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Hannon et al 1995

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Effects of Brain Injury and Age
on Prospective Memory
Self-Rating and Performance
Roseann Hannoo, Peter Adams, Scott Harrington,
Caroline Fries-Dias, and Martin T. Gipson
University of the Pacific
ABSTRACT. The purposes of this study were (1) to assess internal consistency
and test-retest reliability of the Prospective Memory Questionnaire (PMQ)
developed by Hannon and associates; (2) to compare PMQ self-ratings of adults
with brain injury versus younger and older noninjured adults; (3) to develop
short-term and long-term tasks for measuring actual prospective memory
performance; and (4) to study the relationship between scores on the PMQ and
the prospective memory tasks. Internal consistency of the PMQ was .92 and
test-retest reliability was .88. Groups differed significantly on only one PMQ
subscale. Actual prospective memory performance was significantly worse for
adults with brain injury and older adults than for younger adults on two of the
three sets of summary measures. PMQ self-ratings were significantly but
weakly correlated with short-term task performance, but not with long-term
task performance. Implications of the findings for assessment and treatment of
prospective memory impairment are discussed.
Prospective memory (the ability to remember to perform future actions) is one
of the least investigated types of memory in normal adults (Harris, 1984), elderly
adults (Dobbs &Rule, 1987), and adults with brain injury (Mateer, Sohlberg, &
Crinean, 1987). All three of these groups, however, describe prospective
memory as one of their most significant areas of memory deficit. While a
significant literature exists on self-rating of memory generally (Herrmann, 1982,
1984) and there are many types of clinical instruments for assessing memory,
standardized self-rating instruments and clinical measures of prospective memory
are poorly developed. Such instruments are important in the rehabilitation of
deficits in prospective memory in individuals with brain-injury or advanced age,
REHABILITATION PSYCHOLOGY Vol. 40, No. 4, 1995
O 1995 by the Division of Rehabilitation Psychology of the American Psychological Association
Published by Springer Publishing Company, Inc., 536 Broadway, New York, NY 10012
289
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both for initial assessment and for monitoring effectiveness of treatment. Since
people's beliefs about their own memory abilities, whether accurate or inaccu-
rate, infl uence their behavior, the relationship between self-rating of prospec-
tive memory abilities and actual performance must be studied to frilly understand
memory functioning.
Hannon and colleagues (1990) developed the Prospective Memory Questionnaire
(PMQ) with 74 behaviorally anchored items rated on a 9-point Likert-type scale.
Subscales were rationally and theoretically developed based on prior research to
measure five dimensions of prospective memory: Long-Term Episodic Tasks, Short-
Term Episodic Tasks, Long-Term Habitual Tasks, Short-Term Habitual Tasks, and
Techniques to Assist Recall. The questionnaire was administered to 361 subjects
(291 college students, 19 community college students with brain injury, 14
rehabilitation center clients with brain injury, and 37 alcoholics) for its initial
validation. Coefficient alpha was .93 for the PMQ total score, and ranged from .80
to. 90 for the subscales (except for Long-Term Habitual which was .60), confi rming
the value of the subscales. A factor analysis separated the items into five factors,
four of which corresponded largely to the subscales designed for the PMQ (all but
Long-Term Habitual). The PMQ was reduced to 63 items based on this factor
analysis, with Long-Term Episodic, Short-Term Habitual, and Technique scales
retained, and a new Internally Cued scale (which included most of the original
Short-Term Habitual items) added. Nine items with the lowest item-total correla-
tions with any of the scales were dropped.
An unpublished follow-up study was performed in which the PMQ with 63
items was administered to 214 subjects (197 college students, 17 community
college adults with brain injury). Coefficient alpha was .90 for the PMQ total score,
and ranged from .81 to .88 for the subscales. Based on factor analysis of these
results, the 52-item PMQ used in the present study was developed. The purposes
of the present study were (1) to further develop the PMQ, including internal
consistency and test-retest reliability; (2) to compare PMQ self-ratings of adults
with brain injury with older and younger adults; (3) to develop a set of tasks for
measuring actual prospective memory performance; and (4) to study the relation-
ship between scores on the PMQ and the prospective memory tasks.
METHOD
Participants
Participants were 114 younger adults (community college and state university
students, M age = 28.4, SD = 8.6), 27 older adults (healthy retirement home
residents, M age = 73.4, SD = 19.9), and 15 adults with brain injury (community
college students, A/age = 31.8, SD=9.2). Adults with brain injury had experienced
a significant head trauma (all were unconscious following the injury and most were
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Prospective Memory Self-Rating and Performance 291
in a coma), and were 1 to 20 years post injury (Md= 3 years). They were enrolled in
a special program for students with acquired brain injury, and were asked by the
program director if they would like to participate in this study. Older adults were
asked to participate by the social/recreation director of the retirement home where
they resided. Younger adults and adults with brain injury did not differ signifi-
cantly in age (note Ms and SDs above). Groups did not differ significantly in
education, tf(6,N= 148) = 8.47, p > .05 (education was measured categorically
and most participants checked high school graduate or attended college, no
degree).
Procedure
All participants were tested in group sessions, with 5 to 25 participants per
group. To test short-term prospective memory (tasks to be completed within 5
min.), four tasks were administered: 5 min. associative cue task, 2 min. associative
cue task, 5 min. time cue task, 2 min. time cue task (types of tasks modeled on
Sohlberg & Mateer, 1989). The required response for each task was to initial the
response sheet in accordance with the specific associative or time cue instructions.
Task problems were presented by slide projector every 15 sec. Tasks were designed
to make it difficult for participants to constantly rehearse and keep track of the
associative or time cue for a given task, which made the tasks more comparable to
real world situations. Tasks were designed so that most participants could
accurately complete the basic task requirements which did not involve prospective
memory. Tasks are described below, and were presented in the order described:
1.5 min. associative cue task - Items from the WechslerAdult Intelligence Test-
Revised Information subtest were presented every 15 sec. Participants were told to
write their answers on a numbered response sheet, and to write their initials to the
right of their answer when they came to the first question regarding an animal (the
associative cue).
2. 2 min. associative cue task - Participants were shown a word fragment every
15 sec and asked to fill in the missing letters to form a word. They were told to write
their initials to the right of their answer when they came to the first item for which
a color was the correct response (the associative cue).
3.5 min. time cue task - Participants were shown a word every 15 sec. and asked
to write the opposite of the word. They were told to write their initials to the right
of their answer exactly 5 min. after the first word was presented.
4. 2 min. time cue task - Participants were shown a simple addition problem
every 15 sec. and asked to write the answer. They were told to write their initials
to the right of their answer exactly 2 min. after the first problem was presented.
The score for each task was 0 if there were no initials on the response sheet, 1
if initials were present but in the wrong place, and 2 if the initials were present in
the right place. The mean of the scores for the four short-term tasks was used as the
short-term task score in the data analysis.
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292 Hannon et al.
Following these four tasks, participants completed the Symbol Digit Modalities
Test (SDMT, Smith, 1982), modified for group presentation, as a measure of attention
and concentration.
The PMQ was completed next (see Table 1 for subscales and sample items). This
questionnaire was revised and shortened to 52 items based on the previously
described work by Hannon et al. (1990), and contained four subscales: Long-Term
Episodic, Short-Term Habitual, Internally Cued, and Techniques to Assist Memory
(higher scores indicate poorer performance on the PMQ total score and on the
subscale scores). To assess test-retest reliability, 72 participants were readministered
the PMQ 10-14 days later (these participants were selected based on availability, and
represented all three participant groups).
To test long-term prospective memory (tasks to be completed hours or days
later), participants were given two questionnaires to return by mail, the Beck
Depression Inventory (BDI; Beck, 1978), and a shortened version of the Neurop-
sychological Symptom Checklist (NSC; Neuropsychological Status Examination
Manual, 1983). (Higher scores indicate more symptoms on both measures.)
Participants were verbally instructed to return each questionnaire on a different
specified date. They were told to include their name and the date in the upper right
hand corner of each questionnaire. The verbal instructions were repeated twice
after first instructing participants to pay careful attention. Instructions were given
verbally rather than in writing to reduce the chance that a significant other would
see written instructions and return the questionnaires for the participant. Partici-
pants were told that those who returned both questionnaires on the correct dates
would receive one California state lottery ticket, and that 10% of these participants
would be selected in a drawing to receive $10 each.
Two long-term task scores were developed for data analysis: (a) BDI and NSC
questionnaire return mean score, with each questionnaire given 0 for no return, 1 if
returned on the wrong date, and 2 if returned on the right date; and (b) name and date
correct mean score, with each questionnaire given a score ranging from 0 for no name
or date to 4 for both name and date in the upper right hand corner. Scores on these
questionnaires were used to explore possible relationships between these measures
and scores on the PMQ and on short-term and long-term prospective memory tasks.
RESULTS
Prospective Memory Questionnaire
Coefficient alpha was .92 for the PMQ total, and ranged from .78 to .90 for the
subscales. Factor analysis of the 52 items using varimax rotation confirmed the
structure of the subscales. For test-retest reliability, r = .88 for the PMQ total and
ranged from .64 to .88 for the subscales. One-way ANOVAs with multiple
comparisons on the PMQ total and each subscale showed that groups differed
significantly on only one subscale, Short-Term Habitual. Participants with a brain
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Prospective Memory Self-Rating and Performance 293
Table 1. Prospective Memory Questionnaire Subscales and Sample Items
Long-Term Episodic Scale—task is to be completed hours or days after cue
to perform it and occurs on an irregular schedule
I forgot to send a card for a birthday or anniversary.
I forgot to return books to the library by the due date.
Short-Term Habitual Scale—task is to be completed within a few minutes
after cue to perform it and occurs routinely
I forgot to lock the door when leaving my apartment or house.
I forgot to put a stamp on a letter before mailing it.
Internally Cued Scale—task does not have a clear specific external cue
I forgot what I wanted to say in the middle of a sentence.
I was driving and temporarily forgot where I was going.
Techniques to Remember Scale—techniques used to help one remember to
perform a prospective memory task
/ rehearse things in my mind so I will not forget to do them.
I make Post-It (sticky note) reminders and place them in obvious places.
injury rated themselves significantly more poorly on this subscale than did younger
adults, F (2, 150) = 3.60, p < .05.
Prospective Memory Tasks and SDMT
Internal consistency for the prospective memory tasks was analyzed using the
four short-term task scores and the questionnaire return and name and date correct
scores for each questionnaire, and coefficient alpha was .76. Three prospective
memory measures (short-term task mean score, BDI and NSC questionnaire return
mean score, and name/date correct mean score) and the SDMT were analyzed for
group differences using one-way ANOVAs (higher scores indicate better perfor-
mance on all measures). Means and standard deviations for each group on each
measure, as well as Fs and ps for each ANOVA, are presented in Table 2. Groups
differed significantly on short-term tasks, on name/date correct, and on the SDMT.
Adults with brain injury and older adults performed significantly more poorly than
younger adults on all three measures. Groups did not differ significantly on
questionnaire return.
Correlations
All correlations were computed using all participants in order to obtain the most
stable estimate for the computed r values (the relatively small n for older adults and
for adults with brain injury would produce unstable estimates of the true r for these
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Table 2. Means and S tandard Deviations for Each Group on Prospective
Memory Tasks and the Symbol Digit Modalities Test (SDMT)
Task Younger
Short-term tasks
M 1.66
SD 0.47
Name/Date correct
M 3.60
SD 0.97
Questionnaire return
M 1.44
SD 0.71
SDMT
M 59.96
SD 11.20
Group
Older
0.94
0.65
1.75
1.87
1.61
0.67
36.24
15.10
Brain
Injury
0.58
0.51
2.09
1.81
1.29
0.80
31.79
15.10
F
44.65a
25.02b
1.06C
61.55d
P
<.001
<.001
>.10
<.001
a/w='= 2, 151. *>df= 2,129. cdf= 2,150. adf= 2,146.
groups). Intercorrelations of measures of prospective memory performance (short-
term and long-term) with PMQ self-ratings, SDMT, and age are presented in Table
3. Short-term task performance was significantly correlated with PMQ self-rating
scores (total and subscales, except for Techniques to Remember), r = -. 17 to -.25,
showing that higher short-term task scores were related to better (i.e., lower) PMQ
self-ratings. These relationships accounted for only a small portion of the variance.
Neither measure oflong-term performance (questionnaire return, name/date correct)
was significantly correlated in the predicted direction with PMQ self-rating scores.
Better short-term task performance was significantly correlated with younger age
(r = -.43) and with higher SDMT scores (r - .54). These correlations accounted for
substantial portions of the variance (18-29%). Better questionnaire return was
significantly correlated with older age (r =. 19), but was not correlated with SDMT.
Similar to short-term task performance, better name/date correct was significantly
correlated with younger age (r = -.39) and with higher SDMT scores (r = .42).
Some interesting relationships ofBDI and NSC scores with PMQ self-ratings and
measures of prospective memory performance emerged, and intercorrelations are
shown in Table 4. There were positive relationships between PMQ total and BDI
scores (r = A1) and NSC scores (r = .48), showing that participants with less favorable
PMQ self-ratings (i.e., higher PMQ scores) tended to score higher on depression and
on neuropsychological symptoms. Similar correlations occurred for allPMQ subscales
except Techniques to Remember. The PMQ total and subscale correlations with BDI
and NSC accounted for substantial portions of the variance (13-27%).
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Table 3. Intercorrelations of Measures of Prospective Memory
Performance With PMQ Self-Ratings, SDMT, and Age
PMQ
Total score
Long-term episodic
Short-term habitual
Internally cued
Techniques to remember
SDMT
Age
Short-term
Tasks
-.17*
-.19*
-.25**
-.22**
.03
.54**
-.43**
Questionnaire
Return
.01
-.06
-.04
-.00
.10
.10
.19*
Name/Date
Correct
.07
.01
-.12
.04
.17*
.42**
-.39**
Note. PMQ= Prospective Memory Questionnaire; SDMT = Symbol
Digit Modalities Test
*p<-05. **p<.0l.
Table 4. Intercorrelations of PMQ Self-Ratings and Measures of
Prospective Memory Performance With BDI and NSC Scores
BDI NSC
PMQ
Total score
Long-term episodic
Short-term habitual
Internally cued
Techniques to remember
Short-term tasks
Questionnaire return
Name/Date correct
.41**
.36**
.43**
.38**
.17
-.31**
-.21*
-.20*
.48**
.44**
.46**
.52**
.20*
-.47**
.07
-.14
Note. BDI = Beck Depression Inventory; NSC = Neuropsychological Symptom
Checklist; PMQ = Prospective Memory Questionnaire.
*p < .05. **p <-01.
Better short-term task performance was significantly correlated with lower BDI (r
= -.31) and NSC (r = -.47) scores, accounting for 9%-22% of the variance. Better
performance on questionnaire return and name/date correct was also significantly
correlated with lower BDI scores (-.21 and -.20, respectively), but not withNSC scores.
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DISCUSSION
Both coefficient alpha and factor analysis results indicate that the PMQ is an
internally consistent instrument for measuring self-rating of prospective memory.
Test-retest reliability is also sufficiently high. Both adults with brain injury and
older adults performed more poorly than younger adults on short-term prospective
memory tasks, and adults with brain injury rated themselves more poorly than
younger adults on the Short-Term Habitual subscale of the PMQ. Groups did not
differ significantly on any other PMQ subscales, and this finding is particularly
interesting for the Techniques subscale. Since adults who are older and those with
brain injury have more difficulty with short-term tasks, they would be expected to use
more techniques to remember. Our findings suggest that individuals most needing
such techniques may not use them any more frequently than younger adults do.
Rehabilitation strategies which focus on developing such techniques therefore
appear to be especially important.
The prospective memory performance tasks had reasonable internal consistency
for initial development. Adults withbrain injury and older adults performed signifi-
cantly more poorly than younger adults on short-term tasks and also on name and
date correct on returned questionnaires. Groups did not differ on questionnaire
return per se. The relationship between age and performance on different types of
prospective memory tasks is not well understood. Some studies have found declining
performance withage onmore complex tasks (Einstein, Holland, McDaniel, & Guynn,
1992), butnotwith simpler tasks (DobbsA Rule, 1987; Einstein & McDaniel, 1990).
Differentiating the specific types of prospective memory tasks which are sensitive
to aging versus those which are not is an important issue for future research.
Correlation analyses confirmed the typical finding of low association between
self-rating of memory and actual performance (Herrmann, 1982, 1984). Self-
rating of prospective memory was significantly but weakly correlated with short-
term performance and was not significantly correlated with long-term performance.
The three measures of actual performance showed differing sensitivity to other
variables (age, SDMT, BDI, and NSC) assessed in this study. Short-term memory
had significant relationships in the expected direction to all of these variables, with
better short-term memory performance related to younger age, higher SDMT scores,
and lower BDI and NSC scores. Short-term tasks were also the only performance
measure to correlate significantly with the appropriate PMQscale (Short-Term
Habitual). Better name/date correct scores were related to younger age, higher SDMT
scores, and lower BDI scores. Better questionnaire return was related to older age
and lower BDI scores. Future studies should investigate more closely the relation-
ship between prospective memory task performance and attention/concentration,
depression, and neurological symptomotology, as the present study suggests that
these are important variables and that they most clearly relate to performance on
short-term tasks. Since individuals with brain injury also frequently experience
depression, ruture research is needed to determine the degree to which poorer short-
term prospective memory performance is due to depression versus brain injury.
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Prospective Memory Self-Rating and Performance 29 7
Further research on prospective memory is needed inboth adults with brain injury
and older individuals. The types of tasks which are sensitive to aging and to brain
injury must be more clearly delineated. Developing tasks which are more relevant to
everyday functioning should also be explored. Using the kinds of measures explored
in this study, an assessment could be developed which would allow individuals to
compare their self-ratings and their actual performance on a battery of prospective
memory tasks. This comparison might improve recognition of impairment and
increase motivation for treatment. These measures could also be used to monitor
effectiveness of treatment in improving both accurate self-rating and actual perfor-
mance.
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Th
is
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oc
um
en
t i
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op
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 b
y 
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ts
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.
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ad
ly
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298 Harmon et al.
Acknowledgments. The authors thank Carol L. Dais, San Joaquin Delta College, for her
assistance in obtaining data from participants with brain injuries.
Offprints. Requests for offprints or for copies of the PMQ should be directed to
Roseann Hannon, Department of Psychology, University of the Pacific, Stockton, CA
95211.
Submitted: October 1993
Revised: December 1994
Revised: February 1995
Accepted: June 1995
Th
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.

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