Participants
Seven hundred and twelve outpatients of the Memory
Clinic at Huashan hospital presenting with memory
complaints lasting more than 3 months were screened
consecutively between January 5, 2004 and January 5, 2006.
All were native Chinese speakers. Among subjects presenting to the clinic, 329 who met the following criteria were
selected for this study: (1) aged 50 to 80 years old, (2)
achieved between 8 and 15 years of education, (3) scored
greater than or equal to 24 on the Mini-Mental State
Examination-Chinese version (MMSE),9 (4) had no history
of cerebrovascular accident, (5) had no serious physical
disease (eg, myocardial infarction or history of congestive
heart failure), (6) had no chronic mental illness (eg,
schizophrenia), (7) had no visual or auditory decit, and
(8) did not meet the criteria for probable AD of the
National Institute of Neurological and Communicative
Disorders and Stroke and Alzheimer Disease and Related
Disorders Association (NINCDS-ADRDA).10
The average age of the selected group was 67.6 8.1
years. One hundred and eighty-eight were males, and 141
were females. The level of educational achievement
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Assessment Methods
Three separate memory tasks were studied: the
auditory verbal learning test (AVLT), the LM test, and
the ReyOsterrieth complex gure test (CFT). Each of
these tasks is discussed in detail in this section.
AVLT11
The AVLT adopts the rationale and methods of the
California verbal learning test and the Hong Kong verbal
learning test. The following testing procedure is used: the
examiner reads out dierent semantic categories with 4 in
each type. The words of dierent categories are presented
354 subjects
345 subjects
Excluding 9 subjects due to hearing impairment
(unable to complete AVLT)
336 subjects
Excluding 7 subjects due to visual impairment
(unable to complete testing)
329 subjects
Number of individuals at least 2 years from initial evaluation
161 subjects
12 lost to follow-up
149 subjects
FIGURE 1. Flow chart for clinical evaluation.
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LM Test12
A story from the LM test of the Chinese version of
WMS is used. The short simple story is printed in large font
(20 30 cm), and is visually presented to the participant.
The participant is asked to read the story for 2 minutes and
then recall it immediately (LM-I). The participant then
performs a nonverbal test, 25 minutes after the completion
of which the participant recalls the story again (delayed
recall, LM-II). There are 20 scoring points in the story, one
grade for each point. The full mark is 20.
An English translation of the story is given here (the
underlined contents are the scoring points): Long long
ago, there was a youth/who was taking a long journey/.
When he was crossing a river/, he sat along the side of the
boat/and suddenly lost his sword in the river/. The boater
felt sorry for him/, and anchored the boat/for the youth to
look for his sword in the river. The youth said, /Dont
worry/. I have already marked at the side of the boat/.
When the boat pulls into the shore/ I can dive into the river
at the mark/, and my sword must be there/.
Rey-Osterrieth CFT13
The participant copies a gure, and then draws
the gure from memory after about 25 minutes (CFT-II).
The time for copying the gure is limited to 10 minutes. The
scoring standard established by Taylor14 is used, with a full
mark of 36. Rey gure is used in both rst and second
assessments.
The cuto scores of the 3 tests are obtained by
surveying a large sample of middle-aged and elderly
cognitively normal individuals in Shanghai. We grouped
the patients according to age, education levels, and sexes.
The cuto scores are 1.5 SD below the mean scores of the
matching group (Mean 1.5 SD).
Diagnosis of MCI
In this paper, MCI is referred to as amnesic MCI (both
aMCI-single domain and aMCI-multidomain). The operational diagnostic criteria for MCI required (1) memory
complaints and memory diculties, which are veried by
an informant; (2) MMSE score between 24 and 30
(inclusive) (the education level of all the patients ranged
from 8 to 15 y); (3) preserved basic activities of daily living/
minimal impairment in complex instrumental functions;
(4) objective evidence of episodic memory impairment.
Abnormal memory function documented by scoring below
the age and education adjusted cuto on the memory test.
The episodic memory impairment can be isolated or
associated with other cognitive function (language, visuospatial, and executive domains) changes; and (5) exclusion of
other medical disorders severe enough to account for
memory impairment, such as major depression, cerebrovascular disease, toxic and metabolic abnormalities, etc.
RESULTS
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Guo et al
51-60
61-70
71-80
Age (y)
AVLT-I
AVLT-II
LM-I
LM-II
CFT-II
12
11
10
4
3
2
5
5
5
4
4
4
9
6
3
Education: 8 to 15 years.
AVLT indicates auditory verbal learning test; CFT, complex gure test;
LM, logical memory test.
Reversal Rate
The reversal rate is the rate of conversion from MCI
back to SCI. The MCI-III group has the highest reversal
rate (55%) and the MCI-I group has the lowest (11%).
Stability
Conversion Rate
The conversion rate from MCI to AD reects the
predictability power of a particular test. We found a 2-year
conversion rate of 43% in the MCI-II group, the highest
among the 3 groups (MCI-I, MCI-II, and MCI-III).
Assuming that the conversion rate of MCI to AD remained
the same in the rst year and the second year, we therefore
mathematically calculated a 1-year conversion rate of 24%
for the MCI-II group. Conversely, the MCI-I group had the
lowest conversion rate: 2-year, 22% and 1-year, 12%.
DISCUSSION
To make meaningful comparisons across dierent
MCI studies, it is critical to select an appropriate objective
memory test to determine the memory decit. Our research
showed that dierent episodic memory indicators dier as
to the ability to discriminate MCI patients from cognitively
normal patients, the stability of maintaining an MCI
Group (y)
51-60
61-70
71-80
Recognized number
No. MCI
70
108
151
329
AVLT-I (%)
21
34
49
104
(30)
(31)
(32)
(31)
AVLT-II (%)
36
57
74
167
(51)
(53)
(49)
(51)
LM-I (%)
14
26
31
71
(20)
(24)
(21)
(21)
LM-II (%)
15
23
32
70
(21)
(21)
(21)
(21)
CFT-II (%)
16
35
38
89
(22)
(32)
(25)
(27)
AVLT indicates auditory verbal learning test; CFT, complex gure test; LM, logical memory test; MCI, mild cognitive impairment.
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TABLE 3. The Comparison of Performance of Neuropsychologic Tests Among the 3 Groups (Mean SD)
Tests
MMSE score
Clock drawing test
CFT copying
Animal uency test
Figural uency test
TMT-A time (s)
TMT-B time (s)
CWT time (s)
CWT score
(1.4)*
(4.8)*
(3.9)
(4.2)*
(4.3)*
(22.7)*
(74.3)*
(29.0)*
(6.0)*
27.3
20.5
32.9
13.9
6.1
70.0
197.8
105.3
40.1
(1.7)w
(6.1)
(4.2)w
(3.9)w
(3.8)
(30.6)w
(84.6)w
(67.3)
(8.9)
26.0
19.8
30.0
12.2
5.9
80.3
227.6
109.6
38.4
(1.4)z
(6.4)
(8.8)z
(3.6)z
(3.6)z
(49.4)z
(94.7)z
(35.8)z
(9.5)z
F
49.95**
5.99**
8.47**
22.31**
5.27**
10.01**
8.64**
6.29**
9.39**
TABLE 4. The Comparison of Performance of CDR Among the 3 Groups (Mean SD)
CDR Item
Memory
Orientation
Judge and solve problem
Work and sociality
Family life and hobbies
Ability of leading and independent life
CDR total score
0.9
0.2
0.2
0.3
0.3
0.1
2.0
(0.5)w
(0.4)z
(0.3)
(0.3)w
(0.5)w
(0.3)w
(1.3)w
(0.7)
(0.4)
(0.4)
(0.5)
(0.8)
(0.4)
(2.1)
(0.7)y
(0.4)y
(0.3)
(0.4)
(0.9)y
(0.5)y
(2.0)y
F
16.2**
3.57*
1.73
4.67*
18.77**
6.04**
21.57**
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TABLE 5. The Distribution of 149 Participants Based on Different Memory Indicators After 2 Years
SCI (%)
63
8
6
18
(85)
(11)
(21)
(55)
MCI (%)
9
49
10
3
AD (%)
(12)*
(67)
(36)
(9)
2
16
12
12
(3)
(22)
(43)
(36)
Missed Number
3
7
7
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The operational MCI diagnosing standard we advocate takes the score of auditory word delayed recall as the
objective evidence of memory deterioration. An MMSE
score higher than (or equal to) 24 is required, which should
exclude impairment of general cognitive functions other
than memory deterioration. The self-report and memory
function state is obtained through CDR with the patients
and/or their family members.32 In the future, we plan to
more comprehensively examine the sensitivity and specicity of dierent episodic memory indicators and to
construct the most appropriate objective memory impairment indicator, by enlarging the sample size, shortening the
between-visit interval, and lengthening the follow-up
period. We will include those patients with lower education
as well. As for the many studies in imaging, molecular
biology, and medical intervention that are conducted
relating to MCI, we strongly suggest clearly specifying the
particular neuropsychologic tests that are used. Only by
doing so can readers make meaningful comparisons of the
results across the dierent studies.
ACKNOWLEDGMENT
The authors thank Prof Agnes Chan of the Psychology
Department of the Chinese University of Hong Kong for
providing the Hong Kong verbal learning test.
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