Epilepsy & Behavior 51 (2015) 48–52

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Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Subjective cognitive complaints versus objective neuropsychological

performance in older adults with epilepsy
Rachel Galioto a,⁎, Andrew S. Blum b, Geoffrey Tremont a,b
a
Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
b
Rhode Island Hospital, Providence, RI 02903, USA

a r t i c l e i n f o a b s t r a c t

Article history: Memory complaints are common among older adults with epilepsy (OAE), though discrepancy between
Received 28 May 2015 subjective complaints and objective performance often exists. This study examined how accurately OAE and
Revised 16 June 2015 their informants reported on the participant's cognitive difficulties by comparing ratings of everyday cognition
Accepted 18 June 2015
to objective performance. Thirty-seven OAE and 27 older adult controls completed a brief battery of neuropsy-
Available online xxxx
chological tests, the Beck Depression Inventory, and the Cognitive Difficulties Scale (CDS). Each participant had
Keywords:
an informant who completed the CDS. Older adults with epilepsy performed worse than controls on cognitive
Epilepsy testing and reported more subjective cognitive complaints. Neither participant- nor informant-reported
Elderly cognitive complaints were related to performance on any of the neuropsychological tests for either the group
Depression with epilepsy or control group, but both were related to greater depressive symptoms. Results suggest that
Caregiver issues subjective report of cognitive problems by both OAE and their informants may not reliably reflect the extent to
Learning and memory which these problems exist.
© 2015 Elsevier Inc. All rights reserved.

1. Introduction Subjective cognitive complaints are very common among individ-

Subjective cognitive complaints are common among older adults
and may predict cognitive decline. For example, a recent study among
cognitively intact older adults demonstrated that subjective memory
complaints were associated with increased risk of cognitive impairment
and Alzheimer-type brain pathology [1]. Subjective cognitive com-
plaints may be particularly prevalent among older adults with epilepsy
(OAE) given that this group demonstrates objective cognitive deficits
and is at risk for cognitive impairment, particularly for memory tests,
compared to older adults without epilepsy [2–5]. In fact, these
individuals have been shown to have similar memory deficits and great-
er deficits in overall cognition and executive function when compared
to individuals with Mild Cognitive Impairment [2]. One major contribu-
tor to cognitive deficits in OAE is the use of antiepileptic drugs (AEDs),
with AED polytherapy associated with the most severe cognitive deficits
[2–4]. Seizure characteristics such as age of onset [6], epilepsy duration
[7], and seizure frequency [8] may also contribute to cognitive dysfunc-
tion in this population, with earlier onset, longer duration, and greater
seizure frequency commonly showing an association with poorer cogni-
tive functioning; however, these findings are not consistent across the
literature.
⁎ Corresponding author at: Physician's Office Building Suite 430, 110 Lockwood St.,
Providence, RI 02903, USA. Tel.: +1 401 444 4500; fax: +1 401 444 6643.
E-mail address: gtremont@lifespan.org (R. Galioto).
uals with epilepsy of all ages [9] and are a significant predictor of poorer
self-reported quality of life in this group [10]. However, the degree of
subjective complaints is not consistently associated with objective
cognitive dysfunction [11]. Factors such as older age and higher intelli-
gence level have been associated with greater memory complaints [9]
while epilepsy characteristics (e.g., seizure type, frequency, AEDs) are
not consistently related to subjective memory complaints among
these individuals [9,12]. Depression, which is very common among pa-
tients with epilepsy [13,14], has been consistently shown to be related
to both subjective cognitive complaints [10,13,15–19] and objective
cognitive function [20] in this group. In fact, numerous studies in
patients with epilepsy demonstrate a stronger association between
subjective cognitive complaints and mood than between subjective
and objective cognitive functions [15,19,21]. Additionally, reduced
awareness of cognitive deficits among patients with epilepsy may con-
tribute to an underreporting of deficits and partially account for the dis-
crepancy between objective and subjective cognitive complaints [22].
Given this discrepancy, it seems reasonable to examine whether
proxy measures of cognitive complaints, such as informant reports of
cognitive complaints, could more accurately reflect objective cognitive
performance. Informant-reported cognitive complaints have been
shown to be correlated to objective cognitive performance in other pop-
ulations, such as dementia and MCI, and among cognitively normal
adults [23–25]. However, the utility of informant report of cognitive dif-
ficulties has not yet been examined among older adults with epilepsy.

http://dx.doi.org/10.1016/j.yebeh.2015.06.035
1525-5050/© 2015 Elsevier Inc. All rights reserved.
 R. Galioto et al. / Epilepsy & Behavior 51 (2015) 48–52 49

There were three major aims of the present study. First, we sought to
characterize subjective cognitive complaints among OAE by comparing
them to older adult controls without epilepsy and examine the relation-
ship between subjective cognitive complaints and other factors, such as
demographic factors, mood, and seizure characteristics, in this group.
We hypothesized that OAE would endorse greater cognitive complaints
than controls and that older age and greater depressive symptoms
would be related to greater cognitive complaints. In terms of seizure
characteristics, no a priori hypotheses were made given the mixed
findings among younger adults with epilepsy. The second aim was to
examine the accuracy of self-reported cognitive complaints among
OAE by comparing subjective cognitive complaints to objective perfor-
mance on neuropsychological tests. As above, a priori hypotheses
were not made as previous research on the relationship between sub-
jective cognitive complaints and objective cognitive function among
younger patients with epilepsy has been mixed. The third aim of this
study was to examine whether informants of OAE could more accurate-
ly report on the patient's cognitive deficits. It was hypothesized that
informants of OAE would be able to more accurately report cognitive
difficulties than the patients themselves given previous research in
other samples which has shown this pattern.
2. Materials and methods
there was a greater percentage of females in the control group com-
pared to the group with epilepsy, χ2 (1, N = 64) = 9.98, p b .01.
There were no differences between groups for race or education. See
Table 1 for full demographic and seizure characteristics.
Each participant also had one participant-selected informant (n =
64), defined as someone who the participant thought knew them well
enough to provide collateral information about their functioning. Most
informants were spouses or significant others (59.7%), followed by
children (15.6%), siblings (11.3%), friends (11.3%), and parents (1.6%).
On average, informants were 58.27 years old (SD = 14.42), had
14.91 years of education (SD = 2.98), and knew the participants for
34.26 years (SD = 18.75).
2.2. Procedure
Interested participants were contacted via telephone. After
obtaining informed consent, interested participants underwent an in-
office neuropsychological testing and completed a number of question-
naires. Informants accompanied the participants to the evaluation and
completed questionnaires while participants completed neuropsycho-
logical testing. Participants were compensated for their time after
completion of the assessment. All procedures were approved by the
local Institutional Review Board.

2.1. Participants 2.3. Measures

Participants were 37 OAE and 27 older adult controls without
epilepsy. Older adults with epilepsy were recruited through a
hospital-based neurology practice. Controls were recruited through
community advertising. To be eligible for inclusion, participants were
above the age of 55 years and spoke English as their first language.
Diagnosis of epilepsy was determined by a neurologist and required ob-
jective evidence of seizures (i.e., EEG). Exclusion criteria for both groups
included a history of mental retardation or other serious developmental
disorder, other medical illnesses that affect cognition or are terminal,
and severe psychiatric conditions (e.g., schizophrenia, bipolar disorder,
and active substance abuse disorder). The group with epilepsy was sig-
nificantly older, t(60.37) = 2.62, p = .01, than the control group, and
2.3.1. Objective cognitive function
Participants completed a battery of well-established neuropsycho-
logical tests. The tests administered and variables used in analyses
included: Trail Making Test [26] A (TMT-A) and B (TMT-B) time to com-
pletion, Controlled Oral Word Fluency Association Test [27] (COWAT)
total correct words, Boston Naming Test [28] (BNT) total correct
words, Animal Fluency total correct words, Rey Complex Figure Test
[29] (RCFT) copy presence and accuracy score from the Boston Qualita-
tive Scoring System, Hopkins Verbal Learning Test [30] total recall
(HVLT-TR) and delayed free recall (HVLT-DR), and the Brief Visuospatial
Memory Test-Revised [31] total recall (BVMT-TR) and delayed free re-
call (BVMT-DR).

2.3.2. Subjective cognitive complaints

Table 1
Demographic and epilepsy characteristics, CDS scores, and BDI-II of the sample. The Cognitive Difficulties Scale [32] (CDS) is a self-report measure
given to both patients and informants consisting of 38 items and
Epilepsy (n = 37) Control (n = 27)
assesses cognitive difficulties in daily activities over the past week
Mean (SD)/%/[range] Mean (SD)/%/[range] p (e.g., remembering names, phone numbers, driving directions, names
Age 65.22 (8.10) [55–86] 60.93 (4.95) [55–74] .011 of objects, appointments, running errands, maintaining focus on a
Female 51.4% 88.9% .002 task, losing items, using scissors, fastening clothes, or making mistakes
Education 14.54 (3.19) 15.63 (2.04) .10 in typing). Participants and informants answered these questions on a
Caucasian 100% 92.6% .243
I-CDS 0.85 (0.75) 0.32 (0.36) .001
0–4 scale ranging from never to very often with higher scores reflecting
P-CDS 1.16 (0.71) 0.60 (0.43) .001 greater cognitive complaints. In order to adjust for missing item
BDI-II 10.05 (9.82) 2.22 (2.94) .001 responses, an average score for patient and informant CDS score was
Age first seizure 39.67 (25.14) – – calculated by dividing total score by number of items completed. Partic-
Duration (years) 25.25 (21.38) – –
ipant and informant average CDS scores ranged from 0 to 4.
Monthly Sz (past year) 1.43 (1.85) – –
AEDs 1.76 (0.86) – –
Etiology 2.3.3. Participant depression
Idiopathic 54.1% – – The Beck Depression Inventory-II (BDI-II) [33] was used to assess de-
Trauma 13.5% – – pressive symptoms among participants. Scores range from 0 to 63 with
Neoplasia 8.1% – –
higher scores reflecting greater depressive symptoms. Raw scores were
Infection 8.1% – –
Vascular 8.1% – – used in analyses.
Unknown 8.1% – –
Location 2.4. Statistical analyses
Temporal 48.6% – –
Frontal 10.8% – –
Multifocal 10.8% – – Descriptive statistics were used to examine sample characteristics
Generalized 8.1% – – and differences between groups. Raw scores for the neuropsychological
Unknown 21.6% – – tests were corrected for age, gender, and education when possible,
Note: BDI—Beck Depression Inventory-II, Sz—seizures, AED—number of antiepileptic using well-established normative data, and converted into T-scores
drugs, P—patient, I—informant, CDS—Cognitive Difficulties Scale. (mean of 50, standard deviation of 10) to facilitate interpretation.
50 R. Galioto et al. / Epilepsy & Behavior 51 (2015) 48–52

Independent sample t-tests were conducted to examine differences be- Table 3

tween the group with epilepsy and control group on participant CDS Correlations between CDS scores and cognitive function for the group with epilepsy and
control group.
scores and neuropsychological tests. Bivariate correlations were con-
ducted for each group separately to examine the relationships among Epilepsy (n = 37) Control (n = 27)
participant CDS scores, demographic factors, objective cognitive func- Participant Informant Participant Informant
tion, and participant-reported depressive symptoms. For the group
TMT-A .16 .25 .25 −.20
with epilepsy, the relationship between these measures and seizure TMT-B .08 .11 .40 −.10
characteristics and AEDs was also examined. Paired-sample t-tests COWAT .23 .28 −.18 .10
were used to examine differences between participant- and informant- Animals .08 −.03 −.14 −.39
reported CDS scores for both groups. Finally, bivariate correlations BNT −.02 .08 .06 .10
RCFT −.11 −.19 .14 .01
examined the relationship among informant-reported CDS scores and HVLT-TR −.32 −.30 −.06 −.15
patient-reported depressive symptoms for the group with epilepsy. HVLT-DR .08 −.06 −.04 −.27
In order to control for multiple comparisons, significance was defined BVMT-TR −.24 −.26 .02 −.20
as p b .01. BVMT-DR −.18 −.19 .24 −.09
BDI-II .74⁎⁎ .54⁎ .11 −.01
Participant age .13 −.09 .12 .60⁎
3. Results Participant education −.38± −.13 .06 .29
Age onset −.15 −.16 – –
Duration .22 .16 – –
3.1. Objective cognitive function and patient-reported subjective cognitive Seizures per month −.18 .14 – –
complaints AEDs .22 .20 – –

Abbreviations: TMT—Trail Making Test, RCFT—Rey Complex Figure Test, COWAT—

Independent sample t-tests indicated that OAE performed worse
than controls on nearly all cognitive tests including TMT-A, TMT-B,
COWAT, Animal Fluency, HVLT-TR, HVLT-DR, BVMT-TR, and BVMT-DR.
There were no differences between groups for RCFT. For the group
with epilepsy, clinically significant impairment (T-score N 1.5 SD
below the mean) was most common on memory tests (BVMT-TR
(51.4%), BVMT-DR (45.9%), HVLT-TR (29.7%), HVLT-DR (27.0%)), psy-
chomotor speed (TMT-A (35.1%)), and visual organization (27.0%,
RCFT). Impairment was much less common in the control group and
most prevalent for visual memory (BVMT-TR (14.8%), BVMT-DR
(11.1%)). See Table 2 for complete description of neuropsychological
test scores and impairment in both groups.
Participant CDS scores of OAE ranged from 0.05 to 3.00 while control
group participant CDS scores ranged from 0.03 to 1.45. Independent
sample t-tests demonstrated greater participant CDS scores for the
group with epilepsy (M = 1.62, SD = 0.71) compared to the control
group ((M = 0.60, SD = 0.43), t(60.19) = 3.91, p b .001).
3.2. Associations between patient-reported subjective cognitive complaints
and objective cognitive performance
Bivariate correlations were conducted separately in each group to
examine the relationships between participant CDS scores and perfor-
mance on neuropsychological tests. Subjective cognitive complaints
were not significantly related to performance on neuropsychological
tests in either the group with epilepsy or control group. Table 3 presents
full correlations.
Controlled Oral Word Association Test, BNT—Boston Naming Test, HVLT—Hopkins Verbal
Learning Test, BVMT—Brief Visual Memory Test-Revised, TR—total recall, DR—delayed re-
call, AEDs—antiepileptic drugs.
⁎⁎ p b .01.
⁎ p b .05.
±
Trend toward significance (p = .02).
3.3. Contributors to subjective cognitive complaints
Bivariate correlations examined the relationships among demo-
graphic factors, depression, and participant-reported subjective cogni-
tive complaints separately in the group with epilepsy and control
group. In the group with epilepsy, the relationship between subjective
cognitive complaints and seizure characteristics was also examined. In
the control group, CDS scores were not significantly correlated with
age, education, or depression. Given that the two groups differed in
terms of gender composition, independent sample t-tests were used
to examine gender differences on CDS scores; results were not signifi-
cant, t(67) = −0.58, p = .57, indicating that there were no differences
in CDS scores between males and females.
In the group with epilepsy, greater CDS scores were highly related to
greater depressive symptoms (r = .74, p b .001), and there was a trend
toward significance for fewer years of education (r = −.38, p = .02).
Cognitive Difficulties Scale scores were not related to age or any seizure
characteristics including AEDs, seizures per month in the past year,
duration of epilepsy, or age of onset.

Table 2 3.4. Report of cognitive difficulties: relationships with neuropsychological

Performance and impairment on neuropsychological tests for the group with epilepsy and test performance
control group.

Test Epilepsy (n = 37) Control (n = 27) Independent sample t-tests revealed that informants of OAE had sig-
nificantly higher CDS scores than informants of controls, t(55.24) =
Mean (SD) Impaired Mean (SD) Impaired t p
3.74, p b .001. In addition, participants with epilepsy reported greater
TMT-A 37.97 (12.26) 35.1% 48.44 (7.48) 3.7% −4.18 b.001 cognitive difficulties compared to what their informants rated of
TMT-B 43.65 (10.69) 16.2% 52.41 (7.46) 3.7% −3.61 .001
them, t(36) = 3.14, p b .01. This pattern neared significance among
RCFT 47.22 (16.03) 27.0% 51.52 (9.68) 7.4% −1.33 .188
COWAT 43.89 (9.07) 21.6% 55.48 (9.38) 0.0% −4.98 b.001 control participants with the control participants endorsing more
Animals 44.89 (9.71) 16.2% 53.41 (7.47) 0.0% −3.81 b.001 cognitive difficulties than their informants rated of them, t(26) =
BNT 46.84 (14.97) 18.1% 54.89 (4.99) 0.0% −3.05 .004 2.78, p = .01.
HVLT-TR 45.11 (12.13) 29.7% 53.89 (8.09) 0.0% −3.47 .001
For the group with epilepsy, informant report of cognitive difficulties
HVLT-DR 41.27 (15.10) 27.0% 53.96 (7.78) 3.7% −4.38 b.001
BVMT-TR 39.73 (13.84) 51.4% 48.37 (10.33) 14.8% −2.73 .008 was also not related to any of the neuropsychological tests. However,
BVMT-DR 38.57 (16.02) 45.9% 48.30 (14.55) 11.1% −2.49 .015 there was a relationship between informant CDS score and patient-
Note: TMT—Trail Making Test, RCFT—Rey Complex Figure Test, COWAT—Controlled Oral
reported depressive symptoms (r = .54, p b .01). There was also no re-
Word Association Test, BNT—Boston Naming Test, HVLT—Hopkins Verbal Learning Test, lationship between informant CDS scores and neuropsychological tests
BVMT—Brief Visual Memory Test-Revised, TR—total recall, DR—delayed free recall. or depression among the control participants.
 R. Galioto et al. / Epilepsy & Behavior 51 (2015) 48–52
4. Discussion
The present study sought to characterize and examine the accuracy
of subjective cognitive complaints among OAE; examine the relation-
ship between subjective cognitive complaints and demographic factors,
mood, and seizure characteristics; and determine whether informants
of OAE could more accurately report on the patient's cognitive deficits.
It was hypothesized that OAE would endorse more cognitive complaints
than controls, that older age and greater depressive symptoms would be
related to greater cognitive complaints, and that informants of OAE
would be able to more accurately report cognitive difficulties than the
patients themselves.
Results of this study demonstrated that, as expected, OAE demon-
strated poorer cognitive function and endorsed greater cognitive com-
plaints than controls. Consistent with previous research, subjective
cognitive complaints in the group with epilepsy were related to greater
depressive symptoms and lower education. We did not find a relation-
ship between subjective cognitive complaints and seizure characteris-
tics which is, perhaps, not surprising given the mixed results observed
in other studies. Importantly, cognitive complaints were not related to
performance on any of the neuropsychological tests for either group.
This is not entirely surprising for the control group, likely owing to
restricted range of scores both for neuropsychological tests and for the
CDS. However, the absence of a relationship between subjective
complaints and objective cognitive function in OAE deserves attention.
Previous research consistently demonstrates discrepancy between the
degree of cognitive impairment and subjective complaints among indi-
viduals with epilepsy, though this is the first study to demonstrate this
discrepancy among older individuals with epilepsy. One possible reason
for the discrepancy in this sample is the influence of depression on cog-
nitive complaints given the strong relationship between BDI and CDS
scores in the group with epilepsy. It is difficult to determine the extent
to which depression is influencing cognitive complaints in this sample
given the small sample size and relatively low levels of depression ob-
served. However, the highly significant associations between depressive
symptoms and patient-reported cognitive complaints suggest that
cognitive complaints may be a proxy for depressive symptoms in this
population. Another possibility is that existing measures of cognitive
complaints, such as the CDS which was used in this study, are not partic-
ularly sensitive measures of cognitive difficulties in populations with
epilepsy. Future research is needed to further examine this possibility.
Overall, these results raise significant concern for the utility of self-
report measures of cognition in this population.
Such concern has similarly been raised in other populations. For
example, recent work in a sample of patients with Mild Cognitive
Impairment (MCI) demonstrated a tendency of cognitively intact
individuals to overstate their cognitive problems. Additionally, objective
cognitive functioning and self-reported cognitive complaints were not
associated, but there was a significant positive relationship between de-
pressive symptoms and self-reported cognitive complaints. Overall, the
authors concluded that reliance on self-reported cognitive complaints
could lead to misdiagnosis of MCI [34]. We demonstrated that the po-
tential for misdiagnosis of cognitive impairment could extend to OAE,
and therefore, identifying alternative ways of screening for cognitive
impairment may be important.
Perhaps the most interesting and novel finding of this study is that
informants were no better at reporting cognitive complaints than the
patients. This is in contrast to research in other older adult populations
which has shown that informant report of cognitive difficulties is often
more closely associated with objective cognitive function compared to
patient report [35] and can aid in the diagnosis of conditions like MCI
[23] and the prediction of cognitive decline [36–38]. In this sample, in-
formant report of cognitive difficulties also appeared to be influenced
by patient depression, even at minimal levels of reported depressive
symptoms, which may suggest that informants may also be responding
to the patient's depressive symptoms, rather than their cognitive
51
functioning. This finding is consistent with one study in a sample of
elderly individuals without dementia that found informant report of
memory complaints was related to higher patient scores on a self-
report measure of depression [35]. The authors hypothesized that this
relationship may be the result of the informant's misattribution of psy-
chological problems to memory deficits or that the participant was
more likely to discuss their cognitive concerns with the informant due
to their psychological state. Regardless, it seems that depression can in-
fluence informant report of cognitive difficulties and clinicians and re-
searchers should be aware of this. Overall, our results suggest that
informants of OAE may not be able to adequately report on the patients'
cognitive functioning and highlight the need for the identification of ad-
ditional means of assessing cognitive complaints in OAE that are not as
highly influenced by related factors such as mood.
This study must be viewed in light of a number of limitations. First,
the small sample size and entirely Caucasian sample limit the generaliz-
ability of these findings. Second, we found no relationship between sub-
jective cognitive complaints and a number of demographic and
epilepsy-related factors. This may have been due to small sample size,
a relatively healthy sample, or the heterogeneity of individuals in the
group with epilepsy in terms of seizure characteristics. Future research
in a sample large enough to examine possible subgroup effects is need-
ed to clarify these results. Lastly, the OAE and control groups differed in
their gender composition; however, this was unlikely to contribute
highly to the results as independent sample t-tests demonstrated no
differences in CDS scores between genders.
Overall, this study demonstrated that although objective cognitive
impairment is common among OAE, subjective report of cognitive prob-
lems by both patients and informants may not reliably reflect the extent
to which these problems exist, but rather may be a marker for depres-
sive symptoms. Future research is needed to identify alternative
means of assessing cognitive complaints in this population.
Acknowledgments
This work was supported by an Intradepartmental Seed Grant from
the Department of Neurology, Alpert Medical School, Brown University.
Conflict of interest
The authors declare no conflicts of interest.
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