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. Author manuscript; available in PMC: 2023 May 1.
Published in final edited form as: Int J Older People Nurs. 2021 Dec 8;17(3):e12439. doi: 10.1111/opn.12439

Factors that influence the emotional impact of memory problems in older adults: A qualitative descriptive study

Nikki L Hill 1,*, Emily Bratlee-Whitaker 2, Rachel K Wion 3, Caroline Madrigal 4, Sakshi Bhargava 5, Jacqueline Mogle 6
PMCID: PMC9069705  NIHMSID: NIHMS1757989  PMID: 35490354

Abstract

Introduction:

This study examined how memory problems influence emotional well-being in older adults without dementia, and whether this differs by cognitive status and current depressive or anxiety symptoms.

Methods:

A qualitative descriptive design was used to examine our research questions. Community-dwelling older adults without dementia (n=49, Mage = 74.5[10.1], 63% women) completed a cognitive assessment, questionnaires, and two semi-structured interviews. Content analysis was used to code and categorize the transcribed interview data, then identify themes within and across participant groups.

Results:

Five themes described the influence of memory problems on emotional well-being: Evoking Emotions, Fearing Future, Undermining Self, Normalizing Problems, and Adjusting Thinking. Memory problems’ impact on emotional well-being varied by current anxiety symptoms, characteristics of the problem, and personal experience with dementia.

Conclusion:

The emotional impact of memory problems tended to differ by affective symptoms, not cognitive status. Older adults who report memory concerns without objective evidence of impairment may be at risk for negative impacts to mental health and well-being.

Keywords: emotional well-being, memory problems, qualitative, older adults

Introduction

More than a quarter of adults 65 years of age or older report problems with memory or thinking (Fritsch et al., 2014), and worries about changes in cognitive abilities are one of the most common aging-related concerns (Awang et al., 2018). Reports of memory problems are associated with lower quality of life and life satisfaction as well as higher depressive and anxiety symptoms (Hill et al., 2016, 2017; Mogle et al., 2017). These reflect aspects of emotional well-being, or one’s state of mind including affective (e.g., happiness) as well as cognitive (e.g., life satisfaction; Lee & Ishii-Kuntz, 1987) aspects. How individuals experience aging, including awareness of changes in performance, impacts emotional well-being as well as other outcomes such as physical health, cognitive functioning, and longevity (Sabatini et al., 2020).

Characterizing the features of memory problems experienced by older adults, as well as their potential impact on emotional well-being, depends on the way they are assessed (Hill et al., 2019; Rabin et al., 2015). Older adults with normal cognition frequently report experiencing some decline in their memory from earlier ages (Jessen, Amariglio, et al., 2014; Taylor et al., 2018), whereas ratings of current memory are typically in the good to very good range, indicating positive perceptions overall (Hertzog et al., 2018). In addition to cognitive status, depressive and anxiety symptoms can affect experiences with memory problems. Individuals with depression tend to have an altered perception of performance (Dunn et al., 2009) and evaluate themselves negatively (Sachs-Ericsson et al., 2008). Relatedly, older adults with higher depressive symptoms report poorer current memory, more frequent memory problems, and greater perceived memory decline compared to their counterparts (Bhang et al., 2020; Yates et al., 2017). As with depressive symptoms, anxiety can also negatively influence self-schemas (i.e., beliefs about oneself; Dweck et al., 1995), which can contribute to poor memory perceptions (Beaudoin & Desrichard, 2011). Indeed, anxiety specifically about developing dementia (i.e., dementia worry) is associated with more negative memory perceptions, including perceived decline in memory functioning. In a recent scoping review, anxiety and exposure to dementia (i.e., a relative or close friend having dementia) were consistently associated with greater dementia worry (Werner et al., 2020). Thus, older adults with higher depressive or anxiety symptoms, or who have a personal experience with dementia, may be more likely to have poorer memory perceptions.

Associations among psychological health and reports of memory problems in older adults are relatively well-established (Hill et al., 2016, 2017); however, much of this research is quantitative. Although such investigations are important for determining relationships among variables and predicting outcomes, they provide limited context about participants’ lived experiences. For example, quantitative studies have linked memory problems and affective symptoms (Balash et al., 2013; Quaade et al., 2018), but do not identify why the two are linked: what mechanisms connect the experience of memory problems with emotional well-being. Qualitative methods, however, can provide a detailed understanding of the meaning that a person attributes to a problem (Creswell, 2013). Therefore, the purpose of this qualitative descriptive study was to examine how the experience of memory problems influences emotional well-being in older adults without dementia, and whether this differs based on factors identified in previous quantitative research: cognitive status (i.e., normal cognition compared to mild cognitive impairment), depressive symptoms, or anxiety symptoms.

Materials & Methods

Study Design

This study used a qualitative descriptive design (Sandelowski, 2000, 2010). A qualitive descriptive approach is one where the researchers’ interpretations stay “close” to the data (i.e., themes reflect subjective experiences) and the data are less transformed than other qualitative methods (e.g., grounded theory, phenomenology; Sandelowski, 2000, 2010), thus providing a description and understanding of the participants’ experiences (Bradshaw et al., 2017). This design was appropriate to address our study purpose since qualitative descriptive methodology focuses on the experiences of participants (Neergaard et al., 2009).

Further, we conducted a cognitive assessment to determine participants’ cognitive status and administered questionnaires to assess depressive or anxiety symptoms. In addition to providing a description of the sample, these measures were used to create participant groups for further analysis, in line with our study purpose. Study procedures were approved by the university’s institutional review board. This included providing participants with information on locally available resources should they require any assistance.

Sample and Setting

Participants (n=49) were recruited from multiple community locations throughout rural and suburban Pennsylvania via study flyers. Eligibility criteria were: age 60 or over, English speaking, living independently, and absence of moderate or severe cognitive impairment as evidenced by a Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) score of 18 or greater (indicating no or mild cognitive deficits). Recruitment continued until data saturation was reached, i.e., no new information emerged from interviews during data analysis. Interviews were conducted in participants’ homes or another private location, as preferred, each approximately one week apart.

Data Collection

Data were collected by members of the study team with extensive experience working with older adults in clinical, community, and research settings. All team members completed in-person training sessions on study procedures, implementation of study measures, and qualitative interviewing prior to data collection. The team met regularly to ensure consistent implementation of procedures in the field. Audio recordings of interviews were transcribed and fully de-identified for analysis.

The following procedures were used to ensure rigor of procedures and data quality: 1) weekly reviews of transcripts to examine progress toward data saturation (i.e., no new themes emerged in the interviews); 2) regular team member communication to refine study procedures as needed (e.g., provide feedback to interviewers); and 3) sharing of results during weekly team meetings to maximize comparability across interviewers.

Measures

Qualitative Interviews

Each participant completed two in-person qualitative interviews consisting of open-ended questions followed by a series of probes (e.g., ‘Can you give me a specific example?’; (Miles et al., 2013). The aim of the first interview was to examine the impact of memory problems on older adults’ daily activities, while the second interview examined the impact of memory problems on mood. Given the potential relevance of participant responses in both interviews to the current study (i.e., emotional well-being), both were included in our analysis. Examples of interview questions included, ‘Can you give me some specific examples of when memory or thinking problems have influenced your daily activities?’ (Probe: ‘When is this forgetfulness most troublesome?’) and ‘When you have a problem with your memory or thinking, how does it make you feel?’.

Montreal Cognitive Assessment (MoCA)

Objective cognition was assessed with the MoCA, a brief cognitive screening test with established reliability and validity for determining cognitive status (Nasreddine et al., 2005). MoCA scores range from zero to 30 with higher scores indicating better cognitive function. The MoCA has demonstrated 90% sensitivity and 87% specificity in its ability to detect mild cognitive impairment (MCI) when compared to a clinical diagnosis supported by neuropsychological evaluation (Nasreddine et al., 2005). Participants with MoCA scores of 26 or higher were included in the normal cognition group, and those with scores of 18–25 were included in the MCI group, per established criteria (Nasreddine et al., 2005).

Depressive and Anxiety Symptoms

The Patient-Reported Outcomes Measurement Information System (PROMIS) Version 1.0 Emotional Distress – Depression Short Form (eight items; Pilkonis et al., 2011) and Anxiety Short Form (seven items; Pilkonis et al., 2011) were used to assess depressive and anxiety symptoms, respectively. Participants rated how often they experienced symptoms during the past seven days for each item (e.g., Depression: ‘I felt unhappy,’ Anxiety: ‘I felt nervous’) on a 5-point Likert scale, from 1 = never to 5 = always. These PROMIS measures are designed to assess the full spectrum of symptom severity and have been validated in a calibration sample of over 15,000 participants with diverse health conditions (Pilkonis et al., 2011). Standardized scores were calculated via the HealthMeasures Scoring Service software, which converts total raw scores to IRT-based T-scores (μ= 50; SD = 10; Hanmer et al., 2020) while adjusting for missing data. Higher T-scores represent higher depressive or anxiety symptoms than the United States (U.S.) adult population. Participants with scores equal to or higher than the U.S. population average were included in the higher depressive and anxiety symptoms groups; all remaining participants were included in the lower symptoms groups.

Data Analysis

Content analysis was used to code and categorize the transcribed interview data, then identify themes that described the phenomena of interest (Sandelowski, 2000). First, interview transcripts were imported into Dedoose (Dedoose, 2020) and individually analyzed by two study team members (NH and EB). Beginning with open coding, transcripts were independently read line-by-line and initial codes developed based on words, phrases, and statements in the transcript. Subsequently, these codes were discussed, compared, and revised until a consensus was reached on a comprehensive codebook.

Additional rounds of coding were completed using the codebook to establish reliability. The two coders completed several rounds of reliability training with Dedoose’s training center function, designed to build and maintain inter-rater reliability. Cohen’s Kappa coefficients across final training sessions indicated high agreement (κ ranged from 0.88–0.92). In the next phase of analysis, each code was compared and contrasted with other codes in order to build a conceptual understanding of the experiences of participants. Higher level codes (i.e., categories) were assigned, then linkages were identified and discussed. Themes, or patterns within the data, were developed from the categories and further clarified through discussion with the entire study team.

Several strategies were used to ensure the trustworthiness of the data: 1) to assure dependability, an audit trail was documented, and any coding discrepancies discussed until a consensus was met; 2) to assure credibility, the final codes, categories, and thematic descriptions were agreed upon by all team members; and, 3) thematic saturation was reached when no new codes were identified and no new information was obtained relevant to each code.

Differences across Participant Groups

After the themes were finalized, we evaluated each theme as well as the categories within each theme for differences across participant groups: 1) normal cognition vs. MCI, 2) lower vs. higher depressive symptoms, and 3) lower vs. higher anxiety symptoms. The presence of group differences was first determined based on the relative frequency of category codes across groups using the normalization procedure in Dedoose. Rather than using raw percentages of category code application, proportional frequencies were calculated based on the number of participants in each group, thus allowing comparison of data across groups of differing sizes in relative terms (i.e., normalization; Dedoose, 2020). Based on previous research using this method (Magee et al., 2012; Mustanski et al., 2014), we established group difference as a 20% or greater discrepancy of code application frequency across groups. For example, if 30% of the application of a category code was in the normal cognition group and 70% in the MCI group, this was a discrepancy of 40% and therefore considered a group difference. When group differences were identified, the qualitative data were further examined to determine potential contributors.

Results

Table 1 includes demographic information for the sample, including representation across participant groups. About two-thirds of participants had no evidence of cognitive impairment: 67.3% had MoCA scores ≥ 26 (n = 33; normal cognition group) and 32.7% (n = 16) had scores of 18–25 (MCI group). On average, participants reported levels of depressive (M = 49.8, SD = 6.9) and anxiety (M = 48.7, SD = 7.7) symptoms similar to the U.S. adult population average.

Table 1.

Participant Characteristics by Group

Characteristics
Total
(n = 49)		 Normal Cognitiona
(n = 33)		 MCIa
(n = 16)		 Lower Depressive Symptomsc
(n = 22)		 Higher Depressive Symptomsc
(n = 27)		 Lower Anxiety Symptomsc
(n = 25)		 Higher Anxiety Symptomsc
(n = 24)
Age in years: M (SD) 74.5 (10.1) 71.0 (9.4) 81.7 (7.4) 75.9 (9.9) 73.4 (10.3) 74.1 (10.6) 74.9 (9.7)
Education: n (%)
 No college degree 8 (16.3) 3 (9.1) 6 (37.5) 7 (31.8) 2 (7.41) 4 (16.0) 5 (20.8)
 College and beyond 41 (83.7) 30 (90.9) 10 (62.5) 15 (68.2) 25 (92.6) 21 (84.0) 19 (79.2)
Gender: n (%)
 Women 31 (63.3) 23 (69.7) 8 (50.0) 18 (81.8) 13 (48.2) 18 (72.0) 13 (54.2)
 Men 18 (36.7) 10 (30.3) 8 (50.0) 4 (18.2) 14 (51.8) 7 (28.0) 11 (45.8)
Marital Status: n (%)
 Married or partnered 33 (67.4) 23 (69.7) 10 (62.5) 15 (68.2) 18 (66.7) 18 (72.0) 15 (62.5)
 Separated/divorced/widowed/single 16 (32.6) 10 (30.3) 6 (37.5) 7 (31.8) 9 (33.3) 7 (28.0) 9 (37.5)
MoCA Score: M (SD) 26.1 (3.3) 28.1 (1.5) 22.1 (2.1) 26.4 (3.7) 25.9 (3.0) 26.7 (3.2) 25.5 (3.3)
Depressive symptoms T-scoreb: M (SD) 49.8 (6.9) 49.6 (6.5) 50.4 (7.8) 43.6 (4.5) 54.9 (3.5) 46.0 (6.2) 53.8 (5.1)
Anxiety symptoms T-scoreb: M (SD) 48.7 (7.7) 48.0 (7.54) 50.2 (8.1) 44.8 (6.9) 51.9 (6.9) 42.3 (4.4) 55.4 (3.5)
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Note. MoCA = Montreal Cognitive Assessment, (Nasreddine et al., 2005); MCI = mild cognitive impairment.

a

Participants scoring 26 or better on MoCA were included in the normal cognition group; those scoring below 26 were included in the MCI group.

b

IRT-based T-scores were calculated for depressive and anxiety symptoms with the U.S. general adult population as the calibration sample (μ= 50; SD = 10). Higher T-scores indicate higher depression/anxiety symptoms.

c

Participant groups for lower vs. higher depressive and anxiety symptoms were based on T-scores. Those with scores lower than the general U.S. adult population were included in the lower symptom groups; those with scores equal to or higher than the U.S. general adult population were included in the higher symptom groups.

Five themes were identified that described the influence of memory problems on emotional well-being among older adults without dementia: Evoking Emotions, Fearing Future, Undermining Self, Normalizing Problems, and Adjusting Thinking. Table 2 provides exemplar quotes for the categories within each theme and the percentage of participants represented by the theme. Table 3 summarizes differences across participant groups. The following overview includes descriptions of the five themes and representation within the sample, as well as qualitative descriptions of similarities and differences across participant groups within each theme and the categories of which it is comprised.

Table 2.

Themes, Categories, and Exemplar Quotes

Themea Description Categoriesa Exemplar Quote
Evoking Emotions
(100%)		 Emotions surrounding or triggered by the experience of memory problems Frustrated (59.2%)
I think it’s the frustration of having those moments, and then having to recover from it.
Embarrassed (53.1%)
Well, I get embarrassed. I’m trying to remember, when I’m in a social situation I am following the conversation, but because my mind starts, like I said, shot gunning ideas, sometimes I lose track of what the social situation is and I’ll insert something that is kind of off the beaten path, and then it kind of stops conversation, and I don’t like that.
Annoyed (51.7%)
We want to talk about so-and-so, I can’t think of the name. It seems like in everyday conversation I almost come up against a wall, at that moment, and maybe 10 seconds later it’s right in my mind. It’s just constantly annoying me that common names … I just can’t come up, right when it’s time to say it.
Worried (44.9%)
I can sense I’m all anxious about the overall idea of having problems with memory I think partly because my entire life, memory has been a plus for me. I’ve always really been able to remember things, rarely forgot things, so any of these little quirks or cracks in it are anxiety-producing.
Upset (34.7%)
I think the most upsetting about it [memory problems] is I don’t know of any way it will get any better.
Surprised (22.4%)
I had prepared all that data which I wanted to tell this new doctor, and I wrote down the date, and yet, on the day, I forgot. That was a shock to me. My goodness, I didn’t forget this type of thing before, but I forgot.
Sad (18.4%)
I know it can’t be fixed and I know it’s not going to get better. I know I just have to deal with. It’s discouraging. It’s sad.
Overwhelmed (10.2%)
I miss a deadline but I kind of forget about it even though I’m working on the project and all of a sudden I realize this is due tomorrow so it causes added stress and extra work to get things done or I have to ask for help and sometimes that’s hard to get.
Fearing Future (71.4%) Fear of what changes in memory may mean for the future N/A
… I guess everyone, at my age especially, and…so many people that have dementia or Alzheimer’s is that the worry about, “Is that going to happen to me?” You know, what impact that’s going to have on me financially and with my children.
Undermining Self (71.4%) Memory problems inflicting damage to impressions of self and perceptions of abilities Self-doubt (53.1%)
It takes me a step back. I’m … I don’t think I have the confidence that I used to have.
Frustration at self (40.8%)
Sometimes I get concerned about it, but usually I just get pissed off at myself. Like something really stupid, I should remember this, why can’t I remember it, you know?
Adjusting Thinking (83.7%) Strategies used to lessen the emotional impact of memory problems Optimism (73.5%)
I’ve learned over the years that I try to keep my thinking positive… I think about that and then I think okay, there’s no point in being negative about this or there’s no point in worrying about something over which I have no control.
Comparing to others (51.0%)
We all suffer from the same problem of words that we know perfectly well that usually are the names of people or places just drop right out of your memory. You’re looking at someone at the table. If it’s a good table of six, you have one big memory bank going, and so usually someone can fill in the word you need. You, of course, do it for them. If you see that look on their face, like, ‘Oh, God, where did they go?’
Planning ahead (36.7%)
I’m very careful. I don’t trust myself to remember anything. I do everything … I write everything down. Keep notes.
Acceptance (30.6%)
There doesn’t seem like an awful lot you can do about it. Maybe you can go to a memory exercise or something like that, but it’s not like you can go through a lot of exercises, or assure yourself that this medicine here is going to solve the problem, or something like that, or take the memory shot, then you’ve got it all solved.
Normalizing Problems (65.3%) Viewing memory problems as normal in context Aging (59.2%)
I think it’s part of the normal aging process, and I’m sure as I age it will probably get even worse.
Busyness (22.5%)
Sometimes when you have a lot of things you’re doing, you know, I think that factors in. There are times that I tend to be like … I’ll be vacuuming and then, somehow, I’ll get distracted by something else. Not that I forgot I was vacuuming, but I think sometimes doing too many things at once.
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a

Percentages in parentheses indicate percentage of participants represented by each theme/category.

Table 3.

Differences in Themes and Categories across Participant Groups

Cognitive Status Depressive Symptoms Anxiety Symptoms
NC MCI Lower Higher Lower Higher
Evoking Emotions
 Frustrated + − + −
 Embarrassed
 Annoyed + − + -
 Worried + − − +
 Upset − +
 Surprised + −
 Sad − + − +
 Overwhelmed + − − +
Fearing Future − +
Undermining Self + − − +
 Self-Doubt + − − +
 Frustration at Self
Adjusting Thinking + −
 Optimism
 Comparing to Others + − + −
 Planning Ahead − + + −
 Acceptance + − + −
Normalizing Problems + −
 Aging + − − +
 Busyness + −
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Note. NC = normal cognition; MCI = mild cognitive impairment. + = Category or theme more representative of participant group; − = Category or theme less representative of participant group; shaded cells indicate no group differences.

Evoking Emotions

All participants shared that memory problems evoked emotions in some way. However, the types of feelings experienced as well as their level of impact varied across individuals. In order of decreasing prevalence, these included feeling frustrated, embarrassed, annoyed, worried, upset, surprised, sad, and overwhelmed. Feeling frustrated was described most often in interviews, with feeling worried as the second most common. Participants described about three different emotions associated with memory problems on average (M = 2.8, SD = 1.12, range = 1–5), and the most commonly co-occurring emotions were frustrated with embarrassed and annoyed with worried.

There were consistencies in the types of situations or circumstances that could exacerbate emotional effects across participants, most notably whether the things they forgot were important and whether the forgetting affected other people. Forgetting important things led to intensified negative feelings and tended to co-occur with descriptions of feeling embarrassed. Similarly, when a memory lapse impacted another person, such as missing a meeting or forgetting someone’s name, these instances were described as more upsetting:

If it’s not essential it’s not that bad, but if it’s really something important, it’s … I find it extremely frustrating. When you forget and you don’t know you’ve forgotten it doesn’t … you know, but when you realize, it’s discouraging. Like my synapses aren’t working.

[Responding to the probe, ‘What is most upsetting to you?’] I guess the problem with names. I don’t want people to think that they are not important to me. I’m always afraid, and I tell, ‘Sorry, it’s just me now.’ I don’t want them to think that I don’t think they’re important.

Across the overall theme of Evoking Emotions, the presence of negative emotional effects of memory problems did not tend to differ based on cognitive status, depressive symptoms, or anxiety symptoms. Every participant reported at least one negative emotion associated with the experience of memory problems. However, there were notable differences across groups in the specific types of emotions evoked (e.g., feeling frustrated vs. embarrassed), as well as extensive variation in the degree of emotional impact. Feeling frustrated, overwhelmed, or worried as a result of memory problems was more frequent in those with normal cognition compared to those with MCI. Overall, descriptions of emotional effects among participants with normal cognition were more extensive and included richer descriptions as well as discussions of changes over time compared to participants with MCI, which may reflect some of the differences in both frequency and degree of emotional impact:

Well, if I have a thing where it’s like, ‘Oh, I couldn’t remember that guy’s name. What is that guy’s name,’ I think a frequent next thought is, ‘Geez Phil,’ because I’ve always been quick but, ‘Geez Phil. You’ve always been able to do that without any problem,’ so is it anxiety about aging? Is it anxiety about your memory specifically? I don’t know. Those two things are sort of wrapped up somehow for me.

Differences in some emotions were also evident across affective symptom groups. Reports of feeling annoyed or surprised by memory problems were more common in those with lower depressive symptoms, while feeling sad, overwhelmed, or upset were reported more often in those with higher depressive symptoms. Feeling annoyed or frustrated was more common in those with lower anxiety symptoms; those with higher anxiety symptoms tended to report feeling sad or worried. Among participants with higher depressive symptoms, 39% also reported higher than average anxiety symptoms. This overlap in affective symptoms is evident in some participants’ descriptions of emotional responses to memory problems:

It makes me feel very depressed, I have to say. Depressed and anxious, I’ve really struggled with depression and anxiety. I feel like a lot of it had to do with my memory.

Feeling worried about memory problems seemed to intensify feelings of anxiety overall, and particularly among participants with higher anxiety symptoms. An internal process or dialogue was often described in which memory problems were evaluated as additional stressors, thereby feeding into a cycle of anxious thoughts:

This is kind of a cycle. You get worried about it, you get more stress, then your memory gets worse, and then that causes you more stress and worry.

Fearing Future

The Fearing Future theme was characterized by participants’ fear of what perceived changes in their memory may mean for the future, specifically whether their memory functioning would continue to decline or would progress to dementia. Some participants described previous experiences with dementia in family members or spouses influencing their fears of developing dementia. Less commonly, they described fearing other future consequences of memory decline, including concerns for their safety (e.g., forgetting to lock a door).

There were differences in Fearing Future across higher and lower anxiety groups. Participants with lower anxiety symptoms expressed some fear of future decline:

I guess the only worry, I wouldn’t say it’s a worry, I do think about it, I hope this doesn’t get worse and worse…I hope I can keep it from…but you roll with the punches.

In contrast, those with higher anxiety symptoms expressed more severe fear about potential future decline:

… that’s one of the things that looms very big in my mind, because I worry about the time when it will begin to affect my work… I don’t believe it has yet. No one has called my attention to errors in my work.

Undermining Self

This theme reflects the ways in which memory problems undermined one’s sense of self in two main categories: feelings of self-doubt and frustration directed toward themselves. Overall, participants with normal cognition as well as those with lower higher anxiety symptoms more often reported such feelings. In particular, those with normal cognition discussed feelings of self-doubt more often than the MCI group. When participants in the MCI group did share feelings of self-doubt, they described a recognition of memory problems and how this affects their views of themselves:

Stupid. Like I’m just not … something is wrong. Maybe stupid’s not the word. That something is going on that shouldn’t be and that I need to look for some help if that’s what should be.

The majority of comments relevant to the Undermining Self theme were among participants in the higher anxiety symptoms group, and this difference was largely due to the self-doubt category. Those with higher anxiety symptoms elaborated about how their memory problems caused them to question themselves or worry about consequences of decline:

I’m worried that as it gets worse, I’m going to start withdrawing. I always feel like it’s constantly … ‘struggle’ might be a little strong … but it’s constantly a push that I feel I need to be keeping myself … pushing myself to not let the fear and that lack of confidence turn me into just somebody that doesn’t get out there, because I feel like it could just be a stone starts rolling and I start becoming really withdrawn, which would only make the problem worse because then I wouldn’t have any opportunities.

In contrast, older adults with lower anxiety symptoms tended to discuss feelings of self-doubt as dependent upon context and more transitory:

It depends what it is when I have a problem. If it’s just something inconsequential I just can laugh it off, but if it’s something like I missed an appointment, or I missed a date for paying a bill, I get upset with myself. It doesn’t last very long, but there’s a difference.

Adjusting Thinking

In response to potentially negative self-judgments, participants described strategies used to make themselves feel better or lessen the emotional impact of memory problems. In order of decreasing prevalence, these strategies included: optimism, comparing to others in that ‘we all have the same problem,’ planning ahead to avoid problems, and acceptance of cognitive changes. These strategies involved adjusting thinking in response to the experience of memory problems, including potentially adjusting expectations of oneself:

I just keep a sense of humor about it. The little things that we forget, if we forget words that we’re trying to think of the people that I’m around are usually sort of in the same boat where we just can’t remember things… We just laugh it off and say, ‘We’ll think of it as soon as you leave,’ so just accept it and try to keep light about it.

There were no overall differences in Adjusting Thinking based on cognitive status or depressive symptoms. However, these strategies were more often described by those with lower anxiety symptoms, and some specific strategies were more common in certain groups. Among participants who reported planning ahead, more were in the MCI and lower anxiety groups. Acceptance and comparing to others were more common in those with lower depressive or anxiety symptoms.

Normalizing Problems

The theme of Normalizing Problems emerged when participants described interpreting their memory problems as either part of the aging process or, less commonly, attributing memory problems to having ‘too many things going on’ (i.e., busyness). This theme was meaningfully different from Adjusting Thinking, as it did not reflect coping strategies to lessen the emotional impact of memory problems. Rather, participants had an emotional response to problems but viewed them as inevitable or dependent upon situational contexts. Attributing memory problems to aging or busyness was more common in those with normal cognition than MCI. Participants with higher depressive symptoms were more likely to attribute memory problems to aging.

Discussion

Maximizing emotional well-being is a critical part of aging well, and identifying factors that help older adults maintain or enhance their emotional health has important public health implications (Fritsch et al., 2014). Previous research has established links between reports of memory problems and depressive as well as anxiety symptoms in older adults (Gulpers et al., 2019; Hill et al., 2016); however, less is known regarding the internal processes that underlie these associations. Using a qualitative descriptive approach, we found that the experience of a memory problem often provokes negative emotions, but the extent to which emotional well-being is impacted depends on current anxiety symptoms, importance of the experience, as well as personal experience with dementia. Notably, there were limited thematic differences in the emotional impact of memory problems between older adults with normal cognition and those with evidence of MCI. We also identified internal strategies that may underlie effective emotional coping with memory problems. Taken together, these findings provide a deeper understanding of the meaning of memory problems from the perspectives of older adults and how this relates to emotional well-being via affective and cognitive mechanisms.

Reports of memory problems are often the first indicator of cognitive decline, but for many older adults, these reflect normal age-related changes or aging-related concerns. We found few differences in how memory problems influence emotional well-being based on cognitive status. This suggests that emotional reactions may be more meaningfully tied to individual characteristics or situational context rather than objective cognitive performance, in line with previous evidence (Hill et al., 2018). Although some emotional impacts were more common in the normal cognition group (including feeling frustrated, worried, and expressing self-doubt), these participants provided fuller descriptions of their experiences than those with MCI. Mild cognitive deficits can lead to less descriptive language and more simplistic expression (Mueller et al., 2018), which may be reflected in our interviews. Furthermore, awareness of cognitive deficits is highly variable in older adults with MCI (Galeone et al., 2011; Kalbe et al., 2005), and this may influence their ability to reflect on experiences with memory problems. Another difference identified was attribution of memory problems to aging or busyness, rather than a potential worrisome sign such as dementia development, in participants with normal cognition. This is in line with previous research (Begum et al., 2013) and is likely an accurate attribution for most older adults (Schweizer et al., 2018).

The implications of memory problems may take on new meaning in the context of aging, particularly if problems provoke worry about the future. Older adults with higher anxiety symptoms were more worried about the problems they experienced, reported more intense feelings overall, used fewer coping strategies, and described an internal ‘vicious cycle’ in which memory problems made them feel anxious, heightened awareness of problems, and provoked further worry. Although memory complaints are associated with an increased risk for dementia, several studies have found that this risk is even higher when complaints are accompanied by worry (Heser et al., 2013; Jessen et al., 2010; Jessen, Wolfsgruber, et al., 2014). In a recent meta-analysis, older adults with anxiety had a 24% higher risk of future dementia (Santabárbara et al., 2020). It is unclear whether concerns about memory reflect actual cognitive deficits that are in fact early, subtle dementia symptoms, or whether anxiety about dementia negatively impacts psychological health and ultimately cognitive trajectories. Therefore, understanding the mechanisms underlying the associations between the experience of memory problems, associated worries, and concurrent anxiety symptoms may help identify individuals at a higher risk for cognitive decline.

In addition to identifying differences in emotional impact across participant groups, we also characterized features of memory problems that exacerbate negative emotional reactions, regardless of cognitive status or affective symptoms: 1) previous exposure to dementia in a relative or friend, 2) forgetting something considered important, and 3) impacting someone else (such as missing a meeting or forgetting a friend’s name). Regarding dementia exposure, previous work has shown that older adults who have a first-degree relative with dementia are more likely to report memory problems (Mogle et al., 2020; Tsai et al., 2006). In line with our findings, this may be related to emotional reactions to memory problems; these experiences are more salient and therefore likely to be recalled. Forgetting something important or impacting others may have a similar effect. Social relationships play important roles in successful aging (Teater & Chonody, 2019). Therefore, when a memory lapse occurs that puts strain on a personal relationship, emotional consequences could be much greater than in circumstances with lower stakes. In addition to immediate effects on well-being, longer-term health effects such as withdrawal from socialization due to feeling embarrassed or worried could be particularly detrimental.

Our results should be considered alongside several limitations. First, our sample was not representative of all older adults, particularly given their high level of educational attainment. This may influence participants’ experiences with memory problems due to factors associated with education, such as resource availability (Zajacova & Lawrence, 2018). Furthermore, we did not collect descriptive information on participants’ race or ethnicity. Past work suggests race- and ethnicity-based disparities impact health and well-being outcomes for people living with depression (Bailey et al., 2019), anxiety (Asnaani et al., 2010), and cognitive impairment (Zahodne et al., 2016). Future work should confirm and expand these findings using a sample representative of diverse racial, ethnic, socioeconomic, geographical, and educational backgrounds. Second, the MoCA provides valuable information on cognitive status but does not replace neuropsychological testing, the gold standard for identifying subtle cognitive deficits. Finally, our community-based sample may have limited the range of affective symptoms and cognitive impairment represented in our participants. While the sample was recruited intentionally for the questions we set out to answer, future work should include people living with diagnosed depression, anxiety disorders, and cognitive impairment to gain a comprehensive understanding of the impact of memory problems on emotional well-being.

Despite the limitations noted, this study had several strengths. Our sample size was relatively large for a qualitative descriptive study, supporting our investigation of differences across participant groups. Therefore, our findings provide a novel understanding of how cognitive status and affective symptoms influence older adults’ emotional responses to memory problems. Qualitative data, collected over multiple interviews, provided insight into the lived experiences of memory problems among older adults (e.g., undermining self) and demonstrated ways in which they cope with potential emotional consequences (e.g., adjusting thinking). By examining these results across participant groups, we uncovered key differences in the relationships between memory problems and emotional well-being based on current cognitive functioning and affective symptoms.

Conclusion

Overall, these findings describe the internal processes by which memory problems may influence emotional well-being in older adults without dementia. Experiences were similar regardless of cognitive status but did differ based on affective symptoms. Detrimental emotional reactions to memory problems may be more common in older adults with higher anxiety symptoms, even if their symptoms do not meet diagnostic thresholds for an anxiety disorder. Therefore, thorough assessment of reports of memory problems, regardless of cognitive testing outcomes, should consider co-occurring affective symptoms as well as older adults’ evaluations of how memory problems influence their daily lives and well-being.

SUMMARY STATEMENT OF IMPLICATIONS FOR PRACTICE.

What does this research add to existing knowledge in gerontology?

  • Older adults’ memory problems provoked similar negative emotional experiences regardless of cognitive status (normal cognition or mild cognitive impairment).

  • Concerns about memory problems may heighten negative emotional responses to their occurrence and may be further aggravated by dementia worry and general symptoms of anxiety.

What are the implications of this new knowledge for nursing care with older people?

  • Nurses should further investigate reports of memory problems uncorroborated by objective testing, with a focus on psychosocial health.

  • Thorough cognitive assessment should consider how older adults’ evaluations of memory problems influence their daily lives and well-being.

How could the findings be used to influence policy or practice or research or education?

  • Future research on memory complaints and affective symptoms should examine the influence of individual factors, including dementia exposure and perceptions of problem severity.

  • Cognitive screening guidelines should consider best practices for responding to memory complaints when cognitive testing results are normal.

Acknowledgements

This work was partially supported by the Center of Innovation in Long-term Services and Supports at the Providence VA Medical Center via the Office of Academic Affiliation’s Advanced Fellowship in Health Services Research (Dr. Madrigal) and the National Institutes of Health (T32NR018407, Dr. Wion). We would like to thank our research participants for their time and contributions to this study.

Contributor Information

Nikki L. Hill, Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, PA, USA.

Emily Bratlee-Whitaker, Edna Bennett Pierce Prevention Research Center, Pennsylvania State University, University Park, PA, USA.

Rachel K. Wion, School of Nursing, Indiana University, Indianapolis, IN, USA.

Caroline Madrigal, Providence VA Medical Center, Center of Innovation in Long-Term Services and Supports, Providence, RI, USA.

Sakshi Bhargava, Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, PA, USA.

Jacqueline Mogle, Edna Bennett Pierce Prevention Research Center, Pennsylvania State University, University Park, PA, USA.

Data Availability Statement:

Research data are not shared.

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Data Availability Statement

Research data are not shared.

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