capture some salient MC patient-specific phenomenological experiences. On the other hand, some themes were equally mentioned by the two patient groups as well as the healthy controls, suggesting that they are not group-specific and possibly of limited diagnostic value. Unique themes emerged in the different groups which suggest different complaint patterns in MC, MD, and HC. HC reflected that learning gets harder with age and mentioned increased distractibility. A majority of participants talked about problems we categorized as part of prospective memory, also mentioned by MC and MD patients. Memory clinic patients offered the most extensive reflection on their perceived change in cognition. A number of participants reported problems with short-term memory, slowing of cognitive processing speed, concentration difficulties, deceleration, and general complaints about increasing memory problems. In addition, experience of blank mind emerged as a powerful theme specific to this population. A number of MC patients reflected less cognitive flexibility, problems with planning, and visual spatial orientation. Interestingly, they were the only group reporting about complaints one would designate as metacognition (Thöne-Otto & Markowitsch, 2004). With 18 categories in total, the MC group produced the most diverse description of cognitive complaints. In MD patients, we derived the following unique themes from the analytic process: formal thought disorder, initiating action and nonspecific overwork. Accordingly, these symptoms aligned with the clinical symptomatology of depression. In this regard, it is important to point out that participants in this study were asked to talk freely about perceived cognitive changes. The present finding highlights that reports of SCD reflect an individual’s very subjective experience and own understanding of cognition rather than decline in a given set of theoretical cognitive domains. Regarding the current diagnostic criteria, the proposed neurocognitive domains of the DSM-5 section do not fully capture the subjective experience of cognitive decline revealed through IPA in this study. Even if DSM-5 domains were considered as broader categories, they do not encapsulate all complaints presented by MC patients, that is, loss of control experiences, the feeling of general decline, and experience of derealization. These themes were also not covered by the E-Cog. Our findings emphasize the need to rethink theoretical frames of cognitive complaint measurement in light of classifying salient symptoms specific to different diagnostic categories. Qualitatively derived themes demonstrate that participants recognize, and can verbally express, a great variety of cognitive changes. Participants’ experience of cognitive failures varied along groups and individuals and many expressed symptoms that mirror a personal or popular rather than a medical understanding of the condition (e.g., short-term memory was used as a term for working memory). It is apparent from the interviews that the participants of this study had relatively preserved insight into their own experience of cognitive failures. Healthy controls, as well as MC and MD patients, reported cognitive complaints. Thus, the main difference in concerns among different groups is not simply the occurrence of cognitive failures, but rather a more dimensional qualitative aspect of the complaint itself. Current quantitative measurements are unable to adequately capture this level of experience and could potentially confound results in the SCD field, particularly in relation to prevalence and AD risk estimates. This highlights the need of a view beyond, or a more sophisticated approach to, the quantitative aspects of subjective cognitive complaints due to preclinical AD versus due to depression versus an aspect of “healthy” aging. This account challenges the common operationalization of cognitive complaints as a singular symptom that can be easily measured with standardized questionnaires. Study Limitations and Future Research A critique point is that IPA provides no executive step of bracketing. This could lead to a lack of validity in the analysis process (Giorgi, 2011). However, making sense of an experience by using IPA inevitably involves the interpretative engagement of the researcher (Smith et al., 2009). While, on the one hand, this may increase the potential of preconceptions influencing the research process, it is, on the other hand, close to the procedure in clinical routine where physicians interpret patients’ individual reports on the background of their (pre-existing) professional knowledge. Thus, we believe that, despite the limitations concerning bracketing, IPA was likely the most suited method for this study. Furthermore, we employed an iterative procedure within a group setting to support a valid analysis process. Our approach was in the last step deductive and theory driven by labeling the complaint themes with abstract complaint categories. The validation of these categories is a crucial next step which should be done with a different analytic approach. Another possible limitation is, that of the MC patients, 10 individuals had MCI and were potentially less responsive to verbal and nonverbal communication and less likely to demonstrate awareness of functional deficits (Tabert et al., 2002). To try to counteract this issue, we recruited participants on the condition that they were willing to talk about their self-perceived cognitive failures. This necessarily excluded people who were unaware of their cognitive impairments. The MC group had a relatively high MMSE score which supports the unimpaired awareness of our sample (Kalbe et al., 2005). It is possible that a sample of more advanced MCI patients would not demonstrate the level of self-awareness shown in our sample (Galeone, Pappalardo, Chieffi, Iavarone, & Carlomagno, 2011; Okonkwo et al., 2009; Orfei et al., 2010). However, considering that SCD is gaining interest primarily as an indicator of the earliest clinical stages of the AD trajectory, we did not consider this to be of major concern. Similar problems were possible in the MD group; many studies report an association between awareness and symptoms of depression (Burke et al., 1998; Smith, Henderson, McCleary, Murdock, & Buckwalter, 2000), although this finding has been contested (Arkin & Mahendra, 2001; Cummings, Ross, Absher, Gornbein, & Hadjiaghai, 1995). Another limitation of our study is that there were no biomarkers or longitudinal data available to contrast the phenomenology of subjective cognitive complaints in patients with preclinical or prodromal AD versus other groups. While 40%–60% of MC participants in similar settings have signs of amyloid and/or tau pathology (Wolfsgruber et al., 2017) many memory clinic attendees will be worried, but unaffected by AD. In contrast, a substantial proportion of healthy (“noncomplaining”) older adults has evidence of AD pathology (Jansen et al., 2015). Availability of AD biomarker information would be most useful as attention is now focused on diagnostic utility of certain aspects of cognitive complaints with regard to underlying AD pathology (Rabin et al., 2015). With regard to questionnaire data, first interesting results involving biomarkers have been reported (Amariglio et al., 2012; La Joie et al., 2016; van Harten et al., 2013; Wolfsgruber et al., 2017). For example, La Joie and colleagues (2016) found associations between specific SCD items and AD biomarkers. Endorsement of complaints in items of temporal orientation (a domain which was also group-specific for memory clinic patients in our study) was associated with Aß-positivity in amnestic MCI patients. In contrast, higher endorsement in items related to prospective memory and face-name memory were related to Aß-negativity. In line with these results, prospective memory complaints and problems with memory for names were also nonspecific for a diagnostic group in our study (Table 3). Table 3. Overlapping Complaint Categories IPA categories HC group Memory clinic patients Major depressive patients Total Kruskal-Wallisa n (%) n (%) n (%) n (%) χ2 p General complaints about Increasing memory problems 9 (42.9) 9 (50.0) 1 (9.1) 19 (38.0) 5.108 .078 Action monitoring 7 (33.3) 7 (38.9) 2 (18.2) 16 (32.0) 1.347 .510 Forgetfulness 3 (14.3) 9 (50.0) 5 (45.5) 17 (34.0) 6.207 .045* Content memory 4 (19.0) 1 (5.6) 2 (18.2) 7 (14.0) 1.637 .441 Prospective memory 9 (42.9) 7 (38.9) 3 (27.3) 19 (38.0) .739 .691 Memory for names 7 (33.3) 6 (33.3) 3 (27.3) 16 (32.0) .142 .931 Word finding difficulties 5 (23.8) 7 (38.9) 4 (36.4) 16 (32.0) 1.114 .573 Concentration difficulties 1 (4.8) 3 (16.7) 4 (36.4) 8 (16.0) 5.266 .072 IPA categories HC group Memory clinic patients Major depressive patients Total Kruskal-Wallisa n (%) n (%) n (%) n (%) χ2 p General complaints about Increasing memory problems 9 (42.9) 9 (50.0) 1 (9.1) 19 (38.0) 5.108 .078 Action monitoring 7 (33.3) 7 (38.9) 2 (18.2) 16 (32.0) 1.347 .510 Forgetfulness 3 (14.3) 9 (50.0) 5 (45.5) 17 (34.0) 6.207 .045* Content memory 4 (19.0) 1 (5.6) 2 (18.2) 7 (14.0) 1.637 .441 Prospective memory 9 (42.9) 7 (38.9) 3 (27.3) 19 (38.0) .739 .691 Memory for names 7 (33.3) 6 (33.3) 3 (27.3) 16 (32.0) .142 .931 Word finding difficulties 5 (23.8) 7 (38.9) 4 (36.4) 16 (32.0) 1.114 .573 Concentration difficulties 1 (4.8) 3 (16.7) 4 (36.4) 8 (16.0) 5.266 .072 Note. p-Value = .05, two-tailed sign. *Indicates significant results on the α < .05 level. adf for all categories 2. View Large Table 3. Overlapping Complaint Categories IPA categories HC group Memory clinic patients Major depressive patients Total Kruskal-Wallisa n (%) n (%) n (%) n (%) χ2 p General complaints about Increasing memory problems 9 (42.9) 9 (50.0) 1 (9.1) 19 (38.0) 5.108 .078 Action monitoring 7 (33.3) 7 (38.9) 2 (18.2) 16 (32.0) 1.347 .510 Forgetfulness 3 (14.3) 9 (50.0) 5 (45.5) 17 (34.0) 6.207 .045* Content memory 4 (19.0) 1 (5.6) 2 (18.2) 7 (14.0) 1.637 .441 Prospective memory 9 (42.9) 7 (38.9) 3 (27.3) 19 (38.0) .739 .691 Memory for names 7 (33.3) 6 (33.3) 3 (27.3) 16 (32.0) .142 .931 Word finding difficulties 5 (23.8) 7 (38.9) 4 (36.4) 16 (32.0) 1.114 .573 Concentration difficulties 1 (4.8) 3 (16.7) 4 (36.4) 8 (16.0) 5.266 .072 IPA categories HC group Memory clinic patients Major depressive patients Total Kruskal-Wallisa n (%) n (%) n (%) n (%) χ2 p General complaints about Increasing memory problems 9 (42.9) 9 (50.0) 1 (9.1) 19 (38.0) 5.108 .078 Action monitoring 7 (33.3) 7 (38.9) 2 (18.2) 16 (32.0) 1.347 .510 Forgetfulness 3 (14.3) 9 (50.0) 5 (45.5) 17 (34.0) 6.207 .045* Content memory 4 (19.0) 1 (5.6) 2 (18.2) 7 (14.0) 1.637 .441 Prospective memory 9 (42.9) 7 (38.9) 3 (27.3) 19 (38.0) .739 .691 Memory for names 7 (33.3) 6 (33.3) 3 (27.3) 16 (32.0) .142 .931 Word finding difficulties 5 (23.8) 7 (38.9) 4 (36.4) 16 (32.0) 1.114 .573 Concentration difficulties 1 (4.8) 3 (16.7) 4 (36.4) 8 (16.0) 5.266 .072 Note. p-Value = .05, two-tailed sign. *Indicates significant results on the α < .05 level. adf for all categories 2. View Large While these results are encouraging, a biomarker based validation approach has not been done for cognitive complaint aspects derived from qualitative interview data. In this regard, a future study could investigate whether AD biomarker positive versus negative memory clinic patients differ regarding specific complaint categories as derived from the present study. This could involve either a different (i.e., deductive) qualitative approach, such as content analysis, or a mixed-method approach. Ideally, this could lead to a clinically feasible interview and classification schedule for AD typical cognitive complaints, and to more specific cognitive complaint questionnaires. Such measures would be most useful to define SCD due to AD in clinical and research settings. Conclusion Only relatively small amount of research currently exists that explores the experience of cognitive complaints as a qualitative phenomenon. Results showed that cognitive complaints are a complex experience that differs in its exact appearance across patients. Our data suggest that measuring cognitive complaints via currently employed quantitative instruments, on the one hand, leaves out aspects of this complex and heterogeneous experience and, on the other hand, may capture themes with little diagnostic utility. These shortcomings in hitherto existing measures of cognitive complaints may partly explain the heterogeneous findings regarding the association of cognitive complaints with incipient AD. This study reveals that there is much to be gained from talking with and listening to people with cognitive complaints across diagnostic categories. We argue that there is a justification for using clinical interviews to complement questionnaires in SCD assessment and for improving common questionnaires toward a more reliable and valid operationalization of cognitive complaints as a risk factor for AD. Supplementary Material Supplementary data are available at The Gerontologist online. Funding The study was supported by the University of Bonn, Department for Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Department of Psychiatry and Psychotherapy and the German Center for Neurodegenerative Diseases (DZNE). Conflicts of Interest None reported. Acknowledgments We appreciated the support of Wolfgang Maier, Alexandra Polcher, Luca Kleineidam, Sandra Röske, Catherine Widmann, Debora Melo van Lent, and Alexander Koppara. All authors report no disclosures. Ethical approval: The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.The entire study protocol was approved by the local ethic committee at the University of Bonn. References Abdulrab , K. , & Heun , R . ( 2008 ). Subjective memory impairment. A review of its definitions indicates the need for a comprehensive set of standardised and validated criteria . European Psychiatry , 23 , 321 – 330 . doi: 10.1016/j.eurpsy.2008.02.004 Google Scholar CrossRef Search ADS PubMed Albert , M. S. , DeKosky , S. T. , Dickson , D. , Dubois , B. , Feldman , H. H. , Fox , N. C. ,… Phelps , C. H . ( 2011 ). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease . Alzheimer’s & Dementia , 7 , 270 – 279 . doi: 10.1016/j.jalz.2011.03.008 Google Scholar CrossRef Search ADS Amariglio , R. E. , Becker , J. A. , Carmasin , J. , Wadsworth , L. P. , Lorius , N. , Sullivan , C. ,… Rentz , D. M . ( 2012 ). Subjective cognitive complaints and amyloid burden in cognitively normal older individuals . Neuropsychologia , 50 , 2880 – 2886 . doi: 10.1016/j.neuropsychologia.2012.08.011 Google Scholar CrossRef Search ADS PubMed Amariglio , R. E. , Donohue , M. C. , Marshall , G. A. , Rentz , D. M. , Salmon , D. P. , Ferris , S. H .,… Alzheimer’s Disease Cooperative Study . ( 2015 ). Tracking early decline in cognitive function in older individuals at risk for Alzheimer’s disease dementia: The Alzheimer’s Disease Cooperative Study Cognitive Function Instrument . JAMA Neurology , 72 , 446 – 454 . doi: 10.1001/jamaneurol.2014.3375 Google Scholar CrossRef Search ADS PubMed American Psychiatric Association . ( 2013 ). Diagnostic and statistical manual of mental disorders (DSM-5®) . American Psychiatric Pub . Arkin , S. , & Mahendra , N . ( 2001 ). Insight in Alzheimer’s patients: Results of a longitudinal study using three assessment methods . American Journal of Alzheimer’s Disease and Other Dementias , 16 , 211 – 224 . doi: 10.1177/153331750101600401 Google Scholar CrossRef Search ADS PubMed Balash , Y. , Mordechovich , M. , Shabtai , H. , Giladi , N. , Gurevich , T. , & Korczyn , A. D . ( 2013 ). Subjective memory complaints in elders: Depression, anxiety, or cognitive decline ? Acta Neurologica Scandinavica , 127 , 344 – 350 . doi: 10.1111/ane.12038 Google Scholar CrossRef Search ADS PubMed Balash , Y. , Mordechovich , M. , Shabtai , H. , Merims , D. , & Giladi , N . ( 2010 ). Subjective memory decline in healthy community-dwelling elders. What does this complain mean ? Acta Neurologica Scandinavica , 121 , 194 – 197 . doi: 10.1111/j.1600-0404.2009.01159.x Google Scholar CrossRef Search ADS PubMed Broadbent , D. E. , Cooper , P. F. , FitzGerald , P. , & Parkes , K. R . ( 1982 ). The Cognitive Failures Questionnaire (CFQ) and its correlates . The British Journal of Clinical Psychology , 21(Pt 1) , 1 – 16 . doi: 10.1111/j.2044–8260.1982.tb01421.x Google Scholar CrossRef Search ADS PubMed Buckley , R. F. , Ellis , K. A. , Ames , D. , Rowe , C. C. , Lautenschlager , N. T. , Maruff , P. ,… Saling , M. M .; Australian Imaging Biomarkers and Lifestyle Study of Ageing (AIBL) Research Group . ( 2015 ). Phenomenological characterization of memory complaints in preclinical and prodromal Alzheimer’s disease . Neuropsychology , 29 , 571 – 581 . doi: 10.1037/neu0000156 Google Scholar CrossRef Search ADS PubMed Burke , W. J. , Roccaforte , W. H. , Wengel , S. P. , McArthur-Miller , D. , Folks , D. G. , & Potter , J. F . ( 1998 ). Disagreement in the reporting of depressive symptoms between patients with dementia of the Alzheimer type and their collateral sources . The American Journal of Geriatric Psychiatry , 6 , 308 – 319 . Google Scholar CrossRef Search ADS PubMed Chételat , G. , Villemagne , V. L. , Bourgeat , P. , Pike , K. E. , Jones , G. , Ames , D. ,… Rowe , C. C .; Australian Imaging Biomarkers and Lifestyle Research Group . ( 2010 ). Relationship between atrophy and beta-amyloid deposition in Alzheimer disease . Annals of Neurology , 67 , 317 – 324 . doi: 10.1002/ana.21955 Google Scholar PubMed Clare , L. , Roth , I. , Pratt , R. , & Clare , L . ( 2005 ). Perceptions of change over time in early-stage Alzheimer’s disease: Implications for understanding awareness and coping style . Dementia , 4 , 487 – 520 . doi: 10.1177/1471301205058304 Google Scholar CrossRef Search ADS Clare , L. , Rowlands , J. , Bruce , E. , Surr , C. , & Downs , M . ( 2008 ). ‘I don’t do like I used to do’: A grounded theory approach to conceptualising awareness in people with moderate to severe dementia living in long-term care . Social Science & Medicine (1982) , 66 , 2366 – 2377 . doi: 10.1016/j.socscimed.2008.01.045 Google Scholar CrossRef Search ADS PubMed Crook , T. H. III , Feher , E. P. , & Larrabee , G. J . ( 1992 ). Assessment of memory complaint in age-associated memory impairment: The MAC-Q . International Psychogeriatrics , 4 , 165 – 176 . doi: 10.1017/S1041610292000991 Google Scholar CrossRef Search ADS PubMed Cummings , J. L. , Ross , W. , Absher , J. , Gornbein , J. , & Hadjiaghai , L . ( 1995 ). Depressive symptoms in Alzheimer disease: Assessment and determinants . Alzheimer Disease and Associated Disorders , 9 , 87 – 93 . Google Scholar CrossRef Search ADS PubMed de Boer , M. E. , Hertogh , C. M. , Dröes , R. M. , Riphagen , I. I. , Jonker , C. , & Eefsting , J. A . ( 2007 ). Suffering from dementia—The patient’s perspective: A review of the literature . International Psychogeriatrics , 19 , 1021 – 1039 . doi: 10.1017/S1041610207005765 Google Scholar CrossRef Search ADS PubMed Farias , S. T. , Mungas , D. , Reed , B. R. , Cahn-Weiner , D. , Jagust , W. , Baynes , K. , & Decarli , C . ( 2008 ). The measurement of everyday cognition (ECog): Scale development and psychometric properties . Neuropsychology , 22 , 531 – 544 . doi: 10.1037/0894-4105.22.4.531 Google Scholar CrossRef Search ADS PubMed Finlay , L . ( 2012 ). Debating phenomenological methods . In N. Friesen, C. Henriksson, & T. Saevi (Eds.), Hermeneutic phenomenology in education: method and practice (pp. 17 – 37 ). Rotterdam: Sense Publishers. Google Scholar CrossRef Search ADS Galeone , F. , Pappalardo , S. , Chieffi , S. , Iavarone , A. , & Carlomagno , S . ( 2011 ). Anosognosia for memory deficit in amnestic mild cognitive impairment and Alzheimer’s disease . International Journal of Geriatric Psychiatry , 26 , 695 – 701 . doi: 10.1002/gps.2583 Google Scholar CrossRef Search ADS PubMed Giorgi , A . ( 2011 ). IPA and science: A response to Jonathan Smith . Journal of Phenomenological Psychology , 42 , 195 – 216 . Google Scholar CrossRef Search ADS Harman , G. , & Clare , L . ( 2006 ). Illness representations and lived experience in early-stage dementia . Qualitative Health Research , 16 , 484 – 502 . doi: 10.1177/1049732306286851 Google Scholar CrossRef Search ADS PubMed Jansen , W. J. , Ossenkoppele , R. , Knol , D. L. , Tijms , B. M. , Scheltens , P. , Verhey , F. R. ,… Zetterberg , H .; Amyloid Biomarker Study Group . ( 2015 ). Prevalence of cerebral amyloid pathology in persons without dementia: A meta-analysis . JAMA , 313 , 1924 – 1938 . doi: 10.1001/jama.2015.4668 Google Scholar CrossRef Search ADS PubMed Jessen , F. , Amariglio , R. E. , van Boxtel , M. , Breteler , M. , Ceccaldi , M. , Chételat , G. ,… Wagner , M .; Subjective Cognitive Decline Initiative (SCD-I) Working Group . ( 2014 ). A conceptual framework for research on subjective cognitive decline in preclinical Alzheimer’s disease . Alzheimer’s & Dementia , 10 , 844 – 852 . doi: 10.1016/j.jalz.2014.01.001 Google Scholar CrossRef Search ADS Jessen , F. , Wolfsgruber , S. , Wiese , B. , Bickel , H. , Mösch , E. , Kaduszkiewicz , H. ,… Wagner , M . ( 2013 ). AD dementia risk in late MCI, in early MCI, and in subjective memory impairment . Alzheimer’s & Dementia , 10 , 76 – 83 . doi: 10.1016/j.jalz.2012.09.017 Google Scholar CrossRef Search ADS Johansson , M. M. , Marcusson , J. , & Wressle , E . ( 2015 ). Cognitive impairment and its consequences in everyday life: Experiences of people with mild cognitive impairment or mild dementia and their relatives . International Psychogeriatrics , 27 , 949 – 958 . doi: 10.1017/S1041610215000058 Google Scholar CrossRef Search ADS PubMed Jonker , C. , Geerlings , M. I. , & Schmand , B . ( 2000 ). Are memory complaints predictive for dementia? A review of clinical and population-based studies . International Journal of Geriatric Psychiatry , 15 , 983 – 991 . doi: 10.1002/1099–1166(200011)15:11<983::AID-GPS238>3.0.CO;2–5 Google Scholar CrossRef Search ADS PubMed Kalbe , E. , Salmon , E. , Perani , D. , Holthoff , V. , Sorbi , S. , Elsner , A. ,… Herholz , K . ( 2005 ). Anosognosia in very mild Alzheimer’s disease but not in mild cognitive impairment . Dementia and Geriatric Cognitive Disorders , 19 , 349 – 356 . doi: 10.1159/000084704 Google Scholar CrossRef Search ADS PubMed Koppara , A. , Wagner , M. , Lange , C. , Ernst , A. , Wiese , B. , König , H. H. ,… Jessen , F . ( 2015 ). Cognitive performance before and after the onset of subjective cognitive decline in old age . Alzheimer’s & Dementia (Amsterdam, Netherlands) , 1 , 194 – 205 . doi: 10.1016/j.dadm.2015.02.005 Google Scholar PubMed Kroenke , K. , Spitzer , R. L. , & Williams , J. B . ( 2001 ). The PHQ-9: Validity of a brief depression severity measure . Journal of General Internal Medicine , 16 , 606 – 613 . doi: 10.1046/j.1525-1497.2001.016009606.x Google Scholar CrossRef Search ADS PubMed Kudlicka , A. , Hindle , J. V. , Spencer , L. E. , & Clare , L . ( 2017 ). Everyday functioning of people with Parkinson’s disease and impairments in executive function: A qualitative investigation . Disability and Rehabilitation , 1 – 13 . doi: 10.1080/09638288.2017.1334240 La Joie , R. , Perrotin , A. , Egret , S. , Pasquier , F. , Tomadesso , C. , Mézenge , F. , … Chételat , G . ( 2016 ). Qualitative and quantitative assessment of self-reported cognitive difficulties in nondemented elders: Association with medical help seeking, cognitive deficits, and β-amyloid imaging . Alzheimer’s & Dementia (Amsterdam, Netherlands) , 5 , 23 – 34 . doi: 10.1016/j.dadm.2016.12.005 Google Scholar PubMed Lingler , J. H. , Nightingale , M. C. , Erlen , J. A. , Kane , A. L. , Reynolds , C. F. III , Schulz , R. , & DeKosky , S. T . ( 2006 ). Making sense of mild cognitive impairment: A qualitative exploration of the patient’s experience . The Gerontologist , 46 , 791 – 800 . doi: 10.1093/geront/46.6.791 Google Scholar CrossRef Search ADS PubMed McKhann , G. , Drachman , D. , Folstein , M. , Katzman , R. , Price , D. , & Stadlan , E. M . ( 1984 ). Clinical diagnosis of Alzheimer’s disease: Report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease . Neurology , 34 , 939 – 944 . doi: 10.1212/WNL.34.7.939 Google Scholar CrossRef Search ADS PubMed Mitchell , A. J. , Beaumont , H. , Ferguson , D. , Yadegarfar , M. , & Stubbs , B . ( 2014 ). Risk of dementia and mild cognitive impairment in older people with subjective memory complaints: Meta-analysis . Acta Psychiatrica Scandinavica , 130 , 439 – 451 . doi: 10.1111/acps.12336 Google Scholar CrossRef Search ADS PubMed Molinuevo , J. L. , Rabin , L. A. , Amariglio , R. , Buckley , R. , Dubois , B. , Ellis , K. A.,… Jessen , F .; Subjective Cognitive Decline Initiative (SCD-I) Working Group . ( 2016 ). Implementation of subjective cognitive decline criteria in research studies . Alzheimer’s & Dementia , 13 , 296 – 311 . doi: 10.1016/j.jalz.2016.09.012 Google Scholar CrossRef Search ADS Morris , J. C. , Mohs , R. C. , Rogers , H. , Fillenbaum , G. , & Heyman , A . ( 1988 ). Consortium to establish a registry for Alzheimer’s disease (CERAD) clinical and neuropsychological assessment of Alzheimer’s disease . Psychopharmacology Bulletin , 24 , 641 – 652 . Google Scholar PubMed Okonkwo , O. C. , Griffith , H. R. , Vance , D. E. , Marson , D. C. , Ball , K. K. , & Wadley , V. G . ( 2009 ). Awareness of functional difficulties in mild cognitive impairment: A multidomain assessment approach . Journal of the American Geriatrics Society , 57 , 978 – 984 . doi: 10.1111/j.1532-5415.2009.02261.x Google Scholar CrossRef Search ADS PubMed Orfei , M. D. , Varsi , A. E. , Blundo , C. , Celia , E. , Casini , A. R. , Caltagirone , C. , & Spalletta , G . ( 2010 ). Anosognosia in mild cognitive impairment and mild Alzheimer’s disease: Frequency and neuropsychological correlates . The American Journal of Geriatric Psychiatry , 18 , 1133 – 1140 . doi: 10.1097/JGP.0b013e3181dd1c50 Google Scholar CrossRef Search ADS PubMed Perrotin , A. , Mormino , E. C. , Madison , C. M. , Hayenga , A. O. , & Jagust , W. J . ( 2012 ). Subjective cognition and amyloid deposition imaging: A Pittsburgh Compound B positron emission tomography study in normal elderly individuals . Archives of Neurology , 69 , 223 – 229 . doi: 10.1001/archneurol.2011.666 Google Scholar CrossRef Search ADS PubMed Rabin , L. A. , Smart , C. M. , Crane , P. K. , Amariglio , R. E. , Berman , L. M. , Boada , M. , … Sikkes , S. A . ( 2015 ). Subjective cognitive decline in older adults: An overview of self-report measures used across 19 international research studies . Journal of Alzheimer’s Disease , 48 ( Suppl. 1 ), S63 – S86 . doi: 10.3233/JAD-150154 Google Scholar CrossRef Search ADS PubMed Roberts , J. L. , & Clare , L . ( 2013 ). Meta-representational awareness in mild cognitive impairment: An interpretative phenomenological analysis . Aging & Mental Health , 17 ( 3 ), 300 – 309 . doi: 10.1080/13607863.2012.732033 Google Scholar CrossRef Search ADS PubMed Sabat , S. R. , & Harré , R . ( 1992 ). The construction and deconstruction of self in Alzheimer’s disease . Ageing and Society , 12 , 443 – 461 . doi: 10.1017/S0144686X00005262 Google Scholar CrossRef Search ADS Saykin , A. J. , Wishart , H. A. , Rabin , L. A. , Santulli , R. B. , Flashman , L. A. , West , J. D. , … Mamourian , A. C . ( 2006 ). Older adults with cognitive complaints show brain atrophy similar to that of amnestic MCI . Neurology , 67 , 834 – 842 . doi: 10.1212/01.wnl.0000234032.77541.a2 Google Scholar CrossRef Search ADS PubMed Schmand , B. , Jonker , C. , Geerlings , M. I. , & Lindeboom , J . ( 1997 ). Subjective memory complaints in the elderly: Depressive symptoms and future dementia . The British Journal of Psychiatry , 171 , 373 – 376 . doi: 10.1192/bjp.171.4.373 Google Scholar CrossRef Search ADS PubMed Schmid , N. S. , Ehrensperger , M. M. , Berres , M. , Beck , I. R. , & Monsch , A. U . ( 2014 ). The extension of the German CERAD neuropsychological assessment battery with tests assessing subcortical, executive and frontal functions improves accuracy in dementia diagnosis . Dementia and Geriatric Cognitive Disorders Extra , 4 , 322 – 334 . doi: 10.1159/000357774 Google Scholar CrossRef Search ADS PubMed Smith , J. A. , Flowers , P. , & Osborn , M. ( 1997 ). Interpretative phenomenological analysis and the psychology of health and illness . Material discourses of health and illness , 68 – 91 . Smith , C. A. , Henderson , V. W. , McCleary , C. A. , Murdock , G. A. , & Buckwalter , J. G . ( 2000 ). Anosognosia and Alzheimer’s disease: The role of depressive symptoms in mediating impaired insight . Journal of Clinical and Experimental Neuropsychology , 22 , 437 – 444 . doi: 10.1076/1380-3395(200008)22:4;1-0;FT437 Google Scholar CrossRef Search ADS PubMed Smith , J. , Flowers , P. , & Larkin , M . ( 2009 ). Interpretative phoneomological analysis: Theory, method and research . London : SAGE Publications . Tabert , M. H. , Albert , S. M. , Borukhova-Milov , L. , Camacho , Y. , Pelton , G. , Liu , X.,… Devanand , D. P . ( 2002 ). Functional deficits in patients with mild cognitive impairment: Prediction of AD . Neurology , 58 , 758 – 764 . Google Scholar CrossRef Search ADS PubMed Thöne-Otto , A. , & Markowitsch , H. J . ( 2004 ). Gedächtnisstörungen nach Hirnschäden . Göttingen: Hogrefe Verlag . van Harten , A. C. , Visser , P. J. , Pijnenburg , Y. A. , Teunissen , C. E. , Blankenstein , M. A. , Scheltens , P. , & van der Flier , W. M . ( 2013 ). Cerebrospinal fluid Aβ42 is the best predictor of clinical progression in patients with subjective complaints . Alzheimer’s & Dementia , 9 , 481 – 487 . doi: 10.1016/j.jalz.2012.08.004 Google Scholar CrossRef Search ADS Vernooij-Dassen , M. , Derksen , E. , Scheltens , P. , & Moniz-Cook , E . ( 2006 ). Receiving a diagnosis of dementia: The experience over time . Dementia , 5 , 397 – 410 . Google Scholar CrossRef Search ADS Wolfsgruber , S. , Jessen , F. , Koppara , A. , Kleineidam , L. , Schmidtke , K. , Frölich , L.,… Wagner , M . ( 2015 ). Subjective cognitive decline is related to CSF biomarkers of AD in patients with MCI . Neurology , 84 , 1261 – 1268 . doi: 10.1212/WNL.0000000000001399 Google Scholar CrossRef Search ADS PubMed Wolfsgruber , S. , Polcher , A. , Koppara , A. , Kleineidam , L. , Frölich , L. , Peters , O.,… Wagner , M . ( 2017 ). Cerebrospinal fluid biomarkers and clinical progression in patients with subjective cognitive decline and mild cognitive impairment . Journal of Alzheimer’s Disease , 58 , 939 – 950 . doi: 10.3233/JAD-161252 Google Scholar CrossRef Search ADS PubMed World Health Organization . ( 1993 ). The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research . Switzerland: World Health Organization. Yesavage , J. A. , Brink , T. L. , Rose , T. L. , Lum , O. , Huang , V. , Adey , M. , & Leirer , V. O . ( 1983 ). Development and validation of a geriatric depression screening scale: A preliminary report . Journal of Psychiatric Research , 17 , 37 – 49 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Gerontologist Oxford University Press

Cognitive Complaints in Memory Clinic Patients and in Depressive Patients: An Interpretative Phenomenological Analysis

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Abstract

Abstract Background and Objectives Cognitive complaints are discussed as early signs of Alzheimer’s disease (AD). However, they are also very common in cognitively normal older adults and in patients with depression. Qualitative, interview-based approaches might be useful to identify those features of cognitive complaints specific for the experiences of cognitive decline in preclinical or prodromal AD versus those complaints typically reported by depressed patients. Research Design and Methods A semi-structured interview was administered to 21 cognitively normal older adults (HC), 18 nondemented memory clinic patients (MC), and 11 patients with a major depression (MD), all above 55 years. Interpretative phenomenological analysis (IPA) was applied to the interview transcripts to develop emerging complaint themes in each group. To identify thematic correspondence and possibly novel, hitherto unappreciated themes, the extracted complaint categories were compared with the neurocognitive domains in the DSM-5 and the content of the Everyday Cognition questionnaire (E-Cog). Results IPA yielded 18 cognitive complaint categories in MC, 10 in depressive patients, and 10 categories in the HC group. Several themes were common across groups, but some were group-specific, for example, spatial disorientation was only reported in MC patients. Some of these MC-specific themes were neither represented by DSM-5 domains nor by the E-Cog. Discussion and Implications We report a comprehensive qualitative description of cognitive complaints in old age which could help to develop questionnaires or structured interviews to better assess AD-related subjective cognitive decline. This may help to increase specificity in selecting high-risk subjects in research settings and improve clinical judgment of diverse cognitive complaints types mentioned by their patients. Subjective cognitive decline (SCD), Qualitative research methods, Alzheimer’s dementia (AD), Cognition Mounting evidence suggests that cognitive complaints are a sensitive early behavioral marker of Alzheimer’s disease (AD) (Jessen et al., 2014; Mitchell, Beaumont, Ferguson, Yadegarfar, & Stubbs, 2014). Many studies associated subjective cognitive complaints with an increased risk of future cognitive decline (Koppara et al., 2015) and an increased likelihood of abnormal AD biomarkers (Amariglio et al., 2012; Chételat et al., 2010; Perrotin, Mormino, Madison, Hayenga, & Jagust, 2012; Saykin et al., 2006; Wolfsgruber et al., 2015). Other findings suggest associations between memory complaints and depressive symptoms (Balash et al., 2013; Balash, Mordechovich, Shabtai, Merims, & Giladi, 2010; Schmand, Jonker, Geerlings, & Lindeboom, 1997). Based on current findings, attention is now turning to the issue of sensitivity and specificity of cognitive complaints with regard to AD (Rabin et al., 2015). A particularly salient issue relates to the notion of what components of complaints are “AD-like” and which may be more representative of a mood disorder or of aging in general. Primarily, subjective cognitive decline (SCD) has been defined as the “subjective experience of worsening cognitive function in comparison with earlier performance” (Jessen et al., 2014). The SCD Initiative (SCD-I) recently published criteria for the implementation of SCD in research studies (Molinuevo et al., 2016). With regard to the core clinical criteria of mild cognitive impairment (MCI) proposed by the NIA-AA diagnostic framework, evidence of concerns should relate to decline in cognition (Albert et al., 2011). However, much of the early literature has focused only on concerns related to memory. Current methods of measurement of cognitive complaints are as heterogeneous as the different criteria (Abdulrab & Heun, 2008; Jessen et al., 2014; Jonker, Geerlings, & Schmand, 2000; Rabin et al., 2015). There is a lack of well evaluated measures for SCD and the theoretical and empirical development of the existing scales is mostly not well documented. Common instruments such as the Cognitive Failures Questionnaire (CFQ; Broadbent, Cooper, FitzGerald, & Parkes, 1982), the Cognitive Function Instrument (CFI; Amariglio et al., 2015), the Everyday Cognition Scale (E-Cog; Farias et al., 2008) or the Assessment of memory complaint in age-associated memory impairment (MAC-Q; Crook, Feher, & Larrabee, 1992) are based on expert knowledge, theoretical considerations, statistical methods or diagnostic criteria. Importantly, neither of these instruments was developed by a systematic qualitative study of cognitive complaints. This raises the possibility that some complaint themes reflecting cognitive decline due to neurodegenerative processes are not well represented in current instruments. Qualitative methods are advantageous as they address highly nuanced and contextualized aspects of subjective experiences (Smith, Flowers, & Larkin, 2009). Investigations of MCI patients’ self-awareness and experience of their diagnosis have revealed that qualitative approaches may well lead to a more in-depth view than a quantitative measurement (Lingler et al., 2006; Roberts & Clare, 2013). There is already a substantial literature dealing with the qualitative exploration of the lived experience of people with dementia (Clare, Roth, Pratt, & Clare, 2005; Clare, Rowlands, Bruce, Surr, & Downs, 2008; Harman & Clare, 2006; Johansson, Marcusson, & Wressle, 2015; Sabat & Harré, 1992). However, the approach of a qualitative description of the experiences underlying cognitive complaints has only recently been pursued with patients with MCI or SCD. Buckley and colleagues (2015) first examined the subjective experience of memory change in cognitively normal older adults and MCI patients. Using an inductive thematic approach, 12 themes were extracted (Buckley et al., 2015). Many themes were more commonly expressed in MCI patients, and some were also sensitive to β-amyloid (Aβ) load. While the memory complaint categories derived in this study address the different ways of “how” different people express their complaints, the aspect of “what type of” complaints they have is a different one. Quantitative studies dealing with this question are dependent on current measurements and thus suffer from the inherent operationalization problem mentioned above (La Joie et al., 2016). The aim of the current study was to take a “fresh look” at the range of cognitive complaints in older adults. We explored these complaints in cognitively normal older adults (HC), memory clinic patients (MC), and patients with major depressive disorder (MD) using a qualitative method called interpretative phenomenological analysis (IPA). IPA is particularly suited to capture subjective experiences associated with a given phenomenon (Smith et al., 2009). Complaint themes extracted with IPA were compared between the three groups to determine common and group-specific cognitive complaint symptomatology. Themes specific for the MC group (i.e., for potential preclinical/prodromal AD) were also qualitatively compared with established SCD measurements, to determine whether these fully reflect the subjective cognitive complaint experience in nondemented patients at risk for AD. Design and Methods Design The study is a qualitative study, involving a semi-structured interview, with additional quantitative clinical and neuropsychological assessment. Here, quantitative data are only reported for sample description purposes. Participants The total sample of this study includes 21 memory clinic patients, 11 psychiatric inpatients with a diagnosis of MD and 21 healthy controls. All participants were above the age of 55 and spoke German proficiently. MC patients initially sought diagnostic work-up in the Clinical Treatment and Research Center for Neurodegenerative Disorders (KBFZ), Department for Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn. Diagnosis of AD dementia or MCI was made according to the core clinical criteria of the NIA-AA (Albert et al., 2011; McKhann et al., 1984). The diagnostic procedure included a cognitive assessment, detailed medical history, and a neurological examination. Three patients were excluded as they received a diagnosis of AD dementia. Of the remaining 18 subjects, 10 fulfilled the core clinical criteria of MCI according to the NIA-AA criteria (Albert et al., 2011), as they reported cognitive concerns and had an impairment (score of <−1.5 SD below age-, gender-, and education adjusted norms) in at least one test of one or more cognitive domains. The remaining eight patients had subjective concerns without objective impairment, and were classified as SCD patients in line with recently published recommendations for defining SCD in clinical studies (Jessen et al., 2013; Molinuevo et al., 2016). While no biomarker information was available for this study, a high prevalence of AD pathology (~45% with abnormal Abeta42/Tau ratio) has been reported in similar memory clinic samples (Wolfsgruber et al., 2017). MD patients were recruited from the Clinic of Psychiatry and Psychotherapy, University of Bonn. All patients fulfilled a diagnosis of a unipolar, major depressive disorder according to ICD-10 criteria (World Health Organization, 1993). At the time of the interview the MD patients were on stable antidepressive and/or neuroleptic medication for at least 3 weeks and were not in an acute suicidal crisis. The HC group was recruited from a healthy volunteer subject pool of the German Center for Neurodegenerative Diseases (DZNE), Bonn. Exclusion criteria for HC were (a) report of concerns about mental abilities/memory; (b) psychological, psychiatric, or neurological treatment within the last 6 months; (c) severe or chronic disease (e.g., diabetes or MS); (d) experience of head injury with a loss of consciousness; (e) a diagnosis of neurological disease (e.g., AD or Parkinson); or (f) report of a neurodegenerative disease in a first-degree relative. Data Collection: Interview Procedure All participants were interviewed by a clinical psychologist (LM). Interviews were digitally recorded, transcribed verbatim, and pseudonymized by replacement of patient names with a random number and deletion of personal information throughout the whole transcripts. The interview procedure followed a semi-structured format and lasted between 8 and 31 min. The process started with an open question asking whether the interviewee had noticed any changes in memory or thinking during the last years. Each interview had an unstructured beginning, which allowed patients to determine the initial focus of the conversation. If cognitive changes were reported, the participants were asked to give an example of their everyday life. Then the patient was asked whether he/she has noticed further cognitive problems followed by the request to give an everyday example. This process was repeated until the participant did not mention further complaints. He/she was then asked to name the most concerning symptom which was selected for further detailed questioning, that is, 10 detailed questions about the phenomenological experience of the reported cognitive changes/difficulties. Questions were designed to cover all aspects of cognitive complaints proposed by Buckley et al. (2015), Table 1. The interview was tested in a pilot phase on a small number of patients (not included in the present report) with in between iterative discussion in a panel of experienced clinicians and researchers which lead to further amendments and the final version of the interview. Table 1. Semi-structured Interview Questions in the interview 1st Question: Have you noticed any changes in memory or thinking during the last years? When and where was the last time (cognitive complaint) occurred? How common is (…)? Is (…) only in special/ specific situations or is this a general problem? Is (…) in situations where you are distracted or in which you are distracted by others? Is (…) only in situations where you feel burdened emotionally? Do you feel that (…) has increased? / Do you believe that this change isn’t normal for your age? What was your first emotional reaction when you noticed (…) for the first time? Are you worried about (…)? How do you help yourself if (…) occurs? Are you successful with this strategy? Are you looking for help? Questions in the interview 1st Question: Have you noticed any changes in memory or thinking during the last years? When and where was the last time (cognitive complaint) occurred? How common is (…)? Is (…) only in special/ specific situations or is this a general problem? Is (…) in situations where you are distracted or in which you are distracted by others? Is (…) only in situations where you feel burdened emotionally? Do you feel that (…) has increased? / Do you believe that this change isn’t normal for your age? What was your first emotional reaction when you noticed (…) for the first time? Are you worried about (…)? How do you help yourself if (…) occurs? Are you successful with this strategy? Are you looking for help? View Large Table 1. Semi-structured Interview Questions in the interview 1st Question: Have you noticed any changes in memory or thinking during the last years? When and where was the last time (cognitive complaint) occurred? How common is (…)? Is (…) only in special/ specific situations or is this a general problem? Is (…) in situations where you are distracted or in which you are distracted by others? Is (…) only in situations where you feel burdened emotionally? Do you feel that (…) has increased? / Do you believe that this change isn’t normal for your age? What was your first emotional reaction when you noticed (…) for the first time? Are you worried about (…)? How do you help yourself if (…) occurs? Are you successful with this strategy? Are you looking for help? Questions in the interview 1st Question: Have you noticed any changes in memory or thinking during the last years? When and where was the last time (cognitive complaint) occurred? How common is (…)? Is (…) only in special/ specific situations or is this a general problem? Is (…) in situations where you are distracted or in which you are distracted by others? Is (…) only in situations where you feel burdened emotionally? Do you feel that (…) has increased? / Do you believe that this change isn’t normal for your age? What was your first emotional reaction when you noticed (…) for the first time? Are you worried about (…)? How do you help yourself if (…) occurs? Are you successful with this strategy? Are you looking for help? View Large Neuropsychological Assessment Neuropsychological assessment included the German version of the Consortium to Establish a Registry for Alzheimer’s disease (CERAD; Morris, Mohs, Rogers, Fillenbaum, & Heyman, 1988; Schmid, Ehrensperger, Berres, Beck, & Monsch, 2014) and the E-Cog (Farias et al., 2008). Depressive symptoms were assessed with the 15-item version of the Geriatric Depression Scale (GDS; Yesavage et al., 1983) and the PHQ-9 (Kroenke, Spitzer, & Williams, 2001). Qualitative Data Analysis With IPA The transcribed interview material was subjected to qualitative data analysis using the method of IPA as an inductive qualitative approach combining psychological, idiographic, and interpretative components (Smith et al., 2009). The IPA is a systematic phenomenological approach to reduce qualitative information, describe, and search for essences or structures underlying a given phenomenon (Finlay, 2012). The phenomenological perspective of the IPA influenced by Husserl’s philosophy tries to make sense of a personal experience. Therefore, we choose this approach because IPA allows an exploration of an experience with personal significance for example, such as an illness phenomenon (the experience of cognitive complaints questioned in this study; Smith et al., 2009; 1997). First, each transcript was analyzed separately to enable an extraction of themes unique to each individual. The main goal at this step is to derive expressions general enough to allow for thematic connections within and across the groups, but which also express the individual experiences of cognitive complaints. For example, the statement “I’ve lost my key” was interpreted as the subtheme “Losing” and thematically classified under the category “action monitoring.” The first part of the analysis process was an inductive approach which was close to the text itself by using the patient’s own words (Smith et al., 2009). To incorporate the experiences of the patients with an underlying theoretical framework of cognitive complaints, themes were in a second step connected in a deductive way which leads to complaint categories described with text examples. By repeated reading, clustering, and summarizing of themes, categories were integrated across participants in each group to generate a list that captured participant’s shared experiences of cognitive complaints. The themes which are initially described by a participant’s own words (e.g., “I was suddenly absent-minded”) were then labelled with abstract categories (e.g., “blank mind”). The results were discussed and restructured several times by expert consensus (MW, SW, IF, CW, KF, SR, AP, LM), then restructured and aggregated until the group found agreement about category assignment. We gradually refined themes through a cyclical process of reading until we elicited categories that resonated across the data set. We also compiled a glossary with a detailed description of all categories together with example quotations (Supplementary Data). Quantitative Data Analysis Quantitative data are presented for descriptive characterization of the sample. All analyses were performed using IBM SPSS for Windows. Group differences were examined with analysis of variance (ANOVA) for demographical, and analysis of covariance (ANCOVA; controlled for age, gender, and education) for clinical and neuropsychological variables, respectively, all followed by Bonferroni corrected post hoc test for pairwise comparison. For categorical variables, chi-square tests were used. Two-sided p values of less than .05 were considered significant. Results Sample Descriptive Statistics: Demographic, Clinical, and Cognitive Data Characteristics of the total study sample and the specific diagnostic groups are presented in Table 2. Memory clinic patients were older and had a lower MMSE score than controls. The MD group exhibited elevated levels of depressive symptomatology, with most subjects scoring above the GDS cut-off for depression and the PHQ-9 cut-off for moderate depression. Table 2. Sample Description for All Groups Total sample, N = 50 HC group, n = 21 HC vs MC Memory clinic patients, n = 18 MC vs MD Major depressive patients, n = 11 MD vs HC Group comparison n (%) n (%) p n (%) p n (%) p Chi2 p-Value Sex (female) 27 (54) 12 (57.1) n.s. 5 (27.8) ** 10 (90.9) n.s. 11.10 .004** M (SD) M (SD) p M (SD) p M (SD) p F-value p-Value Age 70.52 (7.56) 67.48 (7.20) * 74.06 (6.82) n.s. 70.55 (7.46) n.s. 4.14 .022* Educationa 14.82 (3.43) 15.10 (3.08) n.s. 16.11 (3.38) ** 12.18 (2.92) n.s. 5.42 .008** Interview duration (in min) 16:35 (06:55) 14:32 (06:18) * 20:44 (06:18) * 13:43 (06:12) n.s. 6.26 .004** CERAD-total score 80.90 (11.82) 89.29 (6.68) ** 75.83 (12.56) n.s. 73.18 (8.27) ** 13.02 <.001*** MMSE 28.30 (1.79) 29 (1.22) n.s. 27.10 (3.03) n.s. 27.64 (2.20) n.s. 2.28 .075 E-Cog sum 1.46 (.44) 1.21 (0.16) ** 1.73 (0.52) n.s. 1.52 (0.45) n.s 8.81 .001** E-Cog memory 1.83 (.69) 1.48 (.366) ** 2.24 (.776) n.s. 2.04 (.755) n.s. 7.66 .001** E-Cog language 1.43 (.48) 1.21 (.285) * 1.64 (.570) n.s. 1.58 (.507) n.s. 4.88 .012* E-Cog visuospatial 1.28 (.428) 1.05 (.082) ** 1.54 (.516) n.s. 1.35 (.522) n.s. 7.79 .011* E-Cog planning 1.22 (.386) 1.03 (.072) ** 1.47 (.510) n.s. 1.28 (.337) n.s. 7.72 .001** E-Cog divided attention 1.65 (.652) 1.37 (.365) ** 2.03 (.769) n.s. 1.69 (.726) n.s. 5.51 .007** E-Cog organization 1.35 (.483) 1.11 (2.63) n.s. 1.48 (.601) n.s. 1.64 (.449) * 5.25 .009** GDS 2.63 (3.63) 0.62 (1.80) n.s. 2.53 (2.88) ** 6.64 (4.18) ** 13.00 <.001*** PHQ-9 4.53 (4.82) 2.29 (2.17) n.s. 3.94 (2.94) ** 10.30 (6.91) ** 15.77 <.001*** Total sample, N = 50 HC group, n = 21 HC vs MC Memory clinic patients, n = 18 MC vs MD Major depressive patients, n = 11 MD vs HC Group comparison n (%) n (%) p n (%) p n (%) p Chi2 p-Value Sex (female) 27 (54) 12 (57.1) n.s. 5 (27.8) ** 10 (90.9) n.s. 11.10 .004** M (SD) M (SD) p M (SD) p M (SD) p F-value p-Value Age 70.52 (7.56) 67.48 (7.20) * 74.06 (6.82) n.s. 70.55 (7.46) n.s. 4.14 .022* Educationa 14.82 (3.43) 15.10 (3.08) n.s. 16.11 (3.38) ** 12.18 (2.92) n.s. 5.42 .008** Interview duration (in min) 16:35 (06:55) 14:32 (06:18) * 20:44 (06:18) * 13:43 (06:12) n.s. 6.26 .004** CERAD-total score 80.90 (11.82) 89.29 (6.68) ** 75.83 (12.56) n.s. 73.18 (8.27) ** 13.02 <.001*** MMSE 28.30 (1.79) 29 (1.22) n.s. 27.10 (3.03) n.s. 27.64 (2.20) n.s. 2.28 .075 E-Cog sum 1.46 (.44) 1.21 (0.16) ** 1.73 (0.52) n.s. 1.52 (0.45) n.s 8.81 .001** E-Cog memory 1.83 (.69) 1.48 (.366) ** 2.24 (.776) n.s. 2.04 (.755) n.s. 7.66 .001** E-Cog language 1.43 (.48) 1.21 (.285) * 1.64 (.570) n.s. 1.58 (.507) n.s. 4.88 .012* E-Cog visuospatial 1.28 (.428) 1.05 (.082) ** 1.54 (.516) n.s. 1.35 (.522) n.s. 7.79 .011* E-Cog planning 1.22 (.386) 1.03 (.072) ** 1.47 (.510) n.s. 1.28 (.337) n.s. 7.72 .001** E-Cog divided attention 1.65 (.652) 1.37 (.365) ** 2.03 (.769) n.s. 1.69 (.726) n.s. 5.51 .007** E-Cog organization 1.35 (.483) 1.11 (2.63) n.s. 1.48 (.601) n.s. 1.64 (.449) * 5.25 .009** GDS 2.63 (3.63) 0.62 (1.80) n.s. 2.53 (2.88) ** 6.64 (4.18) ** 13.00 <.001*** PHQ-9 4.53 (4.82) 2.29 (2.17) n.s. 3.94 (2.94) ** 10.30 (6.91) ** 15.77 <.001*** Note: SD = standard deviation; MMSE = Mini-mental state examination; CERAD = Consortium to Establish a Registry for Alzheimer’s disease; GDS = Geriatric Depression Scale. aEducation in years. *Indicates significant results on the α < .05 level. **Indicates significant results on the α < .01 level; ***indicates significant results on the α < .001 level. p-values are adjusted for age, gender, and education; Bonferroni adjusted p-values. View Large Table 2. Sample Description for All Groups Total sample, N = 50 HC group, n = 21 HC vs MC Memory clinic patients, n = 18 MC vs MD Major depressive patients, n = 11 MD vs HC Group comparison n (%) n (%) p n (%) p n (%) p Chi2 p-Value Sex (female) 27 (54) 12 (57.1) n.s. 5 (27.8) ** 10 (90.9) n.s. 11.10 .004** M (SD) M (SD) p M (SD) p M (SD) p F-value p-Value Age 70.52 (7.56) 67.48 (7.20) * 74.06 (6.82) n.s. 70.55 (7.46) n.s. 4.14 .022* Educationa 14.82 (3.43) 15.10 (3.08) n.s. 16.11 (3.38) ** 12.18 (2.92) n.s. 5.42 .008** Interview duration (in min) 16:35 (06:55) 14:32 (06:18) * 20:44 (06:18) * 13:43 (06:12) n.s. 6.26 .004** CERAD-total score 80.90 (11.82) 89.29 (6.68) ** 75.83 (12.56) n.s. 73.18 (8.27) ** 13.02 <.001*** MMSE 28.30 (1.79) 29 (1.22) n.s. 27.10 (3.03) n.s. 27.64 (2.20) n.s. 2.28 .075 E-Cog sum 1.46 (.44) 1.21 (0.16) ** 1.73 (0.52) n.s. 1.52 (0.45) n.s 8.81 .001** E-Cog memory 1.83 (.69) 1.48 (.366) ** 2.24 (.776) n.s. 2.04 (.755) n.s. 7.66 .001** E-Cog language 1.43 (.48) 1.21 (.285) * 1.64 (.570) n.s. 1.58 (.507) n.s. 4.88 .012* E-Cog visuospatial 1.28 (.428) 1.05 (.082) ** 1.54 (.516) n.s. 1.35 (.522) n.s. 7.79 .011* E-Cog planning 1.22 (.386) 1.03 (.072) ** 1.47 (.510) n.s. 1.28 (.337) n.s. 7.72 .001** E-Cog divided attention 1.65 (.652) 1.37 (.365) ** 2.03 (.769) n.s. 1.69 (.726) n.s. 5.51 .007** E-Cog organization 1.35 (.483) 1.11 (2.63) n.s. 1.48 (.601) n.s. 1.64 (.449) * 5.25 .009** GDS 2.63 (3.63) 0.62 (1.80) n.s. 2.53 (2.88) ** 6.64 (4.18) ** 13.00 <.001*** PHQ-9 4.53 (4.82) 2.29 (2.17) n.s. 3.94 (2.94) ** 10.30 (6.91) ** 15.77 <.001*** Total sample, N = 50 HC group, n = 21 HC vs MC Memory clinic patients, n = 18 MC vs MD Major depressive patients, n = 11 MD vs HC Group comparison n (%) n (%) p n (%) p n (%) p Chi2 p-Value Sex (female) 27 (54) 12 (57.1) n.s. 5 (27.8) ** 10 (90.9) n.s. 11.10 .004** M (SD) M (SD) p M (SD) p M (SD) p F-value p-Value Age 70.52 (7.56) 67.48 (7.20) * 74.06 (6.82) n.s. 70.55 (7.46) n.s. 4.14 .022* Educationa 14.82 (3.43) 15.10 (3.08) n.s. 16.11 (3.38) ** 12.18 (2.92) n.s. 5.42 .008** Interview duration (in min) 16:35 (06:55) 14:32 (06:18) * 20:44 (06:18) * 13:43 (06:12) n.s. 6.26 .004** CERAD-total score 80.90 (11.82) 89.29 (6.68) ** 75.83 (12.56) n.s. 73.18 (8.27) ** 13.02 <.001*** MMSE 28.30 (1.79) 29 (1.22) n.s. 27.10 (3.03) n.s. 27.64 (2.20) n.s. 2.28 .075 E-Cog sum 1.46 (.44) 1.21 (0.16) ** 1.73 (0.52) n.s. 1.52 (0.45) n.s 8.81 .001** E-Cog memory 1.83 (.69) 1.48 (.366) ** 2.24 (.776) n.s. 2.04 (.755) n.s. 7.66 .001** E-Cog language 1.43 (.48) 1.21 (.285) * 1.64 (.570) n.s. 1.58 (.507) n.s. 4.88 .012* E-Cog visuospatial 1.28 (.428) 1.05 (.082) ** 1.54 (.516) n.s. 1.35 (.522) n.s. 7.79 .011* E-Cog planning 1.22 (.386) 1.03 (.072) ** 1.47 (.510) n.s. 1.28 (.337) n.s. 7.72 .001** E-Cog divided attention 1.65 (.652) 1.37 (.365) ** 2.03 (.769) n.s. 1.69 (.726) n.s. 5.51 .007** E-Cog organization 1.35 (.483) 1.11 (2.63) n.s. 1.48 (.601) n.s. 1.64 (.449) * 5.25 .009** GDS 2.63 (3.63) 0.62 (1.80) n.s. 2.53 (2.88) ** 6.64 (4.18) ** 13.00 <.001*** PHQ-9 4.53 (4.82) 2.29 (2.17) n.s. 3.94 (2.94) ** 10.30 (6.91) ** 15.77 <.001*** Note: SD = standard deviation; MMSE = Mini-mental state examination; CERAD = Consortium to Establish a Registry for Alzheimer’s disease; GDS = Geriatric Depression Scale. aEducation in years. *Indicates significant results on the α < .05 level. **Indicates significant results on the α < .01 level; ***indicates significant results on the α < .001 level. p-values are adjusted for age, gender, and education; Bonferroni adjusted p-values. View Large Phenomenology of Cognitive Complaints: IPA Results The IPA yielded 18 categories in MC patients and 10 categories each in MD patients and the HC group. To deliver as concise an account as possible, we here focus on themes unique for each group. Overlapping complaint categories are shown in Table 3 and are described in more detail in our glossary (Supplementary Data). In addition, we have chosen to discuss themes on the upper category level rather than breaking them into their constituting subthemes. The presented themes were the most salient across all participants’ accounts and provide a first-person insight into the experience of cognitive complaints (Table 4). Table 4. Nonoverlapping Complaint Categories Per Group With Example From the Interview HC group n (%) Memory clinic patients n (%) Major depressive patients n (%) No changes in cognitive function 7 (33.3) General decline 7 (38.9) Nonspecific overwork 7 (63.6) “I don’t feel a change. I feel fit. I mean, not necessarily physically but mentally at least.” “I perform only with great effort and no longer neatly” “I even don’t get a book, I can’t bring myself to do (read) it, and I think I couldn’t manage that anymore.” Increased distractibility 5 (23.8) Slowing of cognitive processing speed 6 (33.3) Formal though disorder 3 (27.3) “For example when I want to watch the news. I watch them and someone else in the room is singing. I have to say “stop singing please”, otherwise I couldn’t listen to the TV” “I have the feeling it is slowed down, like delayed” “sometimes it feels like I cannot think” Learning 3 (14.3) Planning 6 (33.3) Initiating actions 2 (18.2) “I have problems in remembering new vocabularies” “when I want to order things, I want to build up categories and then everything gets in a muddle” “in the evening I have to think what I have to do for the next morning” Blank mind 4 (22.2) “complete conversations are simply lost” Visual spatial orientation 4 (22.2) “I have problems to find the shortest route” Deceleration 3 (16.7) “everything goes slow…even thinking” Cognitive flexibility 3 (16.7) “it always happens when I have to do multi-tasking” Derealization 2 (11.1) “I have the feeling that I am disconnected from the reality” Dyscalculia 1 (5.6) “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched”. Loss of control experience 1 (5.6) “I don’t have the control anymore and I couldn’t control the things the way as I would like to” HC group n (%) Memory clinic patients n (%) Major depressive patients n (%) No changes in cognitive function 7 (33.3) General decline 7 (38.9) Nonspecific overwork 7 (63.6) “I don’t feel a change. I feel fit. I mean, not necessarily physically but mentally at least.” “I perform only with great effort and no longer neatly” “I even don’t get a book, I can’t bring myself to do (read) it, and I think I couldn’t manage that anymore.” Increased distractibility 5 (23.8) Slowing of cognitive processing speed 6 (33.3) Formal though disorder 3 (27.3) “For example when I want to watch the news. I watch them and someone else in the room is singing. I have to say “stop singing please”, otherwise I couldn’t listen to the TV” “I have the feeling it is slowed down, like delayed” “sometimes it feels like I cannot think” Learning 3 (14.3) Planning 6 (33.3) Initiating actions 2 (18.2) “I have problems in remembering new vocabularies” “when I want to order things, I want to build up categories and then everything gets in a muddle” “in the evening I have to think what I have to do for the next morning” Blank mind 4 (22.2) “complete conversations are simply lost” Visual spatial orientation 4 (22.2) “I have problems to find the shortest route” Deceleration 3 (16.7) “everything goes slow…even thinking” Cognitive flexibility 3 (16.7) “it always happens when I have to do multi-tasking” Derealization 2 (11.1) “I have the feeling that I am disconnected from the reality” Dyscalculia 1 (5.6) “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched”. Loss of control experience 1 (5.6) “I don’t have the control anymore and I couldn’t control the things the way as I would like to” View Large Table 4. Nonoverlapping Complaint Categories Per Group With Example From the Interview HC group n (%) Memory clinic patients n (%) Major depressive patients n (%) No changes in cognitive function 7 (33.3) General decline 7 (38.9) Nonspecific overwork 7 (63.6) “I don’t feel a change. I feel fit. I mean, not necessarily physically but mentally at least.” “I perform only with great effort and no longer neatly” “I even don’t get a book, I can’t bring myself to do (read) it, and I think I couldn’t manage that anymore.” Increased distractibility 5 (23.8) Slowing of cognitive processing speed 6 (33.3) Formal though disorder 3 (27.3) “For example when I want to watch the news. I watch them and someone else in the room is singing. I have to say “stop singing please”, otherwise I couldn’t listen to the TV” “I have the feeling it is slowed down, like delayed” “sometimes it feels like I cannot think” Learning 3 (14.3) Planning 6 (33.3) Initiating actions 2 (18.2) “I have problems in remembering new vocabularies” “when I want to order things, I want to build up categories and then everything gets in a muddle” “in the evening I have to think what I have to do for the next morning” Blank mind 4 (22.2) “complete conversations are simply lost” Visual spatial orientation 4 (22.2) “I have problems to find the shortest route” Deceleration 3 (16.7) “everything goes slow…even thinking” Cognitive flexibility 3 (16.7) “it always happens when I have to do multi-tasking” Derealization 2 (11.1) “I have the feeling that I am disconnected from the reality” Dyscalculia 1 (5.6) “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched”. Loss of control experience 1 (5.6) “I don’t have the control anymore and I couldn’t control the things the way as I would like to” HC group n (%) Memory clinic patients n (%) Major depressive patients n (%) No changes in cognitive function 7 (33.3) General decline 7 (38.9) Nonspecific overwork 7 (63.6) “I don’t feel a change. I feel fit. I mean, not necessarily physically but mentally at least.” “I perform only with great effort and no longer neatly” “I even don’t get a book, I can’t bring myself to do (read) it, and I think I couldn’t manage that anymore.” Increased distractibility 5 (23.8) Slowing of cognitive processing speed 6 (33.3) Formal though disorder 3 (27.3) “For example when I want to watch the news. I watch them and someone else in the room is singing. I have to say “stop singing please”, otherwise I couldn’t listen to the TV” “I have the feeling it is slowed down, like delayed” “sometimes it feels like I cannot think” Learning 3 (14.3) Planning 6 (33.3) Initiating actions 2 (18.2) “I have problems in remembering new vocabularies” “when I want to order things, I want to build up categories and then everything gets in a muddle” “in the evening I have to think what I have to do for the next morning” Blank mind 4 (22.2) “complete conversations are simply lost” Visual spatial orientation 4 (22.2) “I have problems to find the shortest route” Deceleration 3 (16.7) “everything goes slow…even thinking” Cognitive flexibility 3 (16.7) “it always happens when I have to do multi-tasking” Derealization 2 (11.1) “I have the feeling that I am disconnected from the reality” Dyscalculia 1 (5.6) “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched”. Loss of control experience 1 (5.6) “I don’t have the control anymore and I couldn’t control the things the way as I would like to” View Large Healthy Control Group For some individuals, aging was not associated with subjective cognitive changes, while others reported difficulties in prospective memory. A number of subthemes emerged within this key theme. Many participants mentioned situations like: “You are going from one room to another and don’t know what you actually wanted,” “I have to write down all my appointments,” or “Nowadays, I have to make a plan.” Overall the HC group reported a notion of cognitive changes but it was common to refer to these as processes of normal aging. Some did not experience any cognitive changes at all. Learning —This category comprises the experience that learning seems more difficult. This involves examples like: “it’s more difficult to hold new words,” “you are just living from the saved memory more than from the new ones,” “I couldn’t remember numbers like in old times.” Increased Distractibility —Increased distractibility is exemplified by accounts such as “you have to listen clearer to understand and to remember.” Alternatively, increased distractibility involves expressions such as the “background noise is disturbing me nowadays” or “… that I have to force myself to concentrate on the book and not on other things. But I often digress.” Memory Clinic Group Self-experienced cognitive changes in MC patients were mostly described in rich detail and with common examples from everyday life. Some patients reported to perceive their experience of impaired cognition as annoying and as causing worries, sadness, and anger. Visual Spatial Orientation —Problems with visuospatial orientation are exemplified by accounts such as: “Problems to find the shortest route” or “I find the destination but always with great detours.” Others experience failures like: “I start to upset things. If I take something, I grab something but do not notice that there is something beneath and so I upset it.” Cognitive Flexibility —There were also subjectively experienced changes in cognitive flexibility. Cognitive flexibility includes phrases like “It always happens when doing multitasking! It’s hard for me.” Some patients describe problems with “switch(ing)” between different tasks. Planning —While for some patients aging brings problems in scheduling, others experience problems in organizing. For example, “When I order something. And forget about how I ordered it.” Slowing of Cognitive Processing Speed —Many experience a slowing of cognitive processing speed by accounts such as: “I am no longer able to conceive complicated texts that fast. And … eh … likely also not to keep them (in mind).” Deceleration —Deceleration is apparent in phrases such as “that everything is a bit slower, so that I have to search for it even when it’s just a second or a minute.” The theme is also expressed through accounts such as “I have the feeling that everything is slowed down, delayed.” Blank Mind —This category reflects smaller memory lapses up to complete memory “black-outs.” This involves examples like “I was just reading a small part and then suddenly I totally blacked-out,” “complete conversations are simply lost” or “that bothers me at most … I have these … eh memory lapses.” Dyscalculia —Participants also experienced problems in dealing with numbers. This category reflects reports such as “dealing with numbers is becoming worse” or “the worst are situations such as in a supermarket at the check-out counter when I have to pay and want to give the money matched.” Loss of Control Experience —Loss of control experience is exemplified by accounts such as: “so I haven’t had the control and (...) to control the things I wanted to” or “I know that what happened was wrong but I was not able to manage the things the way that everything goes the right way.” Derealization —This category defines experiences in which participants felt disconnected from reality. This involves statements like: “I have the feeling that I am disconnected from reality” or “there are things where I tell someone that they happened in a certain way but that isn’t the truth … and that isn’t meant as a lie by me … it’s just … I have the wrong memory about it. My memory is kind of deformed.” General Decline —Many experience a decline in physical and mental fitness. Participants mention “a lot of things are getting more difficult” and that they “perform only with great effort and no longer neatly.” Major Depressive Group Participants with major depression complained frequently about memory difficulties. In comparison to MC patients, reports of complaints were more abstract, that is, the participants had difficulties in verbalizing and contextualizing specific examples for the experienced difficulties. The expressions were often less detailed as compared to the MC group, and many complaints seemed to emerge from depressive symptoms (i.e., complaints were more related to a lack of drive and a psychical state of exhaustion), rather than from cognitive decline. Formal Thought Disorder —“It feels like I cannot think” illustrates the experiences of formal thought disorder. Common reports include “dull feelings,” “sometimes, tugging and plucking in the brain,” or expressions such as “cannot think.” Initiating actions —People with depression expressed difficulties in initiating actions and in this regard a dependency on auxiliary means (e.g., a structured activity plan). For example, “I have to think about what I can do the next day so that I am not without tasks for the next day.” Unspecific Overwork —Depressive participants expressed feelings of unspecific overwork. A number of subthemes contributed to this upper category. These were experiences like “everything is so hard for me,” “Everything doesn’t work the way it should,” “That something isn’t right,” or “Everything is a bit difficult.” Summary of Results: Similarities and Differences of Cognitive Complaints Across Groups Looking at the similarities of cognitive complaints across groups, it is important to note that even the healthy controls without cognitive impairment recognize subjective cognitive changes and where moreover able to give examples from daily living. Across all groups, participants reported problems in “action monitoring.” This means that actions which were intended by the person cannot be actively recalled in the specific situation or are completely forgotten. Alternatively, routine processes are not fully monitored, that is, the patient is not sure whether he has turned off the stove or not. A majority of participants from every group describe themselves as forgetful and use terms like “forgetfulness.” All participants frequently complained about problems remembering names and content memory, and reported word finding difficulties. As these complaints seem to be rather general in old age, they may contain little diagnostic information. Complaints in the MD group were generally more abstract, containing little detail or context. MD patients described memory problems that were emotionally incriminating and they tended to complain bitterly, however, they were largely unable to provide detailed descriptions compared to other groups. Their complaints were consistent with depressive symptoms, comprising concentration difficulties, a feeling of nonspecific overwork, and problems with initiation actions. Another unique symptom in the depressive group was a formal thought disorder. In the HC group, participants appraised memory changes largely as part of a normal, nonalarming aging process. This was one reason why some HC participants mentioned no marked changes in cognition. However, other participants talked about cognitive failures comprising increased distractibility or problems in learning vocabulary, without being anxious or worried about it. Most unique complaint themes were derived in MC patients. Besides reporting extensive memory problems, they were the only group experiencing executive functioning deficits, for example, in planning and cognitive flexibility. In addition, visuospatial orientation difficulties and dyscalculia were only mentioned by MC patients. Complaints also comprised reports about general physical/mental decline, loss of control experience and derealization. Importantly, these latter categories, although uniquely reported in the MC group, are normally not subsumed under the term “cognitive decline.” The fact that MC patients reported these symptoms suggests that the phenomenological experience of cognitive decline in this group is not confined to memory problems. In addition, they were the only group describing memory lapses drastically as “complete memory lapses,” that is, not only reporting a retrieval difficulty but a total loss of information from memory. They further reported changes in “short-term memory.” However, this term was often used in reports about working memory problems which is why it was summarized into the category “General complaints about increasing memory problems.” Lastly, only MC patients reported experiences of slowing cognitive processing speed. Subjective Cognitive Complaints Compared to Quantitative Assessment and Common Diagnostic Criteria To examine whether common instruments for assessment of subjective cognitive complaints capture all themes reported in our interview, we compared IPA-derived cognitive complaints of MC patients with the item content of the E-Cog (Farias et al., 2008) (Table 5). We found that the E-Cog does not capture all subjective complaints reported by the MC patients. Specifically, the categories “loss of control experience,” “derealization,” and “general decline” were neither found to be represented in the E-Cog nor in the examples provided for the neurocognitive domains enlisted in the DSM-5 neurocognitive disorder section (Table 5). Further, the categories “blank mind” and “action monitoring” could not be assigned to these domains unambiguously. Table 5. Comparison of Memory Clinic Patient’s IPA-derived SCD Themes With the DSM-5 (American Psychiatric Association, 2013) Neurocognitive Domains and the E-Cog (Farias et al., 2008)) SCD themes of memory clinic patients Neurocognitive domains DSM-5 (American Psychiatric Association, 2013) E-Cog domains (Farias et al., 2008) Deceleration Complex alertness — Word finding difficulties speech Language Memory for names speech Language Action monitoring Executive function (Organization) Slowing of cognitive processing speed Complex alertness — Concentration difficulties Complex alertness Divided attention Visual spatial disorientation Visuo-constructive Visuospatial abilities General complaints about increasing memory problems Learning and memory Memory Cognitive flexibility Complex alertness Divided attention Planning Executive function Organization Blank mind (Learning and memory) (memory) Dyscalculia Complex alertness Divided attention Loss of control experience — — Derealization — — General decline — — Forgetfulness Learning and memory Memory Content memory Learning and memory Memory Prospective memory (Executive function) (Planning) — Social cognition — SCD themes of memory clinic patients Neurocognitive domains DSM-5 (American Psychiatric Association, 2013) E-Cog domains (Farias et al., 2008) Deceleration Complex alertness — Word finding difficulties speech Language Memory for names speech Language Action monitoring Executive function (Organization) Slowing of cognitive processing speed Complex alertness — Concentration difficulties Complex alertness Divided attention Visual spatial disorientation Visuo-constructive Visuospatial abilities General complaints about increasing memory problems Learning and memory Memory Cognitive flexibility Complex alertness Divided attention Planning Executive function Organization Blank mind (Learning and memory) (memory) Dyscalculia Complex alertness Divided attention Loss of control experience — — Derealization — — General decline — — Forgetfulness Learning and memory Memory Content memory Learning and memory Memory Prospective memory (Executive function) (Planning) — Social cognition — Note. The table shows a comparison of memory clinic patient’s IPA-derived complaint themes with the DSM-5 neurocognitive domains and the subscales of the E-Cog as a representative quantitative assessment instrument; domains in brackets reflect unclear domain assignment. View Large Table 5. Comparison of Memory Clinic Patient’s IPA-derived SCD Themes With the DSM-5 (American Psychiatric Association, 2013) Neurocognitive Domains and the E-Cog (Farias et al., 2008)) SCD themes of memory clinic patients Neurocognitive domains DSM-5 (American Psychiatric Association, 2013) E-Cog domains (Farias et al., 2008) Deceleration Complex alertness — Word finding difficulties speech Language Memory for names speech Language Action monitoring Executive function (Organization) Slowing of cognitive processing speed Complex alertness — Concentration difficulties Complex alertness Divided attention Visual spatial disorientation Visuo-constructive Visuospatial abilities General complaints about increasing memory problems Learning and memory Memory Cognitive flexibility Complex alertness Divided attention Planning Executive function Organization Blank mind (Learning and memory) (memory) Dyscalculia Complex alertness Divided attention Loss of control experience — — Derealization — — General decline — — Forgetfulness Learning and memory Memory Content memory Learning and memory Memory Prospective memory (Executive function) (Planning) — Social cognition — SCD themes of memory clinic patients Neurocognitive domains DSM-5 (American Psychiatric Association, 2013) E-Cog domains (Farias et al., 2008) Deceleration Complex alertness — Word finding difficulties speech Language Memory for names speech Language Action monitoring Executive function (Organization) Slowing of cognitive processing speed Complex alertness — Concentration difficulties Complex alertness Divided attention Visual spatial disorientation Visuo-constructive Visuospatial abilities General complaints about increasing memory problems Learning and memory Memory Cognitive flexibility Complex alertness Divided attention Planning Executive function Organization Blank mind (Learning and memory) (memory) Dyscalculia Complex alertness Divided attention Loss of control experience — — Derealization — — General decline — — Forgetfulness Learning and memory Memory Content memory Learning and memory Memory Prospective memory (Executive function) (Planning) — Social cognition — Note. The table shows a comparison of memory clinic patient’s IPA-derived complaint themes with the DSM-5 neurocognitive domains and the subscales of the E-Cog as a representative quantitative assessment instrument; domains in brackets reflect unclear domain assignment. View Large Discussion and Implications Summary While a number of qualitative studies have provided insights into the phenomenological experience of living with MCI or receiving a diagnosis of moderate to severe dementia (Clare et al., 2005, 2008; De Boer et al., 2007; Harman & Clare, 2006; Vernooij-Dassen, Derksen, Scheltens, & Moniz-Cook, 2006), the phenomenological (i.e., first person) experience of cognitive complaints has so far only been described in Parkinson’s disease (Kudlicka, Hindle, Spencer, & Clare, 2017). The present study is the first to undertake a detailed description of the experience and components of cognitive complaints in three different diagnostic groups (Finlay, 2012). Our findings provide evidence that common, quantitative SCD instruments do not capture some salient MC patient-specific phenomenological experiences. On the other hand, some themes were equally mentioned by the two patient groups as well as the healthy controls, suggesting that they are not group-specific and possibly of limited diagnostic value. Unique themes emerged in the different groups which suggest different complaint patterns in MC, MD, and HC. HC reflected that learning gets harder with age and mentioned increased distractibility. A majority of participants talked about problems we categorized as part of prospective memory, also mentioned by MC and MD patients. Memory clinic patients offered the most extensive reflection on their perceived change in cognition. A number of participants reported problems with short-term memory, slowing of cognitive processing speed, concentration difficulties, deceleration, and general complaints about increasing memory problems. In addition, experience of blank mind emerged as a powerful theme specific to this population. A number of MC patients reflected less cognitive flexibility, problems with planning, and visual spatial orientation. Interestingly, they were the only group reporting about complaints one would designate as metacognition (Thöne-Otto & Markowitsch, 2004). With 18 categories in total, the MC group produced the most diverse description of cognitive complaints. In MD patients, we derived the following unique themes from the analytic process: formal thought disorder, initiating action and nonspecific overwork. Accordingly, these symptoms aligned with the clinical symptomatology of depression. In this regard, it is important to point out that participants in this study were asked to talk freely about perceived cognitive changes. The present finding highlights that reports of SCD reflect an individual’s very subjective experience and own understanding of cognition rather than decline in a given set of theoretical cognitive domains. Regarding the current diagnostic criteria, the proposed neurocognitive domains of the DSM-5 section do not fully capture the subjective experience of cognitive decline revealed through IPA in this study. Even if DSM-5 domains were considered as broader categories, they do not encapsulate all complaints presented by MC patients, that is, loss of control experiences, the feeling of general decline, and experience of derealization. These themes were also not covered by the E-Cog. Our findings emphasize the need to rethink theoretical frames of cognitive complaint measurement in light of classifying salient symptoms specific to different diagnostic categories. Qualitatively derived themes demonstrate that participants recognize, and can verbally express, a great variety of cognitive changes. Participants’ experience of cognitive failures varied along groups and individuals and many expressed symptoms that mirror a personal or popular rather than a medical understanding of the condition (e.g., short-term memory was used as a term for working memory). It is apparent from the interviews that the participants of this study had relatively preserved insight into their own experience of cognitive failures. Healthy controls, as well as MC and MD patients, reported cognitive complaints. Thus, the main difference in concerns among different groups is not simply the occurrence of cognitive failures, but rather a more dimensional qualitative aspect of the complaint itself. Current quantitative measurements are unable to adequately capture this level of experience and could potentially confound results in the SCD field, particularly in relation to prevalence and AD risk estimates. This highlights the need of a view beyond, or a more sophisticated approach to, the quantitative aspects of subjective cognitive complaints due to preclinical AD versus due to depression versus an aspect of “healthy” aging. This account challenges the common operationalization of cognitive complaints as a singular symptom that can be easily measured with standardized questionnaires. Study Limitations and Future Research A critique point is that IPA provides no executive step of bracketing. This could lead to a lack of validity in the analysis process (Giorgi, 2011). However, making sense of an experience by using IPA inevitably involves the interpretative engagement of the researcher (Smith et al., 2009). While, on the one hand, this may increase the potential of preconceptions influencing the research process, it is, on the other hand, close to the procedure in clinical routine where physicians interpret patients’ individual reports on the background of their (pre-existing) professional knowledge. Thus, we believe that, despite the limitations concerning bracketing, IPA was likely the most suited method for this study. Furthermore, we employed an iterative procedure within a group setting to support a valid analysis process. Our approach was in the last step deductive and theory driven by labeling the complaint themes with abstract complaint categories. The validation of these categories is a crucial next step which should be done with a different analytic approach. Another possible limitation is, that of the MC patients, 10 individuals had MCI and were potentially less responsive to verbal and nonverbal communication and less likely to demonstrate awareness of functional deficits (Tabert et al., 2002). To try to counteract this issue, we recruited participants on the condition that they were willing to talk about their self-perceived cognitive failures. This necessarily excluded people who were unaware of their cognitive impairments. The MC group had a relatively high MMSE score which supports the unimpaired awareness of our sample (Kalbe et al., 2005). It is possible that a sample of more advanced MCI patients would not demonstrate the level of self-awareness shown in our sample (Galeone, Pappalardo, Chieffi, Iavarone, & Carlomagno, 2011; Okonkwo et al., 2009; Orfei et al., 2010). However, considering that SCD is gaining interest primarily as an indicator of the earliest clinical stages of the AD trajectory, we did not consider this to be of major concern. Similar problems were possible in the MD group; many studies report an association between awareness and symptoms of depression (Burke et al., 1998; Smith, Henderson, McCleary, Murdock, & Buckwalter, 2000), although this finding has been contested (Arkin & Mahendra, 2001; Cummings, Ross, Absher, Gornbein, & Hadjiaghai, 1995). Another limitation of our study is that there were no biomarkers or longitudinal data available to contrast the phenomenology of subjective cognitive complaints in patients with preclinical or prodromal AD versus other groups. While 40%–60% of MC participants in similar settings have signs of amyloid and/or tau pathology (Wolfsgruber et al., 2017) many memory clinic attendees will be worried, but unaffected by AD. In contrast, a substantial proportion of healthy (“noncomplaining”) older adults has evidence of AD pathology (Jansen et al., 2015). Availability of AD biomarker information would be most useful as attention is now focused on diagnostic utility of certain aspects of cognitive complaints with regard to underlying AD pathology (Rabin et al., 2015). With regard to questionnaire data, first interesting results involving biomarkers have been reported (Amariglio et al., 2012; La Joie et al., 2016; van Harten et al., 2013; Wolfsgruber et al., 2017). For example, La Joie and colleagues (2016) found associations between specific SCD items and AD biomarkers. Endorsement of complaints in items of temporal orientation (a domain which was also group-specific for memory clinic patients in our study) was associated with Aß-positivity in amnestic MCI patients. In contrast, higher endorsement in items related to prospective memory and face-name memory were related to Aß-negativity. In line with these results, prospective memory complaints and problems with memory for names were also nonspecific for a diagnostic group in our study (Table 3). Table 3. Overlapping Complaint Categories IPA categories HC group Memory clinic patients Major depressive patients Total Kruskal-Wallisa n (%) n (%) n (%) n (%) χ2 p General complaints about Increasing memory problems 9 (42.9) 9 (50.0) 1 (9.1) 19 (38.0) 5.108 .078 Action monitoring 7 (33.3) 7 (38.9) 2 (18.2) 16 (32.0) 1.347 .510 Forgetfulness 3 (14.3) 9 (50.0) 5 (45.5) 17 (34.0) 6.207 .045* Content memory 4 (19.0) 1 (5.6) 2 (18.2) 7 (14.0) 1.637 .441 Prospective memory 9 (42.9) 7 (38.9) 3 (27.3) 19 (38.0) .739 .691 Memory for names 7 (33.3) 6 (33.3) 3 (27.3) 16 (32.0) .142 .931 Word finding difficulties 5 (23.8) 7 (38.9) 4 (36.4) 16 (32.0) 1.114 .573 Concentration difficulties 1 (4.8) 3 (16.7) 4 (36.4) 8 (16.0) 5.266 .072 IPA categories HC group Memory clinic patients Major depressive patients Total Kruskal-Wallisa n (%) n (%) n (%) n (%) χ2 p General complaints about Increasing memory problems 9 (42.9) 9 (50.0) 1 (9.1) 19 (38.0) 5.108 .078 Action monitoring 7 (33.3) 7 (38.9) 2 (18.2) 16 (32.0) 1.347 .510 Forgetfulness 3 (14.3) 9 (50.0) 5 (45.5) 17 (34.0) 6.207 .045* Content memory 4 (19.0) 1 (5.6) 2 (18.2) 7 (14.0) 1.637 .441 Prospective memory 9 (42.9) 7 (38.9) 3 (27.3) 19 (38.0) .739 .691 Memory for names 7 (33.3) 6 (33.3) 3 (27.3) 16 (32.0) .142 .931 Word finding difficulties 5 (23.8) 7 (38.9) 4 (36.4) 16 (32.0) 1.114 .573 Concentration difficulties 1 (4.8) 3 (16.7) 4 (36.4) 8 (16.0) 5.266 .072 Note. p-Value = .05, two-tailed sign. *Indicates significant results on the α < .05 level. adf for all categories 2. View Large Table 3. Overlapping Complaint Categories IPA categories HC group Memory clinic patients Major depressive patients Total Kruskal-Wallisa n (%) n (%) n (%) n (%) χ2 p General complaints about Increasing memory problems 9 (42.9) 9 (50.0) 1 (9.1) 19 (38.0) 5.108 .078 Action monitoring 7 (33.3) 7 (38.9) 2 (18.2) 16 (32.0) 1.347 .510 Forgetfulness 3 (14.3) 9 (50.0) 5 (45.5) 17 (34.0) 6.207 .045* Content memory 4 (19.0) 1 (5.6) 2 (18.2) 7 (14.0) 1.637 .441 Prospective memory 9 (42.9) 7 (38.9) 3 (27.3) 19 (38.0) .739 .691 Memory for names 7 (33.3) 6 (33.3) 3 (27.3) 16 (32.0) .142 .931 Word finding difficulties 5 (23.8) 7 (38.9) 4 (36.4) 16 (32.0) 1.114 .573 Concentration difficulties 1 (4.8) 3 (16.7) 4 (36.4) 8 (16.0) 5.266 .072 IPA categories HC group Memory clinic patients Major depressive patients Total Kruskal-Wallisa n (%) n (%) n (%) n (%) χ2 p General complaints about Increasing memory problems 9 (42.9) 9 (50.0) 1 (9.1) 19 (38.0) 5.108 .078 Action monitoring 7 (33.3) 7 (38.9) 2 (18.2) 16 (32.0) 1.347 .510 Forgetfulness 3 (14.3) 9 (50.0) 5 (45.5) 17 (34.0) 6.207 .045* Content memory 4 (19.0) 1 (5.6) 2 (18.2) 7 (14.0) 1.637 .441 Prospective memory 9 (42.9) 7 (38.9) 3 (27.3) 19 (38.0) .739 .691 Memory for names 7 (33.3) 6 (33.3) 3 (27.3) 16 (32.0) .142 .931 Word finding difficulties 5 (23.8) 7 (38.9) 4 (36.4) 16 (32.0) 1.114 .573 Concentration difficulties 1 (4.8) 3 (16.7) 4 (36.4) 8 (16.0) 5.266 .072 Note. p-Value = .05, two-tailed sign. *Indicates significant results on the α < .05 level. adf for all categories 2. View Large While these results are encouraging, a biomarker based validation approach has not been done for cognitive complaint aspects derived from qualitative interview data. In this regard, a future study could investigate whether AD biomarker positive versus negative memory clinic patients differ regarding specific complaint categories as derived from the present study. This could involve either a different (i.e., deductive) qualitative approach, such as content analysis, or a mixed-method approach. Ideally, this could lead to a clinically feasible interview and classification schedule for AD typical cognitive complaints, and to more specific cognitive complaint questionnaires. Such measures would be most useful to define SCD due to AD in clinical and research settings. Conclusion Only relatively small amount of research currently exists that explores the experience of cognitive complaints as a qualitative phenomenon. Results showed that cognitive complaints are a complex experience that differs in its exact appearance across patients. Our data suggest that measuring cognitive complaints via currently employed quantitative instruments, on the one hand, leaves out aspects of this complex and heterogeneous experience and, on the other hand, may capture themes with little diagnostic utility. These shortcomings in hitherto existing measures of cognitive complaints may partly explain the heterogeneous findings regarding the association of cognitive complaints with incipient AD. This study reveals that there is much to be gained from talking with and listening to people with cognitive complaints across diagnostic categories. We argue that there is a justification for using clinical interviews to complement questionnaires in SCD assessment and for improving common questionnaires toward a more reliable and valid operationalization of cognitive complaints as a risk factor for AD. Supplementary Material Supplementary data are available at The Gerontologist online. Funding The study was supported by the University of Bonn, Department for Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Department of Psychiatry and Psychotherapy and the German Center for Neurodegenerative Diseases (DZNE). Conflicts of Interest None reported. Acknowledgments We appreciated the support of Wolfgang Maier, Alexandra Polcher, Luca Kleineidam, Sandra Röske, Catherine Widmann, Debora Melo van Lent, and Alexander Koppara. All authors report no disclosures. Ethical approval: The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.The entire study protocol was approved by the local ethic committee at the University of Bonn. References Abdulrab , K. , & Heun , R . ( 2008 ). Subjective memory impairment. A review of its definitions indicates the need for a comprehensive set of standardised and validated criteria . European Psychiatry , 23 , 321 – 330 . doi: 10.1016/j.eurpsy.2008.02.004 Google Scholar CrossRef Search ADS PubMed Albert , M. S. , DeKosky , S. T. , Dickson , D. , Dubois , B. , Feldman , H. H. , Fox , N. C. ,… Phelps , C. H . ( 2011 ). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease . Alzheimer’s & Dementia , 7 , 270 – 279 . doi: 10.1016/j.jalz.2011.03.008 Google Scholar CrossRef Search ADS Amariglio , R. E. , Becker , J. A. , Carmasin , J. , Wadsworth , L. P. , Lorius , N. , Sullivan , C. ,… Rentz , D. M . ( 2012 ). Subjective cognitive complaints and amyloid burden in cognitively normal older individuals . Neuropsychologia , 50 , 2880 – 2886 . doi: 10.1016/j.neuropsychologia.2012.08.011 Google Scholar CrossRef Search ADS PubMed Amariglio , R. E. , Donohue , M. C. , Marshall , G. A. , Rentz , D. M. , Salmon , D. P. , Ferris , S. H .,… Alzheimer’s Disease Cooperative Study . ( 2015 ). Tracking early decline in cognitive function in older individuals at risk for Alzheimer’s disease dementia: The Alzheimer’s Disease Cooperative Study Cognitive Function Instrument . JAMA Neurology , 72 , 446 – 454 . doi: 10.1001/jamaneurol.2014.3375 Google Scholar CrossRef Search ADS PubMed American Psychiatric Association . ( 2013 ). Diagnostic and statistical manual of mental disorders (DSM-5®) . American Psychiatric Pub . Arkin , S. , & Mahendra , N . ( 2001 ). Insight in Alzheimer’s patients: Results of a longitudinal study using three assessment methods . American Journal of Alzheimer’s Disease and Other Dementias , 16 , 211 – 224 . doi: 10.1177/153331750101600401 Google Scholar CrossRef Search ADS PubMed Balash , Y. , Mordechovich , M. , Shabtai , H. , Giladi , N. , Gurevich , T. , & Korczyn , A. D . ( 2013 ). Subjective memory complaints in elders: Depression, anxiety, or cognitive decline ? Acta Neurologica Scandinavica , 127 , 344 – 350 . doi: 10.1111/ane.12038 Google Scholar CrossRef Search ADS PubMed Balash , Y. , Mordechovich , M. , Shabtai , H. , Merims , D. , & Giladi , N . ( 2010 ). Subjective memory decline in healthy community-dwelling elders. What does this complain mean ? Acta Neurologica Scandinavica , 121 , 194 – 197 . doi: 10.1111/j.1600-0404.2009.01159.x Google Scholar CrossRef Search ADS PubMed Broadbent , D. E. , Cooper , P. F. , FitzGerald , P. , & Parkes , K. R . ( 1982 ). The Cognitive Failures Questionnaire (CFQ) and its correlates . The British Journal of Clinical Psychology , 21(Pt 1) , 1 – 16 . doi: 10.1111/j.2044–8260.1982.tb01421.x Google Scholar CrossRef Search ADS PubMed Buckley , R. F. , Ellis , K. A. , Ames , D. , Rowe , C. C. , Lautenschlager , N. T. , Maruff , P. ,… Saling , M. M .; Australian Imaging Biomarkers and Lifestyle Study of Ageing (AIBL) Research Group . ( 2015 ). Phenomenological characterization of memory complaints in preclinical and prodromal Alzheimer’s disease . Neuropsychology , 29 , 571 – 581 . doi: 10.1037/neu0000156 Google Scholar CrossRef Search ADS PubMed Burke , W. J. , Roccaforte , W. H. , Wengel , S. P. , McArthur-Miller , D. , Folks , D. G. , & Potter , J. F . ( 1998 ). Disagreement in the reporting of depressive symptoms between patients with dementia of the Alzheimer type and their collateral sources . The American Journal of Geriatric Psychiatry , 6 , 308 – 319 . Google Scholar CrossRef Search ADS PubMed Chételat , G. , Villemagne , V. L. , Bourgeat , P. , Pike , K. E. , Jones , G. , Ames , D. ,… Rowe , C. C .; Australian Imaging Biomarkers and Lifestyle Research Group . ( 2010 ). Relationship between atrophy and beta-amyloid deposition in Alzheimer disease . Annals of Neurology , 67 , 317 – 324 . doi: 10.1002/ana.21955 Google Scholar PubMed Clare , L. , Roth , I. , Pratt , R. , & Clare , L . ( 2005 ). Perceptions of change over time in early-stage Alzheimer’s disease: Implications for understanding awareness and coping style . Dementia , 4 , 487 – 520 . doi: 10.1177/1471301205058304 Google Scholar CrossRef Search ADS Clare , L. , Rowlands , J. , Bruce , E. , Surr , C. , & Downs , M . ( 2008 ). ‘I don’t do like I used to do’: A grounded theory approach to conceptualising awareness in people with moderate to severe dementia living in long-term care . Social Science & Medicine (1982) , 66 , 2366 – 2377 . doi: 10.1016/j.socscimed.2008.01.045 Google Scholar CrossRef Search ADS PubMed Crook , T. H. III , Feher , E. P. , & Larrabee , G. J . ( 1992 ). Assessment of memory complaint in age-associated memory impairment: The MAC-Q . International Psychogeriatrics , 4 , 165 – 176 . doi: 10.1017/S1041610292000991 Google Scholar CrossRef Search ADS PubMed Cummings , J. L. , Ross , W. , Absher , J. , Gornbein , J. , & Hadjiaghai , L . ( 1995 ). Depressive symptoms in Alzheimer disease: Assessment and determinants . Alzheimer Disease and Associated Disorders , 9 , 87 – 93 . Google Scholar CrossRef Search ADS PubMed de Boer , M. E. , Hertogh , C. M. , Dröes , R. M. , Riphagen , I. I. , Jonker , C. , & Eefsting , J. A . ( 2007 ). Suffering from dementia—The patient’s perspective: A review of the literature . International Psychogeriatrics , 19 , 1021 – 1039 . doi: 10.1017/S1041610207005765 Google Scholar CrossRef Search ADS PubMed Farias , S. T. , Mungas , D. , Reed , B. R. , Cahn-Weiner , D. , Jagust , W. , Baynes , K. , & Decarli , C . ( 2008 ). The measurement of everyday cognition (ECog): Scale development and psychometric properties . Neuropsychology , 22 , 531 – 544 . doi: 10.1037/0894-4105.22.4.531 Google Scholar CrossRef Search ADS PubMed Finlay , L . ( 2012 ). Debating phenomenological methods . In N. Friesen, C. Henriksson, & T. Saevi (Eds.), Hermeneutic phenomenology in education: method and practice (pp. 17 – 37 ). Rotterdam: Sense Publishers. Google Scholar CrossRef Search ADS Galeone , F. , Pappalardo , S. , Chieffi , S. , Iavarone , A. , & Carlomagno , S . ( 2011 ). Anosognosia for memory deficit in amnestic mild cognitive impairment and Alzheimer’s disease . International Journal of Geriatric Psychiatry , 26 , 695 – 701 . doi: 10.1002/gps.2583 Google Scholar CrossRef Search ADS PubMed Giorgi , A . ( 2011 ). IPA and science: A response to Jonathan Smith . Journal of Phenomenological Psychology , 42 , 195 – 216 . Google Scholar CrossRef Search ADS Harman , G. , & Clare , L . ( 2006 ). Illness representations and lived experience in early-stage dementia . Qualitative Health Research , 16 , 484 – 502 . doi: 10.1177/1049732306286851 Google Scholar CrossRef Search ADS PubMed Jansen , W. J. , Ossenkoppele , R. , Knol , D. L. , Tijms , B. M. , Scheltens , P. , Verhey , F. R. ,… Zetterberg , H .; Amyloid Biomarker Study Group . ( 2015 ). Prevalence of cerebral amyloid pathology in persons without dementia: A meta-analysis . JAMA , 313 , 1924 – 1938 . doi: 10.1001/jama.2015.4668 Google Scholar CrossRef Search ADS PubMed Jessen , F. , Amariglio , R. E. , van Boxtel , M. , Breteler , M. , Ceccaldi , M. , Chételat , G. ,… Wagner , M .; Subjective Cognitive Decline Initiative (SCD-I) Working Group . ( 2014 ). A conceptual framework for research on subjective cognitive decline in preclinical Alzheimer’s disease . Alzheimer’s & Dementia , 10 , 844 – 852 . doi: 10.1016/j.jalz.2014.01.001 Google Scholar CrossRef Search ADS Jessen , F. , Wolfsgruber , S. , Wiese , B. , Bickel , H. , Mösch , E. , Kaduszkiewicz , H. ,… Wagner , M . ( 2013 ). AD dementia risk in late MCI, in early MCI, and in subjective memory impairment . Alzheimer’s & Dementia , 10 , 76 – 83 . doi: 10.1016/j.jalz.2012.09.017 Google Scholar CrossRef Search ADS Johansson , M. M. , Marcusson , J. , & Wressle , E . ( 2015 ). Cognitive impairment and its consequences in everyday life: Experiences of people with mild cognitive impairment or mild dementia and their relatives . International Psychogeriatrics , 27 , 949 – 958 . doi: 10.1017/S1041610215000058 Google Scholar CrossRef Search ADS PubMed Jonker , C. , Geerlings , M. I. , & Schmand , B . ( 2000 ). Are memory complaints predictive for dementia? A review of clinical and population-based studies . International Journal of Geriatric Psychiatry , 15 , 983 – 991 . doi: 10.1002/1099–1166(200011)15:11<983::AID-GPS238>3.0.CO;2–5 Google Scholar CrossRef Search ADS PubMed Kalbe , E. , Salmon , E. , Perani , D. , Holthoff , V. , Sorbi , S. , Elsner , A. ,… Herholz , K . ( 2005 ). Anosognosia in very mild Alzheimer’s disease but not in mild cognitive impairment . Dementia and Geriatric Cognitive Disorders , 19 , 349 – 356 . doi: 10.1159/000084704 Google Scholar CrossRef Search ADS PubMed Koppara , A. , Wagner , M. , Lange , C. , Ernst , A. , Wiese , B. , König , H. H. ,… Jessen , F . ( 2015 ). Cognitive performance before and after the onset of subjective cognitive decline in old age . Alzheimer’s & Dementia (Amsterdam, Netherlands) , 1 , 194 – 205 . doi: 10.1016/j.dadm.2015.02.005 Google Scholar PubMed Kroenke , K. , Spitzer , R. L. , & Williams , J. B . ( 2001 ). The PHQ-9: Validity of a brief depression severity measure . Journal of General Internal Medicine , 16 , 606 – 613 . doi: 10.1046/j.1525-1497.2001.016009606.x Google Scholar CrossRef Search ADS PubMed Kudlicka , A. , Hindle , J. V. , Spencer , L. E. , & Clare , L . ( 2017 ). Everyday functioning of people with Parkinson’s disease and impairments in executive function: A qualitative investigation . Disability and Rehabilitation , 1 – 13 . doi: 10.1080/09638288.2017.1334240 La Joie , R. , Perrotin , A. , Egret , S. , Pasquier , F. , Tomadesso , C. , Mézenge , F. , … Chételat , G . ( 2016 ). Qualitative and quantitative assessment of self-reported cognitive difficulties in nondemented elders: Association with medical help seeking, cognitive deficits, and β-amyloid imaging . Alzheimer’s & Dementia (Amsterdam, Netherlands) , 5 , 23 – 34 . doi: 10.1016/j.dadm.2016.12.005 Google Scholar PubMed Lingler , J. H. , Nightingale , M. C. , Erlen , J. A. , Kane , A. L. , Reynolds , C. F. III , Schulz , R. , & DeKosky , S. T . ( 2006 ). Making sense of mild cognitive impairment: A qualitative exploration of the patient’s experience . The Gerontologist , 46 , 791 – 800 . doi: 10.1093/geront/46.6.791 Google Scholar CrossRef Search ADS PubMed McKhann , G. , Drachman , D. , Folstein , M. , Katzman , R. , Price , D. , & Stadlan , E. M . ( 1984 ). Clinical diagnosis of Alzheimer’s disease: Report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease . Neurology , 34 , 939 – 944 . doi: 10.1212/WNL.34.7.939 Google Scholar CrossRef Search ADS PubMed Mitchell , A. J. , Beaumont , H. , Ferguson , D. , Yadegarfar , M. , & Stubbs , B . ( 2014 ). Risk of dementia and mild cognitive impairment in older people with subjective memory complaints: Meta-analysis . Acta Psychiatrica Scandinavica , 130 , 439 – 451 . doi: 10.1111/acps.12336 Google Scholar CrossRef Search ADS PubMed Molinuevo , J. L. , Rabin , L. A. , Amariglio , R. , Buckley , R. , Dubois , B. , Ellis , K. A.,… Jessen , F .; Subjective Cognitive Decline Initiative (SCD-I) Working Group . ( 2016 ). Implementation of subjective cognitive decline criteria in research studies . Alzheimer’s & Dementia , 13 , 296 – 311 . doi: 10.1016/j.jalz.2016.09.012 Google Scholar CrossRef Search ADS Morris , J. C. , Mohs , R. C. , Rogers , H. , Fillenbaum , G. , & Heyman , A . ( 1988 ). Consortium to establish a registry for Alzheimer’s disease (CERAD) clinical and neuropsychological assessment of Alzheimer’s disease . Psychopharmacology Bulletin , 24 , 641 – 652 . Google Scholar PubMed Okonkwo , O. C. , Griffith , H. R. , Vance , D. E. , Marson , D. C. , Ball , K. K. , & Wadley , V. G . ( 2009 ). Awareness of functional difficulties in mild cognitive impairment: A multidomain assessment approach . Journal of the American Geriatrics Society , 57 , 978 – 984 . doi: 10.1111/j.1532-5415.2009.02261.x Google Scholar CrossRef Search ADS PubMed Orfei , M. D. , Varsi , A. E. , Blundo , C. , Celia , E. , Casini , A. R. , Caltagirone , C. , & Spalletta , G . ( 2010 ). Anosognosia in mild cognitive impairment and mild Alzheimer’s disease: Frequency and neuropsychological correlates . The American Journal of Geriatric Psychiatry , 18 , 1133 – 1140 . doi: 10.1097/JGP.0b013e3181dd1c50 Google Scholar CrossRef Search ADS PubMed Perrotin , A. , Mormino , E. C. , Madison , C. M. , Hayenga , A. O. , & Jagust , W. J . ( 2012 ). Subjective cognition and amyloid deposition imaging: A Pittsburgh Compound B positron emission tomography study in normal elderly individuals . Archives of Neurology , 69 , 223 – 229 . doi: 10.1001/archneurol.2011.666 Google Scholar CrossRef Search ADS PubMed Rabin , L. A. , Smart , C. M. , Crane , P. K. , Amariglio , R. E. , Berman , L. M. , Boada , M. , … Sikkes , S. A . ( 2015 ). Subjective cognitive decline in older adults: An overview of self-report measures used across 19 international research studies . Journal of Alzheimer’s Disease , 48 ( Suppl. 1 ), S63 – S86 . doi: 10.3233/JAD-150154 Google Scholar CrossRef Search ADS PubMed Roberts , J. L. , & Clare , L . ( 2013 ). Meta-representational awareness in mild cognitive impairment: An interpretative phenomenological analysis . Aging & Mental Health , 17 ( 3 ), 300 – 309 . doi: 10.1080/13607863.2012.732033 Google Scholar CrossRef Search ADS PubMed Sabat , S. R. , & Harré , R . ( 1992 ). The construction and deconstruction of self in Alzheimer’s disease . Ageing and Society , 12 , 443 – 461 . doi: 10.1017/S0144686X00005262 Google Scholar CrossRef Search ADS Saykin , A. J. , Wishart , H. A. , Rabin , L. A. , Santulli , R. B. , Flashman , L. A. , West , J. D. , … Mamourian , A. C . ( 2006 ). Older adults with cognitive complaints show brain atrophy similar to that of amnestic MCI . Neurology , 67 , 834 – 842 . doi: 10.1212/01.wnl.0000234032.77541.a2 Google Scholar CrossRef Search ADS PubMed Schmand , B. , Jonker , C. , Geerlings , M. I. , & Lindeboom , J . ( 1997 ). Subjective memory complaints in the elderly: Depressive symptoms and future dementia . The British Journal of Psychiatry , 171 , 373 – 376 . doi: 10.1192/bjp.171.4.373 Google Scholar CrossRef Search ADS PubMed Schmid , N. S. , Ehrensperger , M. M. , Berres , M. , Beck , I. R. , & Monsch , A. U . ( 2014 ). The extension of the German CERAD neuropsychological assessment battery with tests assessing subcortical, executive and frontal functions improves accuracy in dementia diagnosis . Dementia and Geriatric Cognitive Disorders Extra , 4 , 322 – 334 . doi: 10.1159/000357774 Google Scholar CrossRef Search ADS PubMed Smith , J. A. , Flowers , P. , & Osborn , M. ( 1997 ). Interpretative phenomenological analysis and the psychology of health and illness . Material discourses of health and illness , 68 – 91 . Smith , C. A. , Henderson , V. W. , McCleary , C. A. , Murdock , G. A. , & Buckwalter , J. G . ( 2000 ). Anosognosia and Alzheimer’s disease: The role of depressive symptoms in mediating impaired insight . Journal of Clinical and Experimental Neuropsychology , 22 , 437 – 444 . doi: 10.1076/1380-3395(200008)22:4;1-0;FT437 Google Scholar CrossRef Search ADS PubMed Smith , J. , Flowers , P. , & Larkin , M . ( 2009 ). Interpretative phoneomological analysis: Theory, method and research . London : SAGE Publications . Tabert , M. H. , Albert , S. M. , Borukhova-Milov , L. , Camacho , Y. , Pelton , G. , Liu , X.,… Devanand , D. P . ( 2002 ). Functional deficits in patients with mild cognitive impairment: Prediction of AD . Neurology , 58 , 758 – 764 . Google Scholar CrossRef Search ADS PubMed Thöne-Otto , A. , & Markowitsch , H. J . ( 2004 ). Gedächtnisstörungen nach Hirnschäden . Göttingen: Hogrefe Verlag . van Harten , A. C. , Visser , P. J. , Pijnenburg , Y. A. , Teunissen , C. E. , Blankenstein , M. A. , Scheltens , P. , & van der Flier , W. M . ( 2013 ). Cerebrospinal fluid Aβ42 is the best predictor of clinical progression in patients with subjective complaints . Alzheimer’s & Dementia , 9 , 481 – 487 . doi: 10.1016/j.jalz.2012.08.004 Google Scholar CrossRef Search ADS Vernooij-Dassen , M. , Derksen , E. , Scheltens , P. , & Moniz-Cook , E . ( 2006 ). Receiving a diagnosis of dementia: The experience over time . Dementia , 5 , 397 – 410 . Google Scholar CrossRef Search ADS Wolfsgruber , S. , Jessen , F. , Koppara , A. , Kleineidam , L. , Schmidtke , K. , Frölich , L.,… Wagner , M . ( 2015 ). Subjective cognitive decline is related to CSF biomarkers of AD in patients with MCI . Neurology , 84 , 1261 – 1268 . doi: 10.1212/WNL.0000000000001399 Google Scholar CrossRef Search ADS PubMed Wolfsgruber , S. , Polcher , A. , Koppara , A. , Kleineidam , L. , Frölich , L. , Peters , O.,… Wagner , M . ( 2017 ). Cerebrospinal fluid biomarkers and clinical progression in patients with subjective cognitive decline and mild cognitive impairment . Journal of Alzheimer’s Disease , 58 , 939 – 950 . doi: 10.3233/JAD-161252 Google Scholar CrossRef Search ADS PubMed World Health Organization . ( 1993 ). The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research . Switzerland: World Health Organization. Yesavage , J. A. , Brink , T. L. , Rose , T. L. , Lum , O. , Huang , V. , Adey , M. , & Leirer , V. O . ( 1983 ). Development and validation of a geriatric depression screening scale: A preliminary report . Journal of Psychiatric Research , 17 , 37 – 49 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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The GerontologistOxford University Press

Published: Jan 8, 2018

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