5 Reasons Why Real-Life Memory Difficulties Don't Always Show Up on Standard Tests
Real life makes recall hard in ways psychological tests in controlled environments don't
Some people with chronic mental and physical illnesses experience a distressing difficulty remembering things in real life, yet perform normally on memory tests. Too often, doctors and others assume that means these patients’ memory functions normally, and their difficulties are imaginary.
As a result, others deny what these patients experience and denigrate them, adding insult to injury.
Fortunately, there’s a simple, humane explanation for the difference between patients’ experiences and memory test scores: real life is much more complex and difficult than memory tests.
Wait…Which tests are we talking about?
In the United States, when a person tells their primary care doctor about their memory difficulties, that begins a multi-step process. At each step, the patient may undergo longer, more detailed tests.
A primary care doctor will probably give a screening test, which takes less than 5 minutes. A screening test can’t diagnose anything. It shows whether there is likely to be a problem serious enough to recommend further investigation. Out of context, normal scores on a screening test do not prove anything; a person with mild cognitive impairment can test normally on a screener.
The next step is referral to a specialist. Specialists often start with a 5-15 minute “mental status” test, which looks at several areas of cognitive functioning, such as memory, attention, and language. These tests show which areas are and are not affected by cognitive decline. Follow up testing explores specific areas affected, such as memory, in more depth. These tests are longer, more detailed, and can diagnose specific diseases.
Finally, a patient may be sent for neuropsychological testing, which is the most in-depth possible cognitive testing. If you’re neurodivergent, you’ve probably heard of neuropsychological testing: it’s also used to diagnose learning disabilities and ADHD. Unfortunately, not all patients reach this stage, especially those who have tested normally up to this point.
The first 3 reasons memory difficulties might not show up on a test apply to all sorts of tests, including neuropsychological testing. The last 2 reasons apply to everything but neuropsychological testing.
1. Real life isn’t a controlled environment
Testing environments are controlled environments: quiet, typically white rooms, with minimal visual clutter and noise. The only other people present are giving us the test.
Our real lives occur in more-colorful, noisy rooms full of books, papers, and items, all of which have memory associations attached:
What each book was about, and whether we liked it,
What the papers contain, and why they’re lying here right now,
When and where we bought each item.
Multiple other people are often present. Each person evokes memories of our ongoing relationship with them:
How we met them,
How much we like them, and why,
What places we’ve gone and what activities we’ve done together.
The activities other people are doing in the background might also evoke memories (“You’re making meatloaf again? We just had that last night”).
In real life, recalling something requires us to ignore both the clutter and the irrelevant memory associations. That’s hard.
One implication is that in real-life, memory is more than just pure memory. We often must use other skills too — which adds more ways that remembering can go wrong. We especially need the ability to recognize and block out distractions.
That makes sense. Focusing on what currently matters to the task at hand, while ignoring what doesn’t, improves people’s performance in every other activity humans do, so why not memory?
2. Real life is full of interruptions and distractions
Have you ever entered a room only to stop short, realizing you don’t remember why you went there in the first place? The most common reason we forget why we entered a room is because something interrupted us.
We associate this lapse with elderly people, but it happens to everyone occasionally.
We use working memory to keep in mind what we came into the room to do. Without active efforts to “refresh” that information, such as repeating it to ourselves, it fades within a few minutes. So, a long enough interruption can drive our intended task out of our working memory.
People with ADHD are especially prone to these “why did I come here?” moments at any age, both because they have less effective working memory and because they are more easily distracted.
Real life is full of interruptions: phone calls, text messages, questions from people living or working with us, suddenly having an idea, noticing and cleaning up a nearby mess, and more. Lab tests are purposely kept free of such interference.
The problem is, a person’s real life difficulties might occur, not because of a memory impairment per se, but because of distraction and cognitive overload. The person truly has difficulties functioning, which should be addressed — but these won’t appear on memory tests taken in controlled environments.
3. In real life, we remember more complex, meaningful things, in more complicated situations
In a lab test, people remember specific, simple, meaningless things. Often, they must recall words they recently saw or heard. In real life, we remember more complex things that have meaningful context. For example, we often forget or misremember the details of a news story, but remember the gist of the story.
Context allows us to use a mental filing system to store details. For example, our mental filing system may associate a fact in the news with politics, environmental issues, current events, celebrity gossip, or trivia.
Often, this context helps us remember. However, when the storage system fails, it causes problems. When we fail to “file” facts correctly, we forget them. We may remember that we knew these details, but we can’t access them.
By contrast, we usually don’t interpret new information given in lab tests as having long-term importance, so it won’t be filed this way.
Also, some tests ask people to say as many words as possible from a category, such as “animals” or “fruit.” Such questions draw on information that was stored long ago and has been successfully retrieved for years.
Either way, any difficulties a person has with filing information could be missed.
In standard memory tests, questions often follow a consistent format and require a consistent type of response, which makes it easier to understand how to respond correctly. In real life, we may not even be asked to recall a piece of information; we may do it spontaneously, while thinking about a related topic.
In real life, we recall information for many different reasons: trivia night; making entertaining conversation at parties; impressing bosses; writing effective reports; deciding whether to believe politicians; etc.
There is also no consistent, pre-determined type of output. We might talk about the memory in our own words, write it down, or keep it to ourselves. People make these decisions based on their reason for recalling the detail. They might consider their knowledge of social norms and how to communicate effectively with their audience.
All of these factors add extra complexity to real-life memory functioning that don’t exist in standard tests.
4. Real life and tests often involve different types of memory
There are several types of memory. By studying people with brain injury, we’ve learned that these are separate; a person can have deficits in one type of memory, and not another.
In real life, people tend to be distressed by difficulties with 2 types of memory:
Prospective memory (remembering things we need to do, or events we expect to happen, in the future);
Episodic memory (remembering moments in our lives).
Semantic vs. Prospective Memory
Tests tend to involve memory for things we heard or saw in the past. The real life memory errors that bother us often involve prospective memory. We might forget what day we scheduled a meeting, or leave necessary supplies at home, like the cowboy in the cartoon below.
Prospective memory lapses make us fail to prepare for the future.
Semantic vs. Episodic Memory
In real life, patients often complain of lapses in episodic memory: the memory of a moment in time we experienced, which can include all 5 senses, body sensations, and emotions. Especially vivid episodic memories of an important event are called “flashbulb memories.”
Tests, on the other hand, often assess semantic memory: factual knowledge without associated emotions, where it doesn’t matter how or when you learned it. A semantic memory can often be summed up in a sentence, such as “the current president of the United States is Joseph Biden” or “today is July 14, 2023.”
Semantic memory for facts often comes with episodic memory for how and where we learned them. However, semantic and episodic memory are different.
Semantic memory is knowing what was the first word your child said. Episodic memory is remembering where you were at the time, what you and the child were doing, why you decided it was a word rather than babbling, how you felt and reacted, etc.
You can have one of these without the other. Often, a person can recall the semantic memory, but not the episodic one.
In real life, forgetting a fact usually doesn’t bother us much, but forgetting an episodic memory distresses us.
Doctors should not use tests that measure semantic memory while patients struggle with episodic or prospective memory.
5. The Tests Used Might Not Be Sensitive or Specific Enough
When doctors evaluate memory problems, they typically use general tests of “cognitive functioning” or “mental state” rather than specific tests of memory. These tests are also used to detect “mild cognitive impairment” in older people.
Mild cognitive impairment means “a slight — but noticeable — decline in mental abilities compared to others your age” which isn’t severe enough to interfere with daily routines. The memory-related symptoms include:
Forgetting recent events or repeating the same questions and stories.
Occasionally forgetting the names of friends and family members
Forgetting appointments or planned events.
Misplacing items more often than usual.
Difficulty coming up with the right words.
Trouble understanding written or verbal information as well as you used to.
Younger people with chronic illnesses say they experience similar difficulties. So, it might seem like a good idea to test them using standard tests for mild cognitive impairment.
However, using these tests is a bad idea, for several reasons.
1. The tests are not specifically designed to test memory.
Without enough questions focused on different aspects of memory, it simply may not be possible to detect a problem.
The screening tests used by primary care doctors can take less than 5 minutes. Initial testing by a specialist often takes less than 15 minutes, and this small amount of time includes assessments of other abilities, such as attention, language, or visual-spatial thinking. There just may not be enough test items to detect a mild memory impairment.
In fact, these mental state tests don’t perform very well at differentially diagnosing people known to have mild cognitive impairment. They have unimpressive sensitivity and specificity.
2. The tests are designed to catch severe memory problems such as dementia, so they may not be sensitive enough to catch the more subtle difficulties people experience in everyday life.
Younger adults who experience memory problems are oriented in the present moment: they know the date, the year, that they are at the doctor’s office, and why they came. They know facts such as the current President of the United States. They can draw a clock at a given time accurately, with numbers in order around the circle and hands in the correct place. They can hear a list of 3 unrelated words, do another activity for 3 minutes, then recall them. They can read words, such as “checkers” or “fork,” and identify that checkers is a game and a fork is silverware.
All of these are abilities measured by common tests such as the Mini Mental State Exam (MMSE), the Clock Drawing Test, and the Memory Impairment Screen. Thus, these common tests won’t help them.
3. Tests designed for aging people may not be appropriate for young and middle aged adults.
Younger adults experiencing memory difficulties do so for different reasons than either people going through normal aging or people with dementia. Their brains are in a different state of health and wear.
People trained to use standardized tests know it’s inappropriate to give tests that were normed and validated without people the patient’s age. In other words: Tests developed with one population — such as elderly adults — should not be used with another — such as younger adults.
Where We Go From Here
When people experience memory difficulties in life that don’t show up on memory tests, we should give them the benefit of the doubt. Memory tests don’t much resemble real life.
Real life is complicated, full of distractions that interfere with memory retrieval and make us draw on other abilities, like attention.
Tests are easier, require more predictable responses, and happen in controlled environments.
Tests might even focus on different types of memory than the ones patients struggle with in real life.
Tests might not be appropriate for people the patient’s age.
Tests may not be sensitive enough to detect mild difficulties, and may not even be specifically designed to test memory at all.
If medical professionals develop and use
harder tasks
with distractions
with interruptions
with variable responses
etc.,
then we will find fewer “puzzling” differences between people’s memory performance in the lab versus real life.
Until then, believe the patients.
What do you think?
Have you ever had memory difficulties? If so, have you taken a memory test? Did it seem challenging and relevant?
What else makes it hard to remember in real life?
If you’re a doctor or researcher who uses memory tests: what do you think of them? How would you improve them?
If you’re familiar with psychometrics: have I judged memory tests fairly? What do people need to know about memory tests doctors use? How would you redesign memory tests to better detect patients’ real life challenges?
Source
Blog posts usually don’t include citations, but this time, I’m providing one in case readers don’t have access to UpToDate.
Mendez, MF. Mental status scales to evaluate cognition. In: DeKosky, ST, and Wilterdink, JL, eds. UpToDate. UpToDate; 2023. Accessed July 06, 2023. www.uptodate.com
Thank you, Dr. Matt Morrison, for answering questions and pointing me towards this reference! Any errors are mine.