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Effect of Everyday Distraction on Healthy and Cognitively Impaired Elders' Memory for Stories

Permanent Link: http://ufdc.ufl.edu/UFE0022030/00001

Material Information

Title: Effect of Everyday Distraction on Healthy and Cognitively Impaired Elders' Memory for Stories
Physical Description: 1 online resource (88 p.)
Language: english
Creator: Sisco, Shannon
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: aging, cognition, driving, dual, mci, memory, recall, story
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: This study evaluated how older adults' recall of short stories was affected by simultaneously performing a low- or high-speed simulated driving task. Specifically, recall was examined in qualitative terms: did older adults use more paraphrasing than verbatim recall as the driving challenge increased? Did older adults rely more on recall of main ideas, and remember fewer details, with increasing driving challenge? Did cognitive status (healthy versus mildly impaired) interact with distraction?s effect on performance? A sample of 46 healthy older adults (61% women; mean age = 76.39 years, mean education = 15.83 years) and 15 older adults with amnestic mild cognitive impairment (66% women, mean age = 79.4 years, mean education = 16.07 years) were asked to recall brief short stories that were administered under three conditions: no driving, low-speed (30 mph) driving, high-speed (60 mph) driving. Stories were scored in two ways: 1) as the amount of information recalled verbatim (word-for-word) versus recall in paraphrase, and 2) as the amount of main idea information recalled versus amount of detail. Repeated measures analyses of variance were conducted, contrasting the verbatim/paraphrase and main idea/detail dimensions of recall across the three recall challenge conditions and between the two cognitive status groups. Analyses revealed that verbatim recall was higher than paraphrase recall in every condition, F(1, 104) = 99.94, p < .001, and that only verbatim recall decreased when a simultaneous driving challenge was added. Verbatim recall did not decrease further between the low- and high-speed conditions. Analyses of main idea/detail recall revealed that recall for main ideas was consistently higher than for details in every condition, F(1,104) = 380.17, p < .001. Main idea recall did not decrease significantly with the addition of the simultaneous driving challenge, but did decrease when the driving challenge was raised from low to high speed. Recall for details decreased with the addition of the simultaneous driving, but not when driving speed was increased. Cognitive status was not found to significantly interact with the effect of distraction; dual-task performance costs were equivalent between the healthy and impaired groups. This study demonstrates that when older adults are asked to attend to verbally-presented information while simultaneously driving, their ability to recall details of that information, and their ability to remember it verbatim, declines. As the difficulty of the driving challenge increases, older drivers may additionally recall less of the main points of the information conveyed. This study identifies another potential risk of distracted driving: when potentially important information (e.g., directions, alerts) is presented verbally to older drivers, their ability to retain this information may be substantially degraded.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Shannon Sisco.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Marsiske, Michael.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022030:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022030/00001

Material Information

Title: Effect of Everyday Distraction on Healthy and Cognitively Impaired Elders' Memory for Stories
Physical Description: 1 online resource (88 p.)
Language: english
Creator: Sisco, Shannon
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: aging, cognition, driving, dual, mci, memory, recall, story
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: This study evaluated how older adults' recall of short stories was affected by simultaneously performing a low- or high-speed simulated driving task. Specifically, recall was examined in qualitative terms: did older adults use more paraphrasing than verbatim recall as the driving challenge increased? Did older adults rely more on recall of main ideas, and remember fewer details, with increasing driving challenge? Did cognitive status (healthy versus mildly impaired) interact with distraction?s effect on performance? A sample of 46 healthy older adults (61% women; mean age = 76.39 years, mean education = 15.83 years) and 15 older adults with amnestic mild cognitive impairment (66% women, mean age = 79.4 years, mean education = 16.07 years) were asked to recall brief short stories that were administered under three conditions: no driving, low-speed (30 mph) driving, high-speed (60 mph) driving. Stories were scored in two ways: 1) as the amount of information recalled verbatim (word-for-word) versus recall in paraphrase, and 2) as the amount of main idea information recalled versus amount of detail. Repeated measures analyses of variance were conducted, contrasting the verbatim/paraphrase and main idea/detail dimensions of recall across the three recall challenge conditions and between the two cognitive status groups. Analyses revealed that verbatim recall was higher than paraphrase recall in every condition, F(1, 104) = 99.94, p < .001, and that only verbatim recall decreased when a simultaneous driving challenge was added. Verbatim recall did not decrease further between the low- and high-speed conditions. Analyses of main idea/detail recall revealed that recall for main ideas was consistently higher than for details in every condition, F(1,104) = 380.17, p < .001. Main idea recall did not decrease significantly with the addition of the simultaneous driving challenge, but did decrease when the driving challenge was raised from low to high speed. Recall for details decreased with the addition of the simultaneous driving, but not when driving speed was increased. Cognitive status was not found to significantly interact with the effect of distraction; dual-task performance costs were equivalent between the healthy and impaired groups. This study demonstrates that when older adults are asked to attend to verbally-presented information while simultaneously driving, their ability to recall details of that information, and their ability to remember it verbatim, declines. As the difficulty of the driving challenge increases, older drivers may additionally recall less of the main points of the information conveyed. This study identifies another potential risk of distracted driving: when potentially important information (e.g., directions, alerts) is presented verbally to older drivers, their ability to retain this information may be substantially degraded.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Shannon Sisco.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Marsiske, Michael.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022030:00001


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EFFECT OF EVERYDAY DISTRACTION ON HEALTHY AND COGNITIVELY IMPAIRED
ELDERS' MEMORY FOR STORIES





















By

SHANNON M. SISCO


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA

2008






































O 2008 Shannon M. Sisco



































To Tammy, who at a moment' s notice is ready with fake teeth and Coke-bottle glasses, cherry
tomatoes, more sass than you can shake a stick at, and a reminder to never waste anything I have,
least of all my pretty.









ACKNOWLEDGMENTS

I am first grateful to my mentor, Dr. Michael Marsiske, whose creativity and patience

have guided me in building my own path, and whose wisdom has made each step I take the best

it could be. I also thank my mentoring committee members, Dr. Catherine Price and Dr. Lori

Altmann, whose insight and suggestions on this project were invaluable. I extend special

gratitude to Sarah Cook, who graciously included me in her dissertation proj ect and allowed me

to work with her data, from which this thesis was produced. I thank the ever-supportive Nate,

whose gift for finding ways to take a break is unparalleled, as is his good nature; I also thank

Brian, without whose impromptu dance parties and ad-lib banjo compositions there would be no

House of Awesome. Finally I thank my father and mother, and my brothers Kyle and Brian, for

whom I don't have to be a psychologist or researcher or even anyone terribly interesting, and to

whom I can always come home.












TABLE OF CONTENTS


page

ACKNOWLEDGMENTS .............. ...............4.....


LIST OF TABLES ................. ...............8............ ....


LI ST OF FIGURE S .............. ...............9.....


AB S TRAC T ............._. .......... ..............._ 1 1..


CHAPTER


1 LITERATURE REVIEW ..........._..._ ...............13.......__......


Overview ..........._..._ .. .......... ...............13......

Cognition, Memory, and Aging............... ...............13.
The Utility of Story Memory Measures. ................. ....._._ ...............15. ...
Age Differences in Story Recall ................. ...............16......... ....
Divided Attention in Aging .................. ....... ............ ..........__ ............1
Elders' Performance in Driving Divided Attention Tasks .............. .....................1
Age Differences in Recall Under Divided Attention .............. ...............21....
The Role of Mild Cognitive Impairment ................. ......._ ................21 ...
Introduction to Amnestic Mild Cognitive Impairment. ..........._..._ ................. ......21
Impact of Cognitive Impairment on Story Recall .............. ...............24....
Impact of Cognitive Impairment on Dual-Task Performance ............... ... ........._ ...25
Sum m ary ................. ...............26........ ......


2 STATEMENT OF THE PROBLEM ................. ...............28......... ....


Dual-Task Effect on Precision............... ...............2
Aim One .............. ...............29....

Hypothesis One .............. ...............29....
Dual-Task Effect on Content ....__. ................. ........__. ........2
Aim Tw o............... ...............29..

H ypothesi s Tw o ............... .. ........._.. .. ............... .... ...... ........2
Role of Cognitive Impairment in Dual-Task Effects on Precision and Content ....................30
Aim T hree............... ...............3 0.

Hypothesis Three ................. ...............30........ ......

3 RESEARCH DESIGN AND METHOD S ......... ......._.._.._ ...............31....


Overview. ...._.._................. .......__. ..........3
The Cook Study ................. ...............31..............
Participants .............. ...............32....
Eligibility ................ ...............32........ ......
Recruitment Sources............... ...............32












Study Procedures .............. ...............33....
Screening .................. ......... .. .. ......... .. .. .. ............3
Admini station of Neuropsychological and Experimental Tests ................. .................3 3
Consensus Classification ................. ...............34.................
Neuropsychological Measures ................. ...............35......_._. .....
Telephone Screening Measure .............. ...............35....
Neuropsychological Consensus Measures .............. ...............35....
Experimental Task ................. ...............39.................
Experimental Procedure .............. .. ...............39...
Experimental Measures and Materials .............. ...............40....
Short story measures .............. ...............40....
Short story scoring .............. ...............41....
Scoring reliability ................. ...............42.......... ......
Driving task ................. ...............42.......... ......


4 RE SULT S .............. ...............46....


Overview ................. ...............46.................
Participant Sickness ................. ...............47.................
Preliminary Analyses ................. ...............47.................
V alidity ................. ...............47.......... .....
Reliability .............. .. ....... .... ..............4
Dual-Task Effect on Total Recall ................. .. ............ .... ... ........ ....... 4
Overall Memory Performance between Cognitive Status Groups .............. ..................49
Main Analyses ................. ........ ..............4
Aim One: Dual-Task Effect on Precision............... ...............4
Aim Two: Dual-Task Effect on Content ................................................5
Aim Three: Role of Cognitive Impairment in the Dual-Task Effects ................... ..........51
Follow-Up Analyses ................. ... ............ .... .. ........ .............5
Policy Capturing and Cognitive Status Classification............... .............5
Proportionalized Scoring Relative to Baseline Performance .............. .....................5

5 DI SCUS SSION ................. ...............64................


Overview ................. ...............64.................
Review of Findings ................... ......... ...............65.....
Aim One: Dual-Task Effect on Precision............... ...............6
Aim Two: Dual-Task Effect on Content ................. ....... ........ ...........6
Aim Three: Role of Cognitive Impairment in Dual-Task Effects ................. ................67
Im plications .............. ...............69....
Limitations ................. ...............69.................
Future Directions .............. ...............71....
Conclusion ................ ...............73.................


APPENDIX


A SHORT STORIES USED IN THE EXPERIMENTAL TASK .............. ....................7












B DISTRIBUTIONS OF NEUROPSYCHOLOGICAL DATA ................. .......................77


C FOLLOW-UP ANALYSES USINTG SCORES RELATIVE TO BASELINE
PERF ORMANCE ................. ...............79.................


LI ST OF REFERENCE S ................. ...............8.. 1......... ....


BIOGRAPHICAL SKETCH .............. ...............88....










LIST OF TABLES


Table Page

3-1 Measures used for consensus classification. .............. ...............43....

4-1 Number of participants with complete, partial or no data by cognitive status. .................58

4-2 Means + standard errors of story recall total scores by healthy (N=41) versus
impaired participants (N= 12) ................. ...............58........... ...

B-1 Skewness and kurtosis (N=61) of neuropsychological data distributions by measure......??










LIST OF FIGURES


Figure Page

3-1 Participant visit overview. ............. ...............44.....

3-2 Experiment procedures represented by task condition. ............. ...............44.....

3-3 Calculation of verbatim and paraphrased recall scores ......... ................. ...............45

3-4 Calculation of main idea and detail recall scores............... ...............45.

4-1 Proportion of idea units recalled verbatim or in paraphrase across task conditions
(N=53)................. ...............5

4-2 Proportion of main idea units recalled and proportion of detail idea units recalled
across task conditions (N=53)............... ...............59.

4-3 Proportion of verbatim recall in healthy (N=41) versus impaired (N=12) participants
recall across task conditions............... ...............5

4-4 Proportion of paraphrased recall in healthy (N=41) versus impaired (N=12)
participants across task conditions ................. ...............60................

4-5 Proportion of recall for main ideas in healthy (N=41) versus impaired (N=12)
participants ideas across task conditions............... ...............6

4-6 Proportion of recall for details in healthy (N=41) versus impaired (N=12)
participants across task conditions ................. ...............61................

4-7 Healthy participants' proportions of verbatim and paraphrased recall across task
conditions (N=41). ................ ...............61.......... .....

4-8 Impaired participants' proportions of verbatim and paraphrased recall across task
conditions (N= 12). ............. ...............62.....

4-9 Healthy participants' recall for the proportion of main ideas versus details across
conditions (N=41). ................ ...............62.......... .....

4-10 Impaired participants' recall for the proportion of mail ideas versus details across
conditions (N= 12). ............. ...............63.....

B-1 Histogram representing the frequency distribution of percentile scores for Delayed
Recall on the Hopkins Verbal Learning Test ................. ...............78........... ..

C-2 Comparison of idea units recalled verbatim by healthy (N=41) versus impaired
participants (N=12) across task conditions. .............. ...............79....










C-3 Comparison of idea units recalled in paraphrase by healthy (N=41) versus impaired
participants (N=12) across task conditions.. ............. ...............79.....

C-4 Comparison of main idea units recalled verbatim by healthy (N=41) versus impaired
participants (N=12) across task conditions. .............. ...............80....

C-5 Comparison of detail idea units recalled verbatim by healthy (N=41) versus impaired
participants (N=12) across task conditions.. ............. ...............80.....









Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

THE EFFECT OF EVERYDAY DISTRACTION ON HEALTHY AND COGNITIVELY
IMPAIRED ELDERS' MEMORY FOR STORIES

By

Shannon M. Sisco

August 2008

Chair: Michael Marsiske
Major: Psychology--Clinical and Health Psychology

This study evaluated how older adults' recall of short stories was affected by simultaneously

performing a low- or high-speed simulated driving task. Specifically, recall was examined in qualitative

terms: did older adults use more paraphrasing than verbatim recall as the driving challenge increased?

Did older adults rely more on recall of main ideas, and remember fewer details, with increasing driving

challenge? Did cognitive status (healthy versus mildly impaired) interact with distraction's effect on

performance?

A sample of 46 healthy older adults (61% women; mean age = 76.39 years, mean education =

15.83 years) and 15 older adults with amnestic mild cognitive impairment (66% women, mean age =

79.4 years, mean education = 16.07 years) were asked to recall brief short stories that were administered

under three conditions: no driving, low-speed (30 mph) driving, high-speed (60 mph) driving. Stories

were scored in two ways: 1) as the amount of information recalled verbatim (word-for-word) versus

recall in paraphrase, and 2) as the amount of main idea information recalled versus amount of detail.

Repeated measures analyses of variance were conducted, contrasting the verbatim/paraphrase and main

idea/detail dimensions of recall across the three recall challenge conditions and between the two

cognitive status groups. Analyses revealed that verbatim recall was higher than paraphrase recall in










every condition, F(1, 104) = 99.94, p<.001, and that only verbatim recall decreased when a simultaneous

driving challenge was added. Verbatim recall did not decrease further between the low- and high-speed

conditions. Analyses of main idea/detail recall revealed that recall for main ideas was consistently

higher than for details in every condition, F(1,104) = 380. 17, p<.001. Main idea recall did not decrease

significantly with the addition of the simultaneous driving challenge, but did decrease when the driving

challenge was raised from low to high speed. Recall for details decreased with the addition of the

simultaneous driving, but not when driving speed was increased. Cognitive status was not found to

significantly interact with the effect of distraction; dual-task performance costs were equivalent between

the healthy and impaired groups.

This study demonstrates that when older adults are asked to attend to verbally-presented

information while simultaneously driving, their ability to recall details of that information, and their

ability to remember it verbatim, declines. As the difficulty of the driving challenge increases, older

drivers may additionally recall less of the main points of the information conveyed. This study identifies

another potential risk of distracted driving: when potentially important information (e.g., directions,

alerts) is presented verbally to older drivers, their ability to retain this information may be substantially

degraded.









CHAPTER 1
LITERATURE REVIEW

Overview

This study seeks to examine changes in healthy and impaired older adults' story recall as a

result of performing a simultaneous simulated driving task. First an overview of age-related

changes in cognition, and the effects of age on various forms of memory, will be explored. The

utility of story memory tests for assessing episodic memory will be briefly discussed, followed

by the effects of aging on story recall Next, older adults' performance on dual-tasks will be

addressed, including tasks requiring verbal recall. Finally, the review of older adult performance

in story recall and dual tasks will expand to include the effect of mild memory impairment in

these domains.

Cognition, Memory, and Aging

The gradual general decline in cognition associated with advancing age is well-known.

The pattern of decline is not uniform (e.g. Singer et al., 2003, Schaie, 1990). Types of cognition

related to acquired knowledge, such as fluency and semantic memory, are relatively preserved.

Types of cognition related to procedural abilities including reasoning, attention, and perceptual

speed are more greatly affected by advancing age. These cognitive changes are subserved by

relevant changes in brain structure. Beginning around age 30 and continuing across the adult

lifespan, there is a global reduction in brain volume. However, this pattern of change is also not

uniform, and is seen most prominently in the prefrontal cortex, followed by the temporal and

parietal areas (e.g., Head, 2002). There is also a decline in the integrity of white matter tracts,

which is most significant in the prefrontal cortical regions (Mosley et al., 2002, Head et al.,

2004).










Aging produces varied effects on the different subtypes of memory. Possibly the most

well-known and pronounced effect of aging is on the ability to consciously recall specific events

or episodes, referred to as episodic memory (Zacks et al., 2001). Episodic memory appears to be

relatively stable until around age 60, when it declines at an accelerated rate with increasing age

(Ronnlund et al., 2005). The age-related decline in episodic memory is purported to reflect a

weakened encoding capacity. Some argue this is the result of generalized cognitive slowing,

which reduces the speed of encoding and affects the total amount of information stored (e.g.,

Verhaeghen & Salthouse., 1997). Other theories infer encoding is impacted by deficits in

specific executive components such as working memory, inhibitory control (e.g. Lovden, 2003),

or coordination of cognitive processes (e.g., Fisk & Sharp, 2004). The findings on declines in

prefrontal cortical volume and function would support these theories, although it remains

unresolved whether age-related changes in episodic memory are the result of reductions in

volume or of degraded white matter tracts.

Aging also produces a reliable and significant decrease in worlong memory capacity, or

the ability to simultaneously store and manipulate information. Working memory, like the

cognitive components hypothesized to sub serve episodic memory, is generally agreed to be a

function of the prefrontal cortex. Memory span measures, such as reading span, are commonly

used to assess working memory. In reading span tests, persons concurrently read a series of

sentences and try to remember the last word of each sentence, and are asked after reading to list

each of those words. Older adults consistently demonstrate poorer working memory than

younger adults (e.g., Bopp & Verhaeghen, 2005; Reuter-Lorenz & Sylvester, 2005).

While types of memory dependent upon procedural or fluid abilities are sensitive to age-

related decline, types of memory that depend on accumulated knowledge are relatively robust to









the effects of age. Memory for the contents of a person's cumulative general knowledge- not

requiring recollection of specific place, time, or context is referred to as semantic memory.

Verbal memory measures, such as vocabulary tests, are a common way of assessing semantic

memory. In a cross-sectional study evaluating several types of memory in age groups across the

adult lifespan, Park and colleagues (2002) demonstrated reduced performance with older age in

episodic memory, working memory, and short-term memory, but a stable profile for verbal or

semantic memory. Stable semantic memory ability with increasing age has also been reliably

demonstrated in other studies (e.g., Ronnlund et al., 2005; Allen et al., 2002).

The Utility of Story Memory Measures

Episodic memory can be assessed by recall of text passages such as short stories or

newspaper articles (Adams et al., 1990; Verhaeghen et al., 1993). Participants hear and recall

aloud a passage in which words and ideas follow a logical sequence, which then provides a

context for remembering. The story recall "gold standard" is Wechsler's Logical Memory test

(Wechsler, 1997), consisting of two short stories read aloud and immediately recalled aloud, and

recalled again after a 25-35 minute delay.

Story recall is an episodic memory measure relevant to real-life demands. It is more

ecologically valid to measure memory for a sequence of related events or ideas than, for

example, a list of words not united by any cohesive meaning. Daily life often requires memory

for short narratives (news events, word-of-mouth stories from friends), but rarely rote memory

for word lists. Additionally, story recall allows for the widely accepted notion that real-world

recall is rarely word-for-word, but instead usually abstracted, meaning it is often paraphrased and

gist- or main idea-based. Story memory measures offer an advantage by assessing these more

relevant styles of recall, word lists rely mostly on verbatim recall alone.










Age Differences in Story Recall

The maj ority of research on story recall in aging has focused on age differences. Older

adults consistently remember less story information overall compared to younger groups (Dixon

et al., 2004; Johnson, 2003; Verhaeghen et al., 1993; Pratt et al., 1989). Particularly, when older

adults are asked to memorize a story verbatim, they perform more poorly than younger adults

(Adams et al., 1997). However a recent review suggests that age differences vary depending on

whether verbatim- or gist-based memory (memory for main ideas, regardless of whether correct

wording is recalled) is required. A meta-analysis by Johnson (2003) found the nature of task

instructions and scoring guidelines affects the size of age differences such that age differences

were smaller in studies with scoring based on gist criteria rather than verbatim. Therefore scoring

guidelines emphasizing word-for-word recall, and recall for details, may be more sensitive to age

differences. On the other hand, schemes allowing paraphrasing of information and

summarization of main ideas may lead to relatively better memory performance in older adults.

Effect sizes of age differences are also much larger for word-list verbal memory measures

(Verhaeghen et al., 1993). These tests place greater emphasis on verbatim, text-based recall and

do not allow for synonyms, paraphrases, interpretation of meaning, or varying levels of

information, such as main ideas and secondary details.

Studies examining the content of information recalled main ideas versus details have

found that older adults tend to remember fewer details compared to younger peers. But, like

younger adults, elders demonstrate better recollection for main ideas than for secondary details.

The Victoria Longitudinal Study (Hultsch et al., 1998) that compared to younger age groups,

adults aged 74-84 showed poor recall for details at all testing occasions compared to younger

adults, but maintained a high level of recall for main ideas six years following baseline testing

(Dixon et al., 2004).









A recent study by Chapman and colleagues (2006) investigated older adults' performance

on three kinds of gist: memory for global generalized meaning of a passage, memory for main

ideas of a passage, and memory for categorical clustering of lists of words. This study found that

older adults' memory is poorer for semantic categories and for main ideas than for the global

generalized meaning of a passage. The age differences literature supports this finding. Older

adults recall less than younger adults when asked to literally retell a story, but outperform their

younger peers when asked to interpret the story (Adams et al., 1997). While younger adults excel

at text-based story reproduction, older adults are superior at integrating ideas and interpreting

story meaning (Adams, 1990). In addition to retelling and summarizing story content, they also

often provide more elaborations on the text and inferences from the story than younger adults,

including speculation on the psychological and metaphoric meanings of the passage (Adams,

1991). A cross-cultural study replicated these findings in Japanese older adults (Hosokawa,

2006).

Divided Attention in Aging

Regardless of age, performance on a task is known to decline when attention is divided

between that and performance of a second, simultaneous task (a dual-task challenge). Studies

have shown that this performance decline is also greater with increasing age (Albinet et al.,

2006; Holtzer et al., 2004; Chen, 2000).

However, this age difference has not consistently been found (e.g., Anderson et al., 1998;

Salthouse et al., 1995). The inconsistency of findings may be in part due to lack of understanding

about the underlying reason for differences when they are found. Alternative hypotheses argue

that a) older adults' reduced performance is due to reduced ability to perform concurrent tasks, b)

older adults' poorer performance is the result of general cognitive slowing, or c) the age

difference in dual-tasks is accounted for by different strategies used, with older adults perhaps









strategizing more cautiously (Meyer et al., 2001). A recent dual-task study found age

differences, maintained after adjusting for individual differences and generalized slowing, which

were suggestive of different strategies between the age groups (Rekkas, 2006). Another found

that providing strategy instructions reduced age differences (Naveh-Benj amin et al., 2005).

Riby and colleagues (2004) completed a comprehensive review of dual-task aging

research conducted between 1981 and 2003. They reported a strong overall effect of age-related

dual task impairment (d-.68), but the Eindings among individual studies varied. Subsequent

analyses revealed that one maj or reason for this was the failure to control for baseline

differences. This finding illustrated the value of investigating whether age differences are due to

specific dual-task difficulties or to a general decrement in performance. Somberg and Salthouse

(1982) purported that age differences in dual task performance would disappear if once baseline

differences were controlled for, suggesting dual task age differences were in fact the result of

general age-related decline. However, Riby and colleagues found studies that compared relative-

to-baseline measures of performance obtained larger effects for age-related dual-task costs than

studies that compared absolute measures of performance. These Eindings suggest that controlling

for baseline ability may isolate a true effect of dual-task challenge.

Additionally, this study found that age differences are smaller for verbal tasks and for

verbal reaction time responses than for visuospatial tasks. Perhaps because verbal tasks under

dual-task conditions have smaller age-related decrements, the role of age in verbal recall during

divided attention is somewhat unclear. Several dual-task studies using verbal recall report greater

reductions in recall for older adults during dual-task performance (Craik et al., 1998; Park et al.,

1989), but others report no age difference (Anderson et al., 1998; Nyberg et al., 1997).









The investigators found that the most critical factor associated with variability of Eindings

for dual-task age differences was the task domain used. Namely, simpler tasks or those requiring

relatively automatic processing were associated with smaller age-related performance deficits.

On the other hand, dual-task scenarios involving a motor component demonstrated larger age

differences in performance, such as walking and memorizing (Lindenberger et al., 2002). A

meta-analysis by Verhaeghen and colleagues (2003) expands the relationship between dual-task

age difference and task modality by reporting that matched-modality tasks produced reliably

larger dual-task costs than paradigms utilizing tasks from two different modalities. Other studies

have reported greater age-related dual-task deficits for explicit versus implicit memory (Light,

1991), and for performance of concurrent memory tasks (Salthouse, Rogan, & Prill, 1984),

versus performance of concurrent perceptual tasks (Somberg & Salthouse, 1982). Riby and

colleagues (2004) also observed larger age-related deficits in dual-task scenarios requiring a

substantial amount of effortful, controlled cognitive processing such as working memory,

episodic memory, and reasoning tasks.

Elders' Performance in Driving Divided Attention Tasks

The influence of automatic versus effortful tasks on the size of age differences in dual

tasks may have implications for the present study, which pairs verbal recall with the everyday

task of driving. While driving is a complex task involving the coordination of visual scanning,

attention, decision-making, and motor skills, it is also a relatively automatic, daily-practiced

behavior for most people. How, then, might older adults perform in a dual-task scenario in

which one of the concurrent activities is driving?

The first answer to this question and the most relevant to this paper is the finding from

Cook (2007), the primary analysis on the same dataset from which this paper is derived. Sarah

Cook evaluated older adults' lane navigation performance in a dual-task study of simulated









driving and story recall. She found that the addition of a concurrent story recall task had no

negative effect on participants' ability to maintain lane position; instead, they actually

demonstrated less lane deviation than in the single lane navigation task. One way to resolve

these counterintuitive Eindings is that participants may have prioritized the driving task due to the

real-world dangers distracted driving entails, and sacrificed the verbal recall task. This

explanation is supported by the finding that verbal recall overall did decline under dual-task

conditions, while lane navigation improved. Another piece of the explanation may be that

driving is a relatively automatic task, while episodic recall has been regarded as an effortful task.

It would then make sense for driving performance to be relatively preserved while recall

performance declines. However, the broader Eindings from similar studies have been varied.

Crook and colleagues (1993) compared different age groups across the adult life span on

the simultaneous performance of a verbal recall task and a computer-simulated driving reaction

time task. Participants in the older age groups demonstrated greater performance declines on

both the verbal and reaction time tasks in the dual-task scenario. After controlling for

psychomotor speed, older adults still demonstrated poorer reaction times, suggesting the dual-

task effect was due to cognitive rather than psychomotor factors. The greatest age differences

were observed between the youngest (18-39 yrs) and the oldest groups (70-85 years).

McPhee and colleagues (2004) found similar results in a concurrent task of visual search

for traffic signs and recall of the Wechsler Logical Memory stories. While all age groups

suffered dual-task performance costs, older adults demonstrated differentially greater dual-task

costs on both tasks. They recalled significantly less of the Logical Memory stories than younger

adults in the dual-task condition. They also were slower and less accurate in deciding when a










target sign was not present during dual-task conditions, especially in high-clutter scenes on the

visual search task.

However the findings on older adults' dual task performance of verbal tasks and

simulated driving, like the majority of dual-task literature, is also somewhat inconsistent. A

recent study evaluated the effect of verbal production and verbal comprehension on velocity and

lane position control during a computer driving simulation (Kubose et al., 2006). This study

found that while driving velocity became more variable during verbal production and

comprehension compared to driving alone, the concurrent production of speech while driving

actually yielded better lane position control, and verbal comprehension had no effect on lane

position control. Additionally, verbal production and comprehension performance were not

impacted by the added challenge of simultaneously driving.

Age Differences in Recall Under Divided Attention

The qualitative age differences in recall poorer verbatim memory and superior

integration in older adults appear to be consistent in dual-task scenarios, if not compounded by

the additional challenge of divided attention. Arbuckle and colleagues (1985) found that the level

of verbatim recall decreased in older adults with the addition of a simultaneous verbal task.

Compared to younger adults, they gave fewer verbatim responses and more inferences,

elaborations, and overgeneralizations, indicating that in the presence of a second simultaneous

task, the quality of older adults' recall again focuses on overall ideas more than on text

reproduction.

The Role of Mild Cognitive Impairment

Introduction to Amnestic Mild Cognitive Impairment

The previous sections have focused on changes in verbal recall and dual-task

performance in the context of normal, healthy aging. However the course of aging is varied, and









can deviate from the typical slow general decline of normal aging to the onset of Alzheimer's

Disease (AD) or other cognitive disorders, which become more prevalent with increasing age.

Cognitive aging exists on a continuum then, from healthy typical decline to mild impairment to

severe dementia (Petersen et al., 1999).

Mild Cognitive Impairment (MCI; Petersen et al., 1999) refers to the area in the middle

of the continuum, and has come to represent with some controversy a transitional zone

between normal age-related cognitive decline and the very early clinical stages of AD (Petersen,

2005). The MCI construct does serve as a clinically relevant predictor of progressing to

dementia (Lopez et al., 2003; Daly et al., 2000), and was endorsed as such in 2001 by the

American Academy of Neurology (Petersen et al., 2001). However, MCI does not consistently

predict progression to AD, and can even be associated with subsequent improvements in

cognition. Its presentation is sufficiently heterogeneous as to necessitate clinical

subclassifications (e.g. single domain impairment in memory or another domain, multiple

domain impairment). These different subclassifications may lead to a wide variety of outcomes,

and each is associated with a different set of possible prognoses. The subtypes are primarily

distinguished based on presence or absence of memory impairment, and are therefore

characterized as amnestic (aMCI) or non-amnestic MCI (Petersen, 2004).

This study focuses on patients of the aMCI subtype, which consists of a mild memory

impairment more pronounced than what is normally seen with advancing age (performance 1 1.5

SD below the norm for a patient' s age and education), accompanied by a subj ective memory

complaint. However cognitive function in other domains such as language and attention is

preserved, as are activities of daily living (ADLs; for example, grooming, bathing and feeding),

and these patients do not meet the clinical criteria for dementia.










Importantly, aMCI as a categorically-definable phenomenon is a somewhat artificial

construct. Much research has focused attention on whether MCI is truly a discrete entity,

distinguishable from normal cognitive aging and from dementia. The findings are thus far

inconclusive (Davis & Rockwood, 2004). But the difficulty of characterizing MCI as a discrete

phenomenon is intuitive. It underscores the notion that if cognitive aging does exist along a

continuum, then categorizing cognitive decline into stages is not faithful to its nature. Advocates

of establishing guidelines for identifying MCI as a distinct stage understand this issue, but

acknowledge that quantifiable performance cutoffs are inevitably necessary for MCI to be used

as a clinical entity. The diagnosis and treatment of progressive cognitive decline relies on

obj ective measurement of cognitive abilities, and cutoff points are made as precisely as can be

but could never be exact. One method that would be useful in assessing how cutoff points are

determined, and which neuropsychological measures are used to classify aMCI, is policy

capturing. Policy capturing is a method used by researchers to evaluate how individuals make

decisions (Karren & Barringer, 2002). It uses quantitative methods like cluster analysis,

discriminant functions, and logistic regression to evaluate the way individuals "weight, combine,

and integrate" available information to make a judgment. While this method is frequently used

on an organizational or societal level, in job searches and hiring analyses for example, it has

relevant implications for investigating the way researchers and clinicians formulate diagnoses of

MCI. Policy capturing analyses will be employed later in this document to identify the

underlying algorithm that seemed to guide the classifications decisions of our own study's

consensus conference judgments.

However, this reality does not negate the pragmatic value of developing and

implementing diagnostic criteria to identify MCI. Current clinical criteria have been shown to









predict progression to AD, albeit without perfect consistency to date. The additional

sophistication of the aMCI criteria has been argued to be a more sensitive predictor of AD

pathology, as 10-15% of patients move on to a diagnosis of AD each year, compared to 1-2 of

the general population (Petersen et al., 2001). An aMCI diagnosis has also been associated with

lower rates of survival (Leep Hunderfund et al., 2005).

Impact of Cognitive Impairment on Story Recall

Research indicates that declines in verbal episodic memory, including for paragraph

recall, are among the most commonly reported in older adults with aMCI or in the preclinical

stages of Alzheimer' s disease (Collie & Maruff, 2000, Kluger et al., 1999). But those with aMCI

retain intact activities of daily living, and therefore continue to drive. Because they are still

active and independent in daily life but experiencing early memory loss, these individuals may

be at greatest risk for forgetting episodic information crucial to their daily functioning, and may

be especially vulnerable to forgetting information if they are distracted by other simultaneous,

cognitively complex activities such as driving.

The story recall literature indicates that cognitively impaired individuals consistently

recall less overall than their healthy peers on stories (Gely-Nargeot et al., 2002; Robinson-

Whelen & Storandt, 1992) and on other verbal memory measures (Greenaway et al., 2006;

Balota et al, 1999). A study by Johnson and colleagues (2003) compared young adults, healthy

older adults, very mildly and mildly demented adults (AD) on measures of both verbatim and

gist-based recall for stories. The results of this investigation revealed there was a significant

effect of dementia among the older adults, such that very mildly and mildly demented older

adults remembered less story information verbatim, and less of the gist of the story, than healthy

older adults. The effect of dementia on recall was more severe for verbatim recall than for gist.









Another recent study by Hudon and colleagues (2006) specifically examined recall

content memory for the gist versus the details of a story and found that adults with MCI and

adults with AD recalled less of both the gist and details of a story, compared to healthy adults.

Additionally, they reported that even recognition of gist-level information is decreased in

individuals affected by greater impairment: they found that adults with AD showed additional

deficits in main idea recognition, while this ability was relatively spared in adults with MCI.

Similarly, Chapman and colleagues (2006) found that mildly impaired adults performed poorer

than healthy older adults on three types of gist memory: semantic categories for word-lists, main

ideas of a text passage, and global general meaning of a passage. This is in contrast to healthy

older adults, who demonstrate relatively preserved strength in memory for a story's global

meaning. It suggests that impaired adults' ability to integrate and interpret stories, which is a

strength in healthy older adults, is negatively impacted. Unsurprisingly, in addition to

remembering fewer main ideas and details and less overall meaning, impaired adults also show a

reduced ability to accurately recognize inferences (Bielak et al., 2007).

Impact of Cognitive Impairment on Dual-Task Performance

Research consistently indicates that compared to healthy older adults, the costs to

performance on dual-tasks are significantly larger for those in the early stages of Alzheimer' s

Disease. However the consistency of dual-task costs, as with normal aging compared to younger

adults, is also less clear for persons with MCI. Perry, Watson and Hodges (2000) reported no

differentially greater dual-task costs for MCI participants, but consistent impairment for mildly-

demented AD participants in dual-task performance and other areas of attention. Conversely, a

recent study (Belleville et al., 2007) found that persons with MCI exhibited impaired

performance on a divided attention task but preserved performance on other measures of

attention, while persons in the early clinical stages of AD exhibited impairments on all measures









of attention. Additionally, participants with MCI who demonstrated subsequent declines also

showed impaired attentional performance on tests of manipulation abilities compared to MCI

participants who did not decline.

As in the normal aging literature, it has been postulated that performance decrements at

lower levels of cognitive status are simply the reflection of decreased cognitive capacity and

processing speed, and there is no differential effect of divided attention per se. However, Holtzer

and colleagues (2004) corrected for age, education, and performance among groups of healthy

and cognitively impaired participants and continued to find reliably greater dual-task costs for

impaired participants. They also argued, based on the results of a discriminant function analysis,

that the dual-task measures were more accurate in discriminating impaired and healthy elders

than traditionally-used neuropsychological measures.

Similar to Riby and colleagues' (2004) findings in the normal aging literature, task

selection impacts the size of dual-task effects for cognitively impaired persons. Crossley and

collaborators (2004) demonstrated that dual-task scenarios requiring little effortful processing

may show no impairment-related dual-task costs, but tasks requiring effortful cognitive activity

may produce impairment-related costs. The study compared healthy participants and participants

with early-stage AD in performance on concurrent unimanual tapping and speaking tasks. When

speaking was relatively automatic (speech repetition), there was no discernable difference in

dual-task costs between groups. However when effortful speech was required (speech fluency),

cognitively impaired participants demonstrated larger dual-task costs than their healthy peers.

Summary

This overview of the research illustrates that in terms of story recall, older adults have a

poorer verbatim and detail-based memory compared to younger adults, but are superior at

summarizing story themes, interpreting meaning, and elaborating and making inferences upon

26









the story information. The findings on dual-task performance costs in elders are as yet unclear.

There have been reports of age differences associated with increased dual-task costs for older

adults, but these reports have not been consistent throughout the literature, and several theories

have been postulated to address this issue. Finally, the research on cognitive impairment

consistently reports that older adults with MCI demonstrate greater general reductions in story

recall; however the existing literature provides mixed reports on whether persons with MCI

exhibit larger dual-task costs than healthy older adults. The following chapter will discuss the

specific aims of this investigation.









CHAPTER 2
STATEMENT OF THE PROBLEM

Episodic memory, or memory for specific events and experiences, is more strongly

affected by age-related cognitive decline than semantic memory, or memory for more general,

acquired information (Nyberg & Tulving, 1996; Tulving, 1995). Older adults report this change

in their everyday lives as more-frequent forgetting of acquaintances' names or details for recent

events. Additionally, dividing attention between two simultaneous tasks often reduces cognitive

performance. Older adults may be more prone to forgetting episodic information when they are

distracted by doing something else simultaneously, such as listening to the radio while driving.

Adults whose cognitive decline is greater than normal for age may be especially susceptible to

forgetfulness during distraction. If age-related episodic memory loss is compounded by the effect

of distraction, then older adults are at a greater risk for forgetting information conveyed to them

while driving (such as news bulletins, traffic warnings, or conversations with passengers).

Because important verbal information including verbally-conveyed directions, passenger or

cellular phone conversations, or radio news or alerts is often communicated to older adults

while driving, the risk of forgetting has important functional implications for cognitively healthy

and impaired adults alike.

The goal of this study was to investigate the effect of simultaneous simulated driving on

episodic memory performance, as measured by verbal recall of a brief news story. Driving and

story recall tasks were performed under three conditions: alone, under slow-speed dual-task

challenge (30 mph driving), and fast-speed dual-task challenge (60-mph driving). Sixty-one

community-dwelling older adults with and without memory impairments were asked to

participate. Story memory was evaluated in terms of precision, defined as verbatim (word-for-










word) versus paraphrase recall, and content, defined as recall for main ideas versus recall of

secondary details. There were three main goals of the study.

Dual-Task Effect on Precision

Aim One

To understand the effect of dual-task driving and recall on story memory precision,

defined as verbatim and paraphrase. Recall for the number of "idea units" of the Rivermead story

paragraphs (Wilson et al, 1985) was compared across single-task, slow-speed dual-task, and fast-

speed dual-task conditions in terms of verbatim and paraphrase recall.

Hypothesis One

Story recall will decrease overall with increasing condition difficulty. As a proportion of

all possible idea units, verbatim recall will decrease more greatly than paraphrase recall.

Dual-Task Effect on Content

Aim Two

To understand the effect of dual-task driving and recall on story memory content, defined

as main ideas and details. Recall for the number of "idea units" of the Rivermead story

paragraphs was compared across single-task, slow-speed dual-task, and fast-speed dual-task

conditions in terms of recall for main ideas and details.

Hypothesis Two

Overall, story recall will decrease with increasing condition difficulty. Recall for details,

as a proportion of the number of detail idea units possible, will decrease at a differentially greater

rate than recall for main ideas, quantified as the proportion recalled out of the total main idea

idea units possible.










Role of Cognitive Impairment in Dual-Task Effects on Precision and Content

Aim Three

To investigate the role of cognitive ability in story memory performance during dual-task

driving and recall. Recall across conditions was compared between healthy and cognitively-

impaired older adults in terms of verbatim versus paraphrase and main ideas versus details

recalled.

Hypothesis Three

Cognitively impaired adults will show lower levels of story recall than healthy adults in

all conditions. Additionally, impaired adults will demonstrate a greater decrease in performance

as task condition difficulty increases. Compared to healthy adults, impaired adults will

demonstrate a greater decline in verbatim and paraphrase recall with increasing condition

difficulty, and a greater decline for recall of details. No group differences are expected for recall

of main ideas across increasing condition difficulties.









CHAPTER 3
RESEARCH DESIGN AND METHODS

Overview

Older adults were asked to recall short stories alone and under slow and fast dual-task

conditions while performing a simulated lane navigation task. They also completed

neuropsychological testing for the purpose of identifying possible memory impairment. A

consensus group met to determine cognitive status for all participants. The following sections

describe the relationship of the present study to the parent study (Cook, 2007), participants and

the selection process, study procedures and the measures used, and the design, procedures and

materials of the experimental task.

The Cook Study

This study was conducted as an extension of a study designed and initiated by Sarah Cook

(2007). The present study and parent studies shared the same overarching design and data set,

and were conducted in tandem. The author and Ms. Cook worked together to accomplish

participant recruitment, screening, and consensus classification. The author also completed

approximately half of the data collection, administering neuropsychological tests and conducting

the experimental protocol. The findings from the Cook study are summarized in the literature

review above.

The Cook study used total story recall scores to assess overall changes in recall associated

with the dual task challenge. The present study investigated beyond this general overview to

explore changes within various dimensions of recall (verbatim or paraphrased recall, recall of

main ideas). In order to do this, the author established additional scoring systems to evaluate the

precision and content of recall. Division of stories into individual idea units was used to provide









a detailed analysis. Two levels of scores (verbatim, paraphrase) were used to quantify recall

precision, and each idea unit was coded as a main idea or detail to quantify the content of recall.

Participants

Sixty-one community-dwelling older adults (age 65-91) were recruited from the

community. Efforts were aimed at recruiting both healthy older adults, and those with mild

memory impairments. Forty-six participants were classified as healthy or normal older adults,

and fifteen were classified as impaired, having been identified to have memory impairments.

Impaired participants received consensus classification of amnestic mild cognitive impairment

(aMCI) or dementia. The consensus classification process is described in the sections below.

Eligibility

Participants with a history of conditions or events that potentially disrupting normal

cognitive functioning were excluded. This includes adults with a history of epilepsy, head injury

with loss of consciousness, encephalitis, meningitis, Parkinson's disease, stroke within the last

year with residual motor signs, heart attack within the last year, and current cancer treatment or

past radiation treatment above the chest. Participants were also excluded who had never had a

driver s license or stopped driving more than 2 years ago. Participants with visual or auditory

impairments precluding valid testing (e.g. self-report of severe difficulty reading, or self report of

severe difficulty hearing in conversation) were also excluded. Participants were asked to identify

a friend or relative to who could serve as an informant for the purpose of the Clinical Dementia

Rating Scale (CDR).

Recruitment Sources

Participants were recruited from several sources within the community, including

existing participant pools at the University of Florida (UF) National Older Driver Research and

Training Center (NODRTC) and Institute on Aging. Patients assessed at the UF Psychology









Clinic meeting study criteria were informed of the study by faculty, as well as patients at the UF

Memory and Cognitive Disorders Clinic, who were informed by a recruiting research team

member or whose information was released by UF's Clinical Alzheimer Program. A town hall

meeting was held for recruitment at a local continuing care retirement community, and

advertisements were made in local newspapers (The Gainesville Sun and The West End Journal).

In addition, two graduate student researchers studying similar patient groups provided participant

contact information for those interested in being contacted about future studies.

Study Procedures

Screening

Participants were screened by telephone to exclude those who did not meet the inclusion

criteria stated above. Cognitive functioning was briefly assessed using the Modified Telephone

Interview for Cognitive Status (TICS-M; Brandt et al., 1988). This measure provides a

preliminary estimate of function and possible impairment with cutoff scores for MCI (<34) and

dementia (<20).

Administration of Neuropsychological and Experimental Tests

After giving informed consent, participants completed a neuropsychological assessment

and experimental task, which was completed during a single visit in one 3-hour block. The visit

was broken into 3 parts, each lasting approximately 1 hour (represented in Figure 3.1). First, a

primary neuropsychological battery was administered to assess cognitive status and other

possible factors contributing to task performance. Second the experimental task, described in the

following pages, was administered. Third, questionnaires and secondary neuropsychological

measures were administered as part of a larger study. Breaks were provided during the

experimental task and offered during neuropsychological testing as needed. Some participants

were recruited from another study using some of the same neuropsychological measures: the









Mini Mental Status Examination, the Hopkins Verbal Learning Test, and Useful Field of View.

One participant who had completed these measures within the past month consented to have his

data shared for the study. Those measures were not re-administered to him for this study.

Participants who had completed the other study more than one month ago were re-administered

the tests, taking into account the progressive nature of MCI and the importance of making the

most accurate possible classification.

Consensus Classification

A consensus conference panel consisting of the investigator, a neuropsychology faculty

member, a cognitive psychology member, and a neuropsychology student met at the conclusion

of data collection to identify participants with aMCI and early-stage AD. Assignment to a

cognitive impairment group was decided based upon cognitive performance and on ability to

carry out daily functions as reported on the Clinical Dementia rating scale. Neuropsychological

test results were reviewed in percentile format, with special attention given to participants whose

test scores ranked at or below the 7th percentile (according to the definition of impairment as 1.5

SD below the mean by Petersen et al., 1999). Each panel member individually identified

impaired participants before the list was reviewed and a vote was made for the status of each

participant identified by a panel member. If the vote was unanimous, the participant was

identified as impaired; if there was disagreement, the participant's performance and daily

functions were further discussed until a maj ority vote (3 out of 4) could be reached. After

consensus, the sample sizes of the two impaired groups were found to be much smaller than the

healthy sample. Consequently, a dichotomous (normal vs. impaired) conceptualization was used

for analyses of the results instead of the original three-group experimental design.









Neuropsychological Measures


Telephone Screening Measure

To establish whether participants met inclusion criteria, they were asked several questions

about medical history and demographics. They also received the Modified Telephone Interview

for Cognitive Status (TICS-M; Brandt et al., 1988), a short measure designed to assess cognitive

ability in situations where in-person evaluation is inconvenient or impractical. It is similar to the

Mini-Mental Status Examination, but with a more extensive memory component and can be

administered over the telephone.

Neuropsychological Consensus Measures

To ensure that participants met criteria for inclusion in one of the 3 cognitive groups

(healthy, mild cognitive impairment, or probable dementia), we administered a battery of

measures assessing memory and other areas of cognitive functioning. The battery was chosen

based on measures identified by the Consortium to Establish a Registry for Alzheimer's Disease

(CERAD) to be useful in assessing for Alzheimer's disease and other dementias associated with

aging. The cognitive domains assessed were chosen in order to identify not only memory

impairment, a primary feature of dementia, but also to establish breadth and depth of impairment

across multiple areas of functioning. These domains were also selected in order to rule out

impairment based on primary deficits in areas other than memory, such as attention.

Global cognition. The Mini-Mental Status Exam (MMSE; Folstein et al., 1975) was

used to assess global cognition. The MMSE is a brief 30-point measure of orientation, memory,

language, attention, and visuospatial processing. These abilities were examined more in-depth

with other measures.

Verbal memory. Verbal memory was assessed using the Hopkins Verbal Learning Test

(HVLT; Brandt & Benedict., 2001) and the Wechsler Logical Memory subtest (Wechsler, 1997).









The HVLT is a list-memory task in which 12 semantically-related nouns are read aloud and

participants are asked to recall them. The list is repeated and recalled for 3 trials, and after a 25-

minute delay participants freely recall the list one more time. After the delayed recall, the test

includes a recognition task in which participants hear a list of words from the original list, new

but semantically related to the original list, or new and not semantically related. Participants are

asked to identify whether or not they recognize each word from the original list.

The Wechsler Logical Memory test is a paragraph-memory test in which a short story is

read aloud and participants are asked to recall it immediately after hearing it. Then a second

story is read twice, participants recalling the story each time after hearing it. Participants are

prompted to remember the story for a later time in testing. After a 25-35 minute delay,

participants are asked to recall each of the stories once more. Finally in a recognition trial,

participants are asked 15 yes-or-no questions about each story.

Language. Language was assessed using the Boston Naming Test (BNT; Kaplan et al.,

2001) and the Control Oral Word Association Test (COWAT; Benton & Hamsher, 1989). The

BNT measures the ability to name pictured obj ects; a 15-picture shortened version of the test was

established by CERAD for clinical testing and was used for this study. The COWAT is a

measure of verbal fluency in which participants are given one minute to generate as many words

as they can beginning with a particular letter. Three trials are given, each with a different target

letter. A fourth trial requires participants to name as many members of a category (e.g. animals)

as they can within one minute.

Processing speed. Processing speed was measured using the Trail Making Tests A and

B (Reitan, 1992), in which participants connect circles in a prescribed order as fast as they can.

This task requires visual scanning and sequencing, psychomotor speed, concentration, and










cognitive flexibility.

Visuospatial construction. Constructional ability was assessed using the Rey-Osterrieth

Complex Figure Copy task (Rey, 1941). The participant is shown a complex figure and asked to

copy it on a piece of paper. Scoring is based on both how accurately components of the figure

are drawn, and on how accurately those components are placed within the figure.

Attention. Attention was assessed with both the Wechsler Digit Span subtest (Wechsler,

1997) for verbal attention and the Ruff 2 & 7 Selective Attention Test (Ruff & Allen, 1996) for

selective attention. Digit Span consists of two parts in which participants are first read a string of

digits and asked to repeat them, and second are asked to repeat a string of digits in reverse order.

The Ruff Selective Attention test requires visual search and cancellation, assessing both

sustained and selective attention. It consists of twenty 15-second trials in which the participant is

asked to visually search lines of numbers, or lines of numbers and letters (there are 10 trials of

each type). Participants are to draw a line through the numbers 2 and 7. Scoring takes into

account both correct hits and errors of omission to calculate the tradeoff between speed and

accuracy.

Visual attention. Visual attention and processing speed, which decline with age and can

increase the difficulty of driving performance, was assessed using the Useful Field of View

(UFOV; Ball & Owsley, 1993. This computer-administered task measures sustained, selective,

and divided attention. The first subtest of the task requires identification of a centrally-presented

target (car or truck). The second subtest requires simultaneous identification of the centrally-

presented target and of the location of a peripherally-related target (car). The third subtest is

similar to the second but requires the peripheral target to be located amid visual clutter (triangles

across the visual display). A fourth subtest required participants to determine whether two









centrally presented targets were the same (two cars or two trucks) or different (car and truck), as

well as identifying the location of the peripheral target. Each subtest adapts to the participant's

performance such that the score is based on the fastest speed at which the participant is able to

identify 75% of stimuli accurately.

Working memory. Working memory was assessed using an auditory n-back task

including 1-back, 2-back and 3-back tests. For the 1-back task, participants hear a series of letters

over a sound file and are asked to indicate with a button press whether each letter they hear is the

same or different as the letter before it. Similarly, with the 2- and 3-back tasks, participants are

asked to indicate whether the current letter is the same or different as the letter presented 2 letters

ago or 3 letters ago, respectively. Scoring incorporated both accuracy and response time.

Mood. Mood was assessed with the Geriatric Depression Scale (GDS; Yesavage, 1983).

The GDS consists of 30 yes-or-no, self-report items about symptoms of depression common

among older adults. The GDS was included to account for any possible effect of depression on

participants' memory and attentional performance.

Daily function. The Clinical Dementia Rating Scale (CDR; Morris, 1993) was collected

as a measure of daily functioning for participants whose neuropsychological test results were

ambiguous regarding impairment. This measure was administered over the telephone after

testing. It included questions for both the participant and his or her designated informant about

memory, orientation, judgment and problem solving, home and hobbies, community affairs, and

basic self-care. Scores were based on an algorithm of the scores assigned for each of these

domains. A CDR score of 0 indicated no impairment, 0.5 indicated mild impairment, and 1.0

indicated moderate impairment.










The tests and specific scores used to measure each area of cognitive ability for the purpose

of consensus classification are described in Table 3-1.

Experimental Task

Experimental Procedure

The experimental task was administered after the primary neuropsychological battery and

before the secondary measures and questionnaires, and took approximately one hour to complete.

Participants first heard and, after a 35-second delay, recalled aloud three Rivermead short stories.

Stories were administered and recalled one at a time. All responses were recorded using a digital

recorder, and were later transcribed for scoring. After recalling three stories under single-task

conditions, participants completed a five-minute lane navigation acclimation task on the driving

simulator in order to become comfortable with operating the equipment. They completed two

short driving courses at 30 mph, the first consisting of all right-hand turns and the second of all

left-hand turns.

Following acclimation, the dual-task part of the experiment was administered in two

13.5-minute segments, with a 4.5 break period in between to prevent fatigue. Within each

segment three stories were administered concurrently with simulated lane navigation. Each story

was completed under slow or fast driving conditions (either 30 or 60 mph), and alternated such

that the three stories in segment one were given in slow-fast-slow conditions respectively, and

segment two stories were given as fast-slow-fast. Participants received a period of single-task

driving as a buffer between each story administration.

Participants listened to stories through a digital recording played over a speaker beside

the desktop. At the end of the story, the program instructed them to remember what they just

heard. After 35 seconds, participants were prompted to say aloud what they remembered. To

keep recall from overlapping with the beginning of the next driving condition, response time for









each story was limited to one minute.

An illustration of the experimental study procedure can be found in Figure 3-1.

Experimental Measures and Materials

Short story measures

Nine stories were administered altogether: three alone without simultaneous simulated

driving, three with simultaneous slow driving, and three with simultaneous fast driving. The nine

stories were divided into three groups of three, and each story group was randomly administered

in the alone segment, during the first dual-task segment, or during the second dual-task segment,

so that each participant heard each of the nine stories only once.

Four of the stories were from the Paragraph Recall Task of the Rivermead Behavioral

Memory Test (Wilson et al., 1985). The other five stories had been used in a memory training

study and were created using an algorithm created to make them to correspond directly to the

Rivermead paragraphs in complexity, structure, and number of idea units. The term "idea unit"

is used to refer to each individual lexical item within the story. For example, the following

sample sentence is divided into "idea units":

Ms. Virginia / Boone / a mother of two / won / the mother of the year award / on
Sunday / during a community celebration / in Chicago.


The complete text for all stories is included in Appendix A. For brevity, the Rivermead-type

paragraphs will be referred to as "Rivermead" stories throughout the rest of this document,

acknowledging that not all of them came from the actual Rivermead Behavioral Memory test.

Stories administered alone were read aloud by the testing technician. Stories in the dual-

task condition will be presented on the computer as a recorded male voice. After presentation

(about 45 seconds) participants were given 35 seconds to mentally rehearse the story before









recalling it aloud within a one-minute time limit. Participant responses were digitally recorded

and later transcribed.

Short story scoring

Stories were scored for precision based on the accuracy and completeness of recall. Each

idea unit was scored as 0 (not recalled), 0.5 (paraphrase or incompletely recalled), or 1 point

(verbatim or completely recalled). This scoring method was based on the system already

developed for the Rivermead paragraphs, and adapted also for the algorithm-generated stories.

Stories were also scored for recall content, or how much of recall consists of main ideas and

how much of it consists of supporting details. Idea units were coded as either main idea or detail

information, based on a consensus process. Investigators initially met with language and

discourse experts to evaluate what criteria existed for coding main idea and detail phrases. Given

that no validated method was found, investigators recruited ten college-educated individuals to

code each story. Idea units identified as a main idea by five or more consensus members were

considered main ideas for the purposes of the study; all other idea units were considered

secondary details.

Precision and content were quantified as the percent of idea units recalled out of the total

possible. So in the case of precision, because all idea units could be recalled either verbatim or in

paraphrase, verbatim recall was calculated as the number of idea units recalled verbatim out of

21 possible idea units. Likewise, paraphrase recall was calculated as number of idea units

recalled in paraphrase out of 21. Main idea recall was calculated as the proportion of main idea

idea units recalled out of the number of main ideas possible, which varied for each story. Recall

of details was similarly calculated as the number of detail idea units recalled out of the number

possible within each story. Figures 3-3 and 3-4 depict the formulas used to derive these

proportional recall scores.









Scoring reliability

To ensure reliability, two independent raters scored all story recall responses, and the

average of these two rating was used in all analyses. An analysis of inter-rater reliability was

conducted by correlating the two score sets. Ratings provided by each of the two raters were

positively correlated for each story administered in each condition (ranging from r=0.93 to

r=0.97, p<.001). Story recall ratings can therefore be interpreted as reliable.

Driving task

STISIM Drive software was used for creation and administration of the simulated lane

navigation task. Scenarios were presented on a Dell Optiplex GX270 desktop computer (rather

than a driving simulator due to the high probability of simulator sickness in older adults), with a

19-inch flat screen monitor and Logitech MOMO Force Feedback Steering Wheel. The steering

wheel was attached to a desk in front of the computer, and participants were seated at the desk

with the monitor approximately 18 inches away.

The task involved simulated driving on a two-lane roadway consisting of right and left

turns and varying curve angles. There were no traffic lights or signals, and no other vehicles or

pedestrians on the road. The terrain to either side of the road was flat and void of any objects,

and there was a fixed view of a mountain range in the landscape up ahead. Figure 3.4 depicts a

screen shot typical of the driving scenario. Participants were instructed to drive in the right-hand

lane as they would on a normal road, and to do their best to maintain their lane position through

the curves and through the changes in driving speed.













Total Score


Total score
(using serial 7 subtraction)

Total Immediate, Delay, and
Recognition
Total Immediate, Delay, and
Recognition

Total score

Total (F, A, S)

Total Animals

Time for A, Time for B,
Errors for A, Errors for B
Forward Span and Backward
Span

Automatic Detection
Accuracy, Controlled Search
Accuracy, Speed-Accuracy
Difference
Copy Total

Total score

Total score


Table 3-1. Measures used for consensus classification.


Cognitive
Domain
Telephone
Screener

General
Cognitive
Screener
Memory





Language






Psychomotor
Speed
Attention







Construction
Ability
Mood

Daily
Functioning


Variables of Interest


Published
Source
Brandt et al.,
1988

Fol stein,
Folstein, &
McHugh, 1975
Brandt &
Benedict, 2001
Wechsler, 1997


Morris et al.,
1989
Benton &
Hamsher, 1989
Goodglass &
Kaplan, 1972
Reitan, 1992

Wechsler, 1997


Ruff & Allen,
1996


Rey, 1941

Yesavage &
Brink, 1983
Morris, 1993


Test


Modified Telephone
Interview for Cognitive
Status
Mini-Mental Status Exam


Hopkins Verbal Learning
Test-Revised (HVLT-R)
Wechsler Memory Scale-
Third Edition Logical
Memory
Boston Naming Test 15-item
CERAD version (BNT-15)
Control Oral Word
Association (COWAT)
Category Fluency

Trail Making Test A and B
(Trails A, Trails B)
Wechsler Adult Intelligence
Test- Third Edition, Digit
Span Subtest
Ruff 2 & 7 Selective
Attention Test


Rey-Osterrieth Complex
Figure
Geriatric Depression Scale
(GDS)
Clinical Dementia Rating
Scale (CDR)











Administer Secondary
Neuropsychological
Battery and
Questionnaires:
60 minutes


Greeting, Study Administer Primary
Explanation, Neuropsychological
Consent, and Battery and
Payment Paperwork: Questionnaires:
10-20 minutes 60 minutes


Administer
Experimental
Acclimation and
Tasks :
50-60 minutes


Figure 3-1. Participant visit overview. Participants are introduced to the study for 10-20
minutes. They next complete the primary neuropsychological battery, which takes
approximately 60 minutes. They then complete the experimental task, lasting 60
minutes, and finish the remainder of the neuropsychological battery after the
experimental task.


ISlow Fast Slowl

Dual Task Segment 1


Note: S = one story unit; Administered alone = single-task condition; Slow = slow-
speed dual-task condition; Fast = fast-speed dual-task condition.


Figure 3-2. Experiment procedures represented by task condition. The experimental task was
divided into three segments, each consisting of three story administrations. In the
first segment, three stories were recalled without the simultaneous driving task. In
the second and third segments, participants completed the story recall and driving
tasks simultaneously, alternating between low and high levels of speed for each story.


IAdministered alone I

Single Task Segment


IFast Slow Fast

Dual Task Segment 2













Total propositions
recalled verbatim
Verbatim Recall=
21 (All possible propositions)



Total propositions recalled
in paraphrase
ParanhrasedPP~~PP~~~PP~~PP Recall =
21 (All possible propositions)




Figure 3-3. Calculation of verbatim and paraphrased recall scores





Total "main idea"
MainIdeaRecal =propositions recalled
All possible "main idea" propositions
(varies with story)

Total "detail"
propositions recalled
Detail Recall
All possible "detail" propositions
(varies with story)





Figure 3-4. Calculation of main idea and detail recall scores









CHAPTER 4
RESULTS

Overview

This study investigated recall of short stories in older adults aged 65 and older, whose

cognitive status ranged from normal to memory impaired. We examined how the addition of a

secondary task condition (simulated lane navigation) affected the style of older adults' recall,

under two levels of secondary task difficulty (slow speed of 30 mph and high speed, 60 mph).

We also investigated whether the effect of distraction by a secondary task would be similar for

healthy and impaired participants.

The study addressed three main experimental hypotheses. First, we aimed to confirm that

both verbatim and paraphrased recall would decrease as a function of increasing task difficulty,

and verbatim recall would decrease more than paraphrased recall. Second, we aimed to confirm

that recall for both main ideas and details would decrease with increasing task difficulty, and that

this decrease would be greater for recall of details than for main ideas. Third, we sought to

determine whether these changes in recall quality (verbatim, paraphrase) and content (main

ideas, details) would be disproportionately greater for impaired versus healthy participants.

Preliminary questions were explored regarding the reliability and validity of the story

recall measure. We expected scores to be reliable among stories administered in the same

condition. To assess the validity of the stories, we investigated whether total recall scores on

stories administered in the single-task condition were consistently related to total immediate

recall scores obtained on the Wechsler Memory Scale (WMS) Logical Memory paragraphs.

Preliminary analyses also evaluated the effect of the secondary driving task on total recall

scores. Setting the specific dimensions of recall (precision and content) aside, adding a

simultaneous secondary task was expected to decrease story recall overall. Also, to verify that









participants identified as memory-impaired truly differed from those classified as cognitively

healthy, preliminary analyses were conducted to identify overall recall differences between the

groups on the memory task.

Participant Sickness

Because all assessments for each participant were completed within a single session,

there was no participant dropout. There was, however, missing experimental (driving and

remembering) data because some participants were unable to complete the experimental task due

to sickness associated with the driving simulator task. Although four of the participants

completed part of the driving task, eight participants were unable to complete any of the dual-

task condition stories, and were excluded from analyses for this reason. Two of these eight were

classified as impaired. Because analyses were based on the average percent recalled within each

condition, participants who completed at least one story recall in each condition were included in

the analyses (with their averages computed from those stories they did manage to recall).

Seventeen participants completed at least one story in each condition, but discontinued the

experimental task after the end of the first dual-task segment. Reasons for discontinuation

included fatigue, complaints of dizziness from driving, or excessive frustration with the task.

Table 4-1 contains information on the number of participants with complete, partial, or no data.

Preliminary Analyses

Validity

To evaluate the validity of the Rivermead measures, we tested them against the Logical

Memory component of the Wechsler Memory Scale (WMS), a widely-validated measure of

immediate verbal short story recall. Every participant in the study recalled three Rivermead

stories in the absence of distraction. Every participant also completed both of the WMS Logical

Memory short stories without distraction, as part of the neuropsychological battery used for

47









consensus classification. It was expected that if the Rivermeads are a valid measure of short

story memory, participants' mean total recall on the Rivermead stories in the distraction-free

condition would positively correlate with the Total Immediate Recall score on Logical Memory

(Trial One on Stories A and B). Analyses using Pearson bivariate correlations revealed that

averaged Rivermead scores correlated significantly with Logical Memory recall scores, r=.672,

p<.001. This comparison may be interpreted as supportive evidence of the Rivermead stories'

validity relative to the story recall gold standard, with the caveat that the relationship is only

moderate. It was not possible to directly compare participants' percentile ranking on the

Rivermead-type and Logical Memory stories, since such percentile data did not exist for many of

the Rivermead-type stories.

Reliability

If the Rivermead measures are reliable, it is expected that total recall scores of stories

administered within the same task condition should positively correlate with one another. We

conducted correlational analyses among story scores within each condition, and found that

stories were well-correlated within the single-task condition (r=.62-.69, p<.001), the slow dual-

task condition (r=.49-.62, p<.001), and the fast dual-task condition (r=.64-.71, p<.001). These

findings may be interpreted as evidence that the Rivermead stories are a reliable measure of short

story recall.

Dual-Task Effect on Total Recall

Before looking at qualitative characteristics within story recall, we aimed to verify the

impact of task difficulty (i.e. addition of a secondary task, at two levels of challenge) on overall

memory performance. This question was investigated as part of the primary data analysis

conducted by Cook (2007). It was hypothesized that with increasing levels of task difficulty,

total recall scores would decline. A repeated-measures analysis of variance (RM-ANOVA)









revealed that memory performance did decrease significantly with each greater level of task

difficulty (F(2, 102)=19.36, p<.001). Paired-samples t-tests were then used to compare recall

among each of the three difficulty levels (single task, slow dual task, fast dual task). Compared

to the single task scenario, memory performance was significantly reduced in the slow dual-task

(p<.001) and fast dual-task (p<.001) conditions. If Bonferroni-corrected, the critical level of

alpha would be .017; thus, these comparisons remain significant even after correction. However,

there was no significant decline in memory performance between the slow and fast conditions

within the dual-task scenario.

Overall Memory Performance between Cognitive Status Groups

To verify that the groups identified as cognitively healthy and cognitively impaired

differed on memory performance overall, a one-way ANOVA was conducted comparing total

story recall scores between each of the groups across all task conditions (N=41 healthy, 12

impaired). Mauchly's test of sphericity was violated; therefore Greenhouse-Geisser corrections

were used. This analysis revealed significant differences between the groups' recall scores in

every condition, F(1,5 1)=16.3 8, p<.001, r,2=.24 The means and standard errors of each

group's total recall score in each condition are illustrated in Table 4-2. These findings were also

part of the primary data analysis conducted by Cook (2007).

Main Analyses

Aim One: Dual-Task Effect on Precision

A repeated measures analyses of variance (RM-ANOVA) was conducted to examine the

effect of task condition on recall precision, defined as information recalled verbatim versus

information recalled in paraphrase (N=53). The dependent variable for the first analysis was

defined as the proportion of idea units recalled out of the 21 possible, averaged across the 3

stories within each condition. We used the 2-level independent variable of recall precision

49









(verbatim, paraphrase), and the 3-level independent variable of condition (single-task, slow dual-

task, fast dual-task). This analysis revealed a significant two-way interaction, F(2,104)=11.32,

p<.001, r,2=.28. Verbatim recall was consistently higher than paraphrased, but with increasing

task condition difficulty the proportion of idea units recalled verbatim decreased at a

differentially greater rate than the proportion recalled in paraphrase. In fact, the proportion of

idea units recalled in paraphrase did not change across any level of task difficulty. Post hoc

analyses (least squares difference) revealed that while verbatim recall dropped significantly with

each higher level of task difficulty (p=.001-.015; significant after Bonferroni correction,

oc=.017)., paraphrase recall did not differ among any of the levels of difficulty. These results are

illustrated in Figure 4-1.

Aim Two: Dual-Task Effect on Content

A repeated measures analyses of variance (RM-ANOVA) was conducted to examine the

effect of task condition on recall content, defined as main idea recall versus recall for details

(N=53). This analysis used recall as the dependent variable, this time defined in terms of the

average proportion of either main idea or detail idea units recalled out of the number possible

within each story. As with the first analysis, this proportion was then averaged across all stories

given within the same condition. The 2-level independent variable of recall content defined as

main ideas and details was used, as well as the 3-level independent variable of task condition as

defined above. There was no significant interaction in this analysis. However, there was a

significant main effect of content, F(1,104) = 380. 17, p<.001, r,2=.88. with the proportion of

recall for main ideas being consistently higher than the proportion of recall for details. There was

also a main effect of condition, F(2,104) = 17.55, p<.001, r,2=.25, with overall decreasing recall

with increasing task difficulty.









Post hoc comparisons revealed that recall for main ideas was significantly reduced in the

fast dual-task condition compared to the single-task and slow dual-task conditions; however, the

increase in difficulty between the single and slow dual-task had no effect on main idea recall.

(p=.001-.021; significant after Bonferroni correction, a=.017). Additionally, post hoc analyses

showed that detail recall was significantly reduced in the slow and fast dual-task conditions

relative to the single-task condition, but did not differ between the two dual-task conditions

(p<.001; significant after Bonferroni correction, a=.017). In other words, main idea recall was

most reduced at the highest level of difficulty, and detail recall was most reduced when the

secondary task was introduced and was not further reduced by increasing difficulty in the

secondary task. The results of this analysis are illustrated in Figure 4-2.

Aim Three: Role of Cognitive Impairment in the Dual-Task Effects

The two dimensions of recall, precision and content, were combined in a 3x2x4 RM-

ANOVA to examine the within-subj ects effect of task condition (single, slow dual-task, high

dual-task), and the added between-subj ects effect of cognitive status (healthy, N=41; impaired,

N=12), on overall recall style. Precision and content were combined to create 4 levels of the

independent variable recall style, defined idea units called verbatim, idea units recalled in

paraphrase, main idea idea units recalled, and detail idea units recalled. Recall for each category

was calculated as a proportion of the idea units recalled out of all the idea units possible within

each story. A significant three-way (task condition, cognitive status, recall style) interaction was

obtained (F(6,3 06)=2.62, p=. 03 7, r,2=.049). The results of this interaction are illustrated

separately for each dimension of recall (verbatim, paraphrase, main ideas, details) in Figures 4-3

through 4-6.









To better understand the interaction, this analysis was further decomposed into two

separate 3x2x2 RM-ANOVAs evaluating the effect of impairment on recall precision and

content individually. The first RM-ANOVA explored the effect of condition (single-task, slow

dual-task, fast dual-task) and cognitive status (healthy, N=41; impaired, N=12) on recall

precision (verbatim, paraphrase). There was a significant two-way interaction of precision and

condition F(2,102)=6.43, p=.002, r,2=. 11, as seen in the analyses for Hypothesis 1, but the

three-way interaction was not significant, indicating recall did not vary by impairment.

Least Squares Difference post hoc comparisons indicated that the cognitive status groups

differed significantly on verbatim recall at every level of task difficulty, with impaired adults

consistently recalling less information word-for-word than healthy adults (p=.001-.003); these

comparisons sustained significance after Bonferroni correction using critical a level of

.017. However at the paraphrase level of recall, there was no difference between the two groups

at any difficulty level, and in fact there was also no difference for paraphrase recall within either

group among any levels of difficulty. There were differences in verbatim recall within each

group related to task condition, such that healthy adults demonstrated a decline in recall at every

increasing level of difficulty (p=.016-.018, significant after Bonferroni correction, a=.017).

Impaired adults, on the other hand, showed a more gradual decline: while verbatim recall

steadily decreased across conditions, a statistically significant difference was obtained only

between the single-task and fast dual-task levels of difficulty. The results of this analysis are

illustrated separately for healthy and impaired subj ects in Figures 4-7 and 4-8.

The second 3x2x2 RM- ANOVA explored the effect of condition (single-task, slow dual-

task, fast dual-task) and cognitive status (healthy, N=41; impaired, N=12) on recall content

(main ideas, secondary ideas). Mauchly's test of sphericity was violated; therefore Greenhouse-









Geisser corrections were used. The three-way interaction was not significant, but a significant

two-way interaction was obtained for content and cognitive status, F(1,51)=5.38, p=.024,

r,2=.095. This suggests again that the effect of task difficulty on recall performance does not

vary by cognitive status. Both groups demonstrated higher recall for main ideas than for details,

but the difference between main ideas and details recalled was larger for healthy participants

than for the impaired. Although it did not contribute significantly to the interaction, there was a

main effect of condition, F(2,102)=9.98, p<.001, r1,2=.16, with recall decreasing overall as a

function of increasing condition difficulty.

Least Squares Differences post hoc analyses showed that the cognitive status groups

differed at every difficulty level for detail recall, with impaired participants recalling fewer

details in each condition (p=.001-.046); these comparisons would have sustained significance

after Bonferroni correction using a critical a level of .017. Regarding main idea recall, impaired

participants recalled less information than healthy participants in the single-task and slow dual-

task conditions only; in the fast dual-task condition, the two groups performed equally.

Within-group post hoc comparisons revealed that there was no effect of task difficulty on

main idea recall within the impaired group, but the healthy group demonstrated a significant

decline in main idea recall during the fast dual-task condition (p=.001; this would have held

significance under Bonferroni correction, a=.017). In terms of details recall, the impaired group

showed a steady but slight decline in performance such that only the single-task and fast dual-

task conditions reflected significantly different levels of recall. The healthy group demonstrated

a significant reduction in detail recall between the single-task and slow dual-task conditions, but

performance did not continue to decline between the slow and fast dual-task conditions.









The results of this analysis are illustrated separately for healthy and impaired adults in

Figures 4-9 and 4-10.

Follow-Up Analyses

Policy Capturing and Cognitive Status Classification

Policy capturing, a method used to evaluate how individuals make decisions, lends insight

for this study in understanding the process employed to classify cognitive status groups. The

present study relied substantially on the decision-making of the consensus conference to conduct

its analyses. Participants were classified into healthy and impaired cognitive groups based on the

collective decision of the neuropsychological consensus panel. The neuropsychological data

from all measures was available to the panel, represented as scaled or T scores and percentile

ranks. However, decisions about a participant' s cognitive status were made in accordance with

the most up-to-date criteria for MCI classification. That is, special attention was given to

measures of memory, such as the Hopkins Verbal Learning Test (HVLT) and Wechsler' s

Logical Memory Scales. It was scores of <1.5 SD below the mean score on these measures that

were used to make assignments of amnestic MCI.

To verify the consistency of the panel's classification, policy capturing analyses were

conducted on the assignment of cognitive status groups. A single discriminant function was

extracted to separate the two groups. This function had a canonical correlation of 0.90 with

group membership, suggesting that the function was strongly predictive of normal-vs.-MCI

classification. Congruently, the function was significantly predictive of group membership

(h=. 19, X2(5)=83 .91, r,2=. 81, p <.001).

Standardized canonical discriminant function coefficients (which assess the unique

contribution of each predictor, controlling for others in the model) were used to identify the

relative salience of our variables for predicting group membership. The loadings (L) [note to









Shannon...put each of these "L" s in italics] were as follows: HVLT Percent Retention percentile,

L = .68; UFOV Same/Diff, L= -.51; HVLT Recognition Index T Score, L=.44; HVLT Delayed

Recall T Score, L= .38; and Digit Span percentile, L= .33. Consistent with prediction, three of

the variables are HVLT-based (i.e., verbal memory), with a particular emphasis on variables that

should be lower in amnestic MCI (i.e., impaired delayed recall and reduced ability to profit from

retrieval support via recognition). The other two variables (Useful Field of View and Digit

Span) are somewhat less central to the amnestic MCI definition. This may either have reflected

the idea that the consensus panel used additional expertise regarding concepts that might aid in

classification, or that these other measures were correlated with MCI group membership,

reflecting the onset of more global decline processes associated with incipient dementia. In any

event, the results suggest that while there were elements of policy capturing (four of the five

variables reflected some component of memory), group assignments did not seem to be based on

a single one or two variables.

The discriminant function analysis achieved a high degree of sensitivity and specificity in

the classification of participants. Overall, 60 out of 61 participants were classified correctly

(98.4%). Sensitivity was 100% (15 out of 15 persons with MCI were correctly identified by the

function), and specificity was 97.8% (45 out of 46 unimpaired individuals were correctly

classified). Leave-one-out cross-validation was further explored to assess generalization of the

classification efficiency to the larger population. Here, akin to the jackknifing procedure,

classification was examined in N resamples from the data set, with each resample leaving out one

participant and reexamining the discriminant function classifications for that reduced sample.

The results of the leave-one-out cross-validation suggested that, identically to the sample-










specific results, 100% of persons with MCI were correctly classified and 97.8% of persons

without MCI were correctly classified.

Thus, given high measures of association between the discriminant function and group

membership, and high classification accuracy, the results suggest that the obtained discriminant

function did an excellent j ob of capturing the underlying policies that, de facto, governed case

classification.

Related to the question of policy capturing is the controversy of using a cutoff point,

namely 1.5 SD below the mean or 7th percentile of a distribution, to extract two groups from a

continuous distribution. Differentiating two groups out of performances which operate along a

continuum is difficult to defend unless the distribution of scores is bimodal. Importantly, one of

the memory-based predictors identified using discriminant function analysis, the HVLT Delayed

Recall scores, does have a bimodal distribution, as illustrated in Figure 6-1 in Appendix B. Other

variables which emerged as important in the discriminant function analysis did not have visibly

identifiable bimodal distribution. Participants' scores on the maj ority of other

neuropsychological measures were normally distributed, as reflected in Table B-1 skewnesss and

kurtosis estimates were generally non-significant, with the exceptions of scores on the TICS and

the UFOV Processing Speed and Selective Attention subtests. Performance on these measures

typically "ceilings" in healthy adults, causing the distribution of scores to be positively skewed

rather than bell-shaped).. This underlies the fact that cognition generally operates along a

continuum, and that groups based on neuropsychological performance represent opposite sides of

a cutoff point in that continuum, rather than discriminable groups. This issue will be discussed

further in the Discussion chapter.










Proportionalized Scoring Relative to Baseline Performance

Reviews of the dual-task literature indicate that discrepancies among findings have

historically been due to inconsistencies in controlling for baseline differences. Therefore, we ran

an additional set of analyses to address this question in our own dataset. Because the only

between-groups comparison was made for Aim 3 (healthy participants versus cognitively

impaired), a follow-up analysis was conducted solely for this question. Baseline differences

were controlled by dividing each participant's score in each condition (single-task, slow dual

task, fast dual task) by his or her score in the single task condition.

Two 3x2x2 (condition by precision by impairment, N= 53; condition by content by

impairment, N=53) repeated measures analyses of variance were conducted in the same format

as the original analyses conducted separately for precision and content in Aim 3; the only

difference for these follow-ups was the use of recall scores adjusted for baseline differences as

described above instead of absolute recall. The first RM-ANOVA revealed that when using

relative-to-baseline scores as the dependent variable, no significant interaction was obtained for

condition by precision by impairment. The second RM-ANOVA similarly identified that there

was no significant interaction of condition by content by precision using relative-to-baseline

scores. Although the results of these analyses were not significant, they are represented as

additional data in Figures 6.1-6.4 in the Appendix C.





















































Dual Task Slow Dual Task Fast


Task Condition



Figure 4-1. Proportion of idea units recalled verbatim or in paraphrase across task conditions
(N=53). Verbatim recall is consistently higher than paraphrase in all conditions, and
decreases at a significantly greater rate with increasing task condition difficulty. The
proportion of information recalled in paraphrase remains relatively stable. Total
recall (not shown) would be equal to the sum of verbatim and paraphrase recall, as
shown. Error bars represent the 95% confidence interval of the mean.


1


Table 4-1. Number of participants with complete, partial or no data by cognitive status.
Normal Impaired
Complete Data 38 9
Partial Data 3 3
No Data 5 3
Total 46 15


Table 4-2. Means + standard errors of story recall total scores
impaired participants (N=12).
Cognitive Status Group Single-Task Slow Dual-Task
Healthy 8.98 1 .37 7.36 + .41
Im aired 5.63 + .67 4.81 +..54


by healthy (N=41) versus


Fast Dual-Task
7.47 + .41
4.29 + .75


0.4

0.35


0.3

" 0.25

Fl0.2

S0.15

0.1

0.05

0


O Verbatim
SParaphrase


Single Task













0.8

0.7



e 0.5

S0.4

g 0.3

0.2

0.1

0


0 Main Ideas
HDetails


Single Task Dual Task Slow Dual Task Fast
Task Condition



Figure 4-2. Proportion of main idea units recalled and proportion of detail idea units recalled
across task conditions (N=53). Recall for main ideas is consistently higher than recall
for details, and both types of recall decrease at equal rates with increasing task
difficulty. Total recall would be equal to the sum of main ideas and details recalled.
Error bars represent the 95% confidence interval of the mean.



0.9
0.8


S0.7
8 0.6
Fl0.5
a0.4

& 0.3


O Healthy
SImpaired


Single Task Dual Task Slow Dual Task Fast
Task Condition


Figure 4-3. Proportion of verbatim recall in healthy (N=41) versus impaired (N=12) participants
recall across task conditions. The impaired group demonstrated less verbatim recall
than the healthy participants in each condition. There was no interaction between
cognitive status and task condition. Error bars represent the 95% confidence interval
of the mean.










1
0.9
0.8
S0.7

8 0.6
Fl0.5
a0.4
S0.3


O Healthy
SImpaired


Single Task


Dual Task Slow


Task Condition


Figure 4-4. Proportion of paraphrased recall in healthy (N=41) versus impaired (N=12)
participants across task conditions. Paraphrased recall did not differ between groups,
and did not change across conditions. Error bars represent the 95% confidence
interval of the mean.


O Healthy
SImpaired


Single Task Dual Task Slow
Task Condition


Dual Task Fast


Figure 4-5. Proportion of recall for main ideas in healthy (N=41) versus impaired (N=1 2)
participants ideas across task conditions. Post hoc comparisons revealed the impaired
group recalled significantly fewer main ideas than healthy adults. There was no
significant cognitive status-task condition interaction. Error bars represent the 95%
confidence interval of the mean.


Dual Task Fast


















p O Healthy
S0.5
.9 Impaired
8 0.4
S0.3
0.2
0.1


Single Task Dual Task Slow Dual Task Fast
Task Condition


Figure 4-6. Proportion of recall for details in healthy (N=41) versus impaired (N=12)
participants across task conditions. No significant interaction was observed between
cognitive status and task condition. Error bars represent the 95% confidence interval
of the mean.


0.5
0.45
0.4
," 0.35
S 0.3
p ~ I I II I I O Verbatim
a 0.25
.2 Paraphrase
te 0.2
O
o 0.15
0.1
0.05


Single Task


Dual Task Slow Dual Task Fast


Task Condition


Figure 4-7. Healthy participants' proportions of verbatim and paraphrased recall across task
conditions (N=41). Verbatim recall decreased across conditions, while paraphrased
recall remained stable. Total recall would be equal to the sum of verbatim and
paraphrased recall. Error bars represent the 95% confidence interval of the mean.











0.5
0.45
0.4
0.35
03 .


FrO oVerbatim
Fl 0.25
-S Paraphrase
0.2 -



0.


Single Task Dual Task Slow Dual Task Fast
Task Condition


Figure 4-8. Impaired participants' proportions of verbatim and paraphrased recall across task
conditions (N=12). Paraphrase recall remained stable, while verbatim recall declined
slightly with increasing task difficulty. Total recall would be equal to the sum of
verbatim and paraphrased recall. Error bars represent the 95% confidence interval of
the difference.



0.9
0.8
S0.7


FI 0.0.6 nO M ain Ideas
-9 Details


Single Task Dual Task Slow Dual Task Fast
Task Condition


Figure 4-9. Healthy participants' recall for the proportion of main ideas versus details across
conditions (N=41). Recall for main ideas declined steadily with increasing task
difficulty, while detail recall remained stable. Total recall would be equal to the sum
of main ideas and details recalled. Error bars represent the 95% confidence interval
of the mean.


T











1-

0.9

0.8

0.7

0.6

0.5 _

0.4

0.3

0.2

0.1

0

Single Task


0 Main Ideas
SDetails


Dual Task Slow Dual Task Fast


Task Condition



Figure 4-10. Impaired participants' recall for proportion of main ideas versus details across
conditions (N=12). Recall for main ideas remained stable, while recall for details
declined slightly across conditions. Total recall would be equal to the sum of the main
ideas and details recalled. Error bars represent the 95% confidence interval of the
mean.









CHAPTER 5
DISCUSSION

Overview

This study examined the effect of a simultaneous secondary task, simulated lane

navigation, on two dimensions of story recall in older adults. One dimension was the precision of

recall, in terms of the proportion of information remembered either verbatim or in paraphrase.

The other dimension was the content of recall, in terms of the proportion of main idea

information recalled versus the proportion of detail information. The within-subj ects variable of

task difficulty was examined under three conditions: story recall alone, story recall in the

presence of a slow-speed simultaneous driving task, and story recall in the presence of a fast-

speed simultaneous driving task. Cognitive status (specifically, cognitively healthy versus

memory impaired) was investigated as a between-subj ects variable. The study evaluated the

effects of task difficulty and cognitive status, separately and in interaction, on the precision and

content dimensions of story recall.

Preliminary analyses examined the reliability and validity of the story recall measure.

Results revealed that the Rivermead stories are a reliable measure of story recall: paragraphs

administered within the same condition correlated positively with one another. Results also

indicated that the Rivermead stories are also comparable to a widely-validated test of story

recall, the Wechsler Logical Memory Scales: total immediate recall scores on both measures,

administered under single-task conditions, were positively correlated.

The remainder of this chapter will address the findings in regard to the study's three

specific aims. Next, the theoretical and practical implications of the results will be considered.

Finally, we will discuss the study's limitations, as well as possible future directions for this

research.









Review of Findings

Aim One: Dual-Task Effect on Precision

The first aim of this study was to evaluate the effect of simultaneous simulated driving on

the precision of story memory in terms of verbatim versus paraphrase recall. It was hypothesized

that both types of recall would decrease with increasing condition difficulty, but that the decline

would be greater for verbatim recall than for paraphrased recall. The analyses revealed that

increasing levels of task difficulty were associated with decreasing levels of verbatim recall, but

had no significant effect on the proportion of paraphrased recall. But Post-hoc analyses showed

that the effect of task difficulty decreased verbatim recall across all conditions, and had no effect

on paraphrased recall for any condition. Additionally, participants consistently demonstrated

higher levels of verbatim than paraphrased recall.

These results are essentially in support of the hypothesis: the ability to recall information

word-for-word is vulnerable to increasing demand on attentional resources, and more so than the

ability to paraphrase information. However, it had been hypothesized that paraphrased recall

would also decline with task difficulty, albeit at a smaller grade than verbatim recall. The total

lack of effect of task difficulty on paraphrased recall suggests this ability is more resistant to

increasing cognitive load.

This indication should be interpreted with consideration, though, for the fact that

participants relied predominantly on a verbatim style of recall, which was their instructed goal.

The proportion of paraphrased recall was low across all conditions, ranging from 15% in the

single-task condition to 14% in the two dual-task conditions. This is a small proportion and range

compared to verbatim recall, which was 73% in the single-task condition, 65% in slow speed

dual-task, and 55% in the fast-speed dual-task condition. It may be that in a population instructed

to paraphrase, the proportion and range of paraphrased recall may be more sensitive to changes









in attentional demand.

Aim Two: Dual-Task Effect on Content

The second aim of the study was to examine the effect of simultaneous simulated driving

on the content of story memory in terms of recall for main ideas versus details. It was

hypothesized that while recall would decline overall as condition difficulty escalated, this decline

would be stronger for detail recall than for main ideas. Results indicated that recall did generally

decrease as the task condition became more difficult; however, the diminishing effect on recall

was equivalent for main ideas and details. Post hoc analyses further indicated that detail recall

decreased only between the single- and slow dual-task conditions, but decreased across all

conditions for main ideas.

One reason for participants' memory for details to be preserved in the face of increasing

task difficulty may be primacy and recency effects. These phenomena, well known in the

memory literature, refer to the higher frequency of recall for the first and last items in a list or

story. That is, primacy and recency effects may cause participants to be more likely to remember

the beginning and end of a story, regardless of whether it is main idea or detail information. In

the nine stories used for this study, 83% of the first and last two idea units consisted of detail

information. If memory for first and last information is also more resistant to increasing



attentional demand, participants were more likely to continue recalling the detail information

contained at the beginning and end of each story.

Additionally, recall for main ideas was higher than for details across all conditions. This

suggests that although memory for main ideas may be more sensitive to cognitive load than

memory for details, participants were nonetheless likely to remember more of the key points and

themes of the story than to remember its details.









Aim Three: Role of Cognitive Impairment in Dual-Task Effects

The third aim of the study was to evaluate the interaction of cognitive status (healthy

versus memory impaired) with the dual-task effect of simultaneous simulated driving on story

recall. It was hypothesized that participants with compromised cognitive status would

demonstrate lower levels of recall overall, but in addition, they would show greater costs to

memory performance associated with increasing task difficulty. Precision of recall (verbatim,

paraphrase) in impaired participants was hypothesized to show differentially greater decrements

in both verbatim and paraphrase recall compared to their healthy peers. For recall content (main

ideas, details), impaired participants were hypothesized to show a greater decrease in recall for

details as condition difficulty increased, but recall for main ideas was expected to remain

relatively stable.

Results demonstrated that impaired participants consistently remembered less overall

compared to healthy participants, and that higher levels of task difficulty consistently reduced

recall for both groups. However, there was no interactive effect between cognitive status and task

difficulty; in other words, being memory-impaired did not amplify the cost to memory

performance created by increasing levels of challenge. At first glance, it seems counterintuitive

for impaired participants to handle increasing demands similarly to their healthy peers; the

impact of dividing attention between two tasks would seemingly be more taxing for a person

whose cognitive capacity is compromised.

However, the reason for this apparent disparity is likely explained by the match between

the type of cognitive task required and the type of impairment studied. In this study, task

difficulty was defined as single- versus dual-task, which was further subcategorized in two levels

of secondary task speed. Adding a second task requires participants to divide their attention

between two simultaneous activities, which increases the burden on attentional resources but not









on memory capacity. Participants for the impairment group were selected based specifically on

amnestic impairment. Their performance on the memory task supports their classification; they

consistently demonstrate poorer memory than their healthy peers. However their impairment is

primarily in the memory domain and not necessarily in attention. This is supported by the

observation that they perform similarly to healthy participants in terms of coping with greater

attentional load. So while we hypothesized a differential effect of divided attention for impaired

participants, they in fact perform exactly as we should expect: they demonstrate consistently

poorer memory, but in the presence of increasing attentional burden, they demonstrate the same

costs to performance as their healthy peers.

Analyses of group differences within precision of recall (verbatim vs. paraphrase)

revealed that verbatim recall in both groups was equally reduced, while paraphrase recall was not

affected by task difficulty in either group. Recall of main ideas was not significantly affected by

task difficulty for either group, but recall for details decreased significantly for each group with

increasing task difficulty. This cost to performance was equivalent for both healthy and impaired

participants. So again, no interaction was observed between cognitive status and task difficulty.

But within the dimension of recall precision, there was also no effect of difficulty on paraphrase

recall for either group only on verbatim recall. Additionally within the dimension of recall

content, there was no effect of difficulty on recall for main ideas for either group only for

details. This suggests that while memory impairment does not amplify the effect of task

difficulty, task difficulty itself has a negative effect for both groups on the capacity for verbatim

recall and for recall of details. Both results are consistent with what would be expected, given

that these types of recall are typically more demanding of memory than paraphrase recall and

recall for main ideas.










Implications

The findings from Aims 1 and 2 illustrate the impact of divided attention on verbal

memory performance for older adults in general. Our results suggest that when older adults are

required to listen to and remember verbally-conveyed information while driving, their ability to

recall that information may be substantially degraded by the additional challenge of driving. In

particular, older adults may experience a reduced ability to remember verbal information

precisely, and may recall less of the content, both in terms of main idea- and detail-level

information. Older adults may experience these difficulties more strongly if the verbal

information is conveyed under especially challenging driving conditions.

Aim 3 demonstrates the impact of divided attention on memory-impaired older adults'

story recall, as compared to their healthy peers. Our findings suggest that impaired adults are

more vulnerable to forgetting verbally-conveyed information than those who are cognitively

healthy. Our findings also indicate that impaired adults experience lowered verbal memory

performance when their attention is divided between remembering and driving; however this

reduction is comparable to that experienced by healthy older adults. Therefore, although

impaired older adults show a reduced capacity for remembering verbal information, they are at

no greater risk for forgetting while distracted by driving than are their healthy peers.

Limitations

The study possesses several possible limitations. First, as mentioned in the literature

review, smaller age differences are found in dual-task studies employing a relatively automatic

task. For many people, driving is a task learned at a young age and practiced almost daily

throughout the life span. While at its initial learning it may be an effortful coordination of

cognitive processes involving motor coordination, visual attention, and time-sensitive decision-

making, it is also an activity that becomes relatively automatic for most people as a result of










regular practice.

Second, even if driving is an adequately effortful task, the simulated driving task did not

fully emulate the complexity of real-world driving. Participants had no gas or brake pedals and

so were unable to adjust their speed as they normally would when navigating sharp curves.

Additionally, little visual scanning was required because the landscape was flat and unchanging.

Because the only challenge was then to stay within the right lane, the task was far simpler than

the complex task of driving in the real world, where numerous cognitive processes occur

simultaneously. Such limitations are common to controlled experiments: to evaluate a real-life

situation, it must sometimes be simplified in order to be accessible to meaningful analysis.

Third, the method used to classify cognitive status may have played into the absence of a

condition-by-impairment interaction. While the memory measure most used to discriminate

between groups appeared to be bimodal, the maj ority of cognitive measures were normally and

continuously distributed. Cognition, and cognitive decline in aging, operate along a continuum.

The division of participants into groups based on a cutoff is an imprecise conceptualization of

cognitive function, and may have led to a loss of interaction effect that would have surfaced if

cognition were used as a continuous variable. On the other hand this classification, if somewhat

untrue to the nature of cognition, is also necessary for the sake of dissemination for public use.

While the point at which cognitive impairment begins is not yet well-defined and certainly not

discrete, cognitive impairment itself is nonetheless a real phenomenon with important

implications for those who experience it. Classification systems are intrinsic to the application

of research findings in clinical diagnostics and treatment; as it is, they are also rarely without

flaws. In the case of MCI, it involves the classifying individuals on opposite sides of a dividing

line in distributions that do not actually consist of two separate groups. It also reflects, as seen in










this study's simplified policy capturing analysis, that while cognition has many dimensions

which are represented by many measures, only a handful of measures are typically actually used

in the process of classification.

A fourth limitation that could have confounded recall performance is the issue of

interference among stories. Participants heard nine short stories within a relatively brief time

period, so there is reasonable risk of information from one story becoming mixed up in another.

Because the stories were written based on an algorithm, several contained similar items of

information such as the story's location, time of day, and character's first and last names. For

example, participants sometimes would describe one story's events as having happened "last



night", even if this phrase was not part of the story and instead had been heard in a previous

story .

Other limitations include the sample population and size. The study sample consisted

mostly of highly-educated Caucasian older adults, which is not representative of the broader

senior population. The advantage of high education may have led to better performance and

possibly different learning strategies in the sample compared to the general population.

Additionally, the size of the cognitively impaired group was smaller than was needed for

adequate statistical power. The obtained group differences may have demonstrated greater

significance had there been a larger group of impaired participants.

Future Directions

One clearly useful next step for the present study would be to match the cognitive

demand of the experimental task to the type of cognitive deficit in the population studied. In this

study the cognitive demand manipulated was related to attention, but the population studied was

memory-impaired. It appears that despite the fact that a recall task was involved in this










experiment, a better way to observe differential dual-task effects in an impaired population may

be to more systematically manipulate the cognitive burden that is directly related to the

population in question. For example, a similar future study may vary the difficulty of the

memory task in a dual-task scenario instead of increasing driving difficulty, or may choose to

pair a verbal memory with a visual memory test. Such a study should also aim to recruit larger

samples of cognitively impaired participants, allowing enough statistical power for group

differences to be detected.

Additionally, cognitive status group differences in dual-tasks or simply age differences

in general may be more readily detected by a scenario employing two tasks within the same

modality. As it was mentioned in the literature, same-modality tasks typically yield larger age

differences, likely because of greater competition for the same cognitive resources. This study

used an auditory story memory task and a visual-motor navigation task, requiring dual-task

performance from two different, non-competing modalities. Such experiments have typically

been shown to have smaller age differences in dual task performance costs, so perhaps a bigger

effect would emerge if tasks using the same modality were performed.

Looking at the driving portion of the experiment, another future direction may be to

manipulate the automaticity of this task. As the literature indicated, dual tasks employing

relatively automatic cognitive processing such as driving often yield smaller performance costs

than those requiring effortful processing. The level of effort required for this task could be

increased by incorporating other aspects of the driving experience (e.g., use of brake pedals,

varied terrain, participant-controlled speed), or perhaps by increasing the difficulty of the driving

scenario. These kinds of changes to the driving component would have the added benefit of

increasing the ecological validity of the task. Similar changes could be made to improve the









relevance of the verbal task, such as carrying a conversation (or some other experimental task of

speech production and comprehension) while driving.

Anecdotally, participants often approached the dual-task challenge by stating they

intended to ignore the memory task and focus on driving, since that's what they would do if a

news story were on in the car. This occurrence underscores the potential future issue of

manipulating attentional allocation, which was not controlled in this study. A more thorough

future study might systematically evaluate the effect of attention allocation by emphasizing that

participants first prioritize the driving task and sacrifice the story recall, then prioritize the story

recall and sacrifice the driving.

Finally, other qualitative aspects of recall could be more deeply explored. Because it was

a verbal recall task, responses often contained irrelevant utterances that may be related to lapses

in memory or attention. Such utterances include um's, ah's, and verbalizations not directly related

to the story, such as comments on the difficulty of the task or unsolicited opinions on the story

content. Such information is not typically coded in story recall scores, but is nevertheless useful

in understanding the style and quality of responses. This kind of data can be especially

informative in comparative studies involving the cognitively impaired.

Conclusion

This study evaluated the precision and content of story recall as affected by memory

impairment and by the addition of a simultaneous simulated driving task at both slow and fast

speeds. As we hypothesized, overall recall was reduced in the presence of increasing difficulty

within the task condition. Verbatim but not paraphrased recall decreased with greater task

difficulty, and recall for both main ideas and details decreased at the same rate with increasing

task difficulty. Memory impairment was associated with lower overall recall, but impaired

individuals demonstrated similar task difficulty-related performance costs when compared to









healthy individuals. Maj or limitations of the study the small sample size of the impaired group,

leading to insufficient power to detect potential group differences, potential over-simplification

of the secondary task, which reduces ecological validity, and the classification of continuously

distributed variables to create cognitive status groups.

This study's findings have valuable implications for the everyday life of older adults.

Important information is often conveyed during the everyday activity of driving. This can

include driving directions given over a cellular phone, radio traffic alerts, and information

conveyed in passenger conversation. When potentially important information is presented

verbally to older adults while they are simultaneously driving, their ability to retain this

information may be substantially degraded. Specifically, the precision of their recollection, as

well as their memory for details of the information, declines. As the difficulty of the driving

challenge increases, older drivers may additionally recall less of the main points of the

information conveyed. This study also demonstrates that for mildly memory impaired older

adults, the risks of forgetting verbal information while driving also apply, but are no greater for

persons with mild memory impairment than for those who are cognitively healthy.









APPENDIX A
SHORT STORIES USED INT THE EXPERIMENTAL TASK


Ms. Virginia / Boone / a mother of two / won / the mother of the year award / on Sunday / during
a community celebration / in Chicago. / The nominating committee/ of Chicago-Cares / hosted
the event / in the flower-decorated / Grace Cathedral. / News reporters / were a large presence /
at the event. / A church representative said, / "She is an amazing lady. / She raised those kids / in
a rough neighborhood / without a dime of help from anyone."

A Dutch / oil tanker / sank / ten miles / off the Norfolk coast / last night. / The crew / were
picked up / by a coast guard patrol boat. / An oil slick / is already forming / and conservationists
/ are worried / about the effects / on wildlife. / Local enthusiasts / are mounting an operation / to
save / any birds / found stranded / on the beaches.

Adam / Aubrey / a Nobel prize winner / was kidnapped / from his home / during a surprising /
terrorist attack / in Zurich / yesterday. / The attackers / were all hooded / and were said / to be
fleeing / in a private plane. / Swiss representatives / were seeking clues. / A US embassy /
representative said, / "We take this very seriously. / He is an international treasure / and we will
bring him back home.

Nicolette / Zabrinsky / a Red Cross / volunteer / was infected / with a viral disease / during a
blood bank / drive / in Los Angeles / last March. / An accidental slip / while trying to adjust / an
intravenous needle / caused the problem. / Disease control experts / were tying to contain / the
spread of the virus. / She is highly infectious now, / which is sad. / She was just trying / to help
others.

Firemen / and volunteers / worked all day / yesterday / putting out / a bush fire / six miles / south
/ of San Diego / in southern California. / Fire engines / were unable to reach the area / so
firefighting equipment / was brought in by helicopter. / Livestock / was evacuated / from the
neighboring / Johnson's Farm / as it was engulfed / in clouds / of dense white smoke.

Mr. Brian / Kelly / a Pinkerton employee / was shot dead / on Monday / during a bank robbery /
in Atlantic City. / The four robbers / all wore masks / and one carried / a sawed-off / shotgun. /
Police detectives / were sifting through / eyewitness accounts / last night. / A police spokesman
said, / "He was a very brave man. / He went for / the armed robber / and put up a hell of a fight."

Two hundred men / at a shipyard / in New Jersey / went on strike / this morning. / The men
walked out / over a dispute / concerning fifty / lay-offs. / The shop steward, / Mr. Thomas / told
reporters, / "It is outrageous! / The company has full-order books / for the next two years." / A
management spokesperson said, / "We are hoping to begin / fresh negotiations / at main office /
tomorrow."

Joellen / Reese, / a kindergarten pupil, / shocked spectators / with a performance / of
Beethoven's Fifth Symphony / last night. / She was inspired / by a piano / at Garden Place Mall./
Mall-goers / were astounded / by the beautiful music. / Said one mother, / "I was amazed / that a
little girl like that / could play / so well. / The piano / just seemed / to take her over."











Mr. Luther / Nathanson, / a Chrysler employee, / was injured / on the job / at a plant / in Toledo.
/ The assembly line / stopped suddenly / causing a large / car bumper / to hit his chest. / Plant
safety officers / were trying to understand / the problem / last night. / A company spokesperson
said, / "He's been a great worker. / We're looking forward to / a speedy recovery / and return to
the job."










APPENDIX B
DISTRIBUTIONS OF NEUROPSYCHOLOGICAL DATA

Table B-1. Skewness and kurtosis (N=61) of neuropsychological data distributions by measure.
Illustrates that scores on most measures are fairly normally distributed, without
intrinsic evidence of bimodality.


TICS Score
MMSE Total
HVLT Trial 1-3 %tile
HVLT Delayed Recall T Score
HVLT Percent Retention Percentile
HVLT Recognition Index Percentile
WMS LM Trial 1 Total Scaled Score
WMS LM Stories 1 Total Scaled Score
WMS LM Story B Learning Scaled Score
WMS LM Stories 2 Total Scaled Score
WMS LM Percent Retention Scaled Score
COWA Fluency FAS Total Scaled Score
Category Animals Total Percentile
BNT Total Score Percentile
Rey-Osterrieth Copy Percentile
Trails A Time Scaled Score
Trails B Time Scaled Score
Digit Span Scaled Score
Ruff Automatic Speed T Score
Ruff Continuous Speed T Score
Ruff Total Speed T Score
Ruff Total Accuracy T Score
UFOV Processing Speed
UFOV Divided Attention
UFOV Selective Attention
UFOV Same/Different
GDS Total


SE
-2.57 0.31
-1.33 0.31
-0.37 0.31
-0.89 0.31
-0.63 0.31
0.10 0.31
-0.17 0.31
-0.77 0.31
0.30 0.31
-1.17 0.31
-1.35 0.31
0.08 0.31
-0.67 0.31
-0.91 0.31
-0.04 0.31
0.28 0.31
-0.49 0.31
0.54 0.31
-0.14 0.31
0.12 0.31
-0.22 0.31
-1.64 0.31
3.83 0.32
2.01 0.32
0.45 0.32
-0.52 0.32
1.72 0.31


Kurtosis Kur tosis
SE
13.54 0.61
1.68 0.60
-1.32 0.60
-0.38 0.60
-1.05 0.60
-1.20 0.60
-0.18 0.60
0.33 0.60
-0.53 0.60
2.08 0.60
2.27 0.60
-0.43 0.60
-0.86 0.60
-0.37 0.60
-1.50 0.60
-0.30 0.60
-0.29 0.60
-0.47 0.60
-0.46 0.60
-0.47 0.60
-0.13 0.60
3.49 0.60
13.94 0.62
3.97 0.62
-0.61 0.62
-0.37 0.62
2.55 0.60


















12-


10 0-





S75-










25-


Mean =54 03
Std Dev =33 32
N =61
vu
0 20 40 60 80 100

HVLT Delayed Recall %tile

Figure B-1. Histogram representing the frequency distribution of percentile scores for Delayed
Recall on the Hopkins Verbal Learning Test, the primary predictor of cognitive status

group as detected by discriminant function analysis.
















1.2-




~0.8-

0.6 -o- Helthy
- -Impaired
S0.4-



~30

Single Task Dual Task Slow Dual Task Fast
Task Condition


APPENDIX C
FOLLOW-UP ANALYSES USING SCORES RELATIVE TO BASELINE PERFORMANCE


Figure C-2. Comparison of idea units recalled verbatim by healthy (N=41) versus impaired
participants (N=12) across task conditions. Scores are represented as relative to
baseline; this was accomplished by dividing each participant' s score over their score
at baseline. Error bars represent the 95% confidence interval of the mean.


1.4

1
0.8


~g0.6


S0.4


-o Healthy
-- -Impaired


Single Task


Dual Task Slow
Task Condition


Dual Task Fast


Figure C-3. Comparison of idea units recalled in paraphrase by healthy (N=41) versus impaired
participants (N=12) across task conditions. Scores are represented as relative to
baseline; this was accomplished by dividing each participant' s score over their score
at baseline. Error bars represent the 95% confidence interval of the mean.


















0.8 -o Healthy


0.4


2 0.2-


Single Task Dual Task Slow Dual Task Fast
Task Condition


1.2-

1-



0.6 Heathy
0.4 -6

~0.2

~30

Single Task Dual Task Slow Dual Task Fast
Task Condition


Figure C-4. Comparison of main idea units recalled verbatim by healthy (N=41) versus
impaired participants (N=12) across task conditions. Scores are represented as
relative to baseline; this was accomplished by dividing each participant' s score over
their score at baseline. Error bars represent the 95% confidence interval of the mean.


Figure C-5. Comparison of detail idea units recalled verbatim by healthy (N=41) versus
impaired participants (N=12) across task conditions. Scores are represented as
relative to baseline; this was accomplished by dividing each participant' s score over
their score at baseline. Error bars represent the 95% confidence interval of the mean.










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BIOGRAPHICAL SKETCH

Shannon Sisco graduated with honors from Calvin College with a bachelor' s degree in

psychology and a minor concentration in biology. She then spent two years working at a

research associate in the Department of Psychiatry and in the Center for Stroke Research in the

Department of Neurology, both at the University of Illinois-Chicago. Ms. Sisco was accepted

into the doctoral program in Clinical and Health Psychology at the University of Florida in 2006.

She is currently there working toward her doctorate in clinical and health psychology, with a

specialization in clinical neuropsychology. She is concurrently working toward her certificate in

Public Health, also at the University of Florida.