Associations between working memory, health literacy, and recall of the signs of stroke among older adults.
Article Type: Report
Subject: Short-term memory (Physiological aspects)
Short-term memory (Research)
Aged (Health aspects)
Stroke (Disease) (Research)
Health literacy (Research)
Authors: Ganzer, Christine A.
Insel, Kathleen C.
Ritter, Leslie S.
Pub Date: 10/01/2012
Publication: Name: Journal of Neuroscience Nursing Publisher: American Association of Neuroscience Nurses Audience: Professional Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2012 American Association of Neuroscience Nurses ISSN: 0888-0395
Issue: Date: Oct, 2012 Source Volume: 44 Source Issue: 5
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 303641391

Stroke remains a major cause of mortality and disability among older adults. Although early treatment after stroke is known to reduce both mortality and disability, the first step in seeking early treatment is dependent on the rapid recognition of the signs of stroke. Recall of the signs of stroke may be dependent on factors that exist before the stroke itself. Although it is known that both working memory and health literacy decline with advancing age, these factors have not been thoroughly examined with respect to recall of the signs of stroke. Therefore, the purpose of the current study was to investigate associations between working memory, health literacy, and recall of the signs of stroke among older adults. Community dwelling older adults ([greater than or equal to] 65 years of age) were recruited from two senior centers. Fifty-six participants meeting inclusion criteria provided demographic and health information and were asked to read a public service brochure listing the five warning signs of stroke. Working memory was then assessed using the Wechsler Adult Intelligence Scale 3rd Edition Working Memory Index. Health literacy was assessed by the Short Test of Functional Health Literacy in Adults. Participants' recall of the five warning signs of stroke was evaluated. The mean age was 80.4 years. The mean number of the signs of stroke recalled was 2.9 [+ or -] 1.33. Working memory and health literacy were positively correlated with recall of the signs of stroke (r = .38, p < 0.01; r = .44, p < 0.01). In a simultaneous regression, only health literacy remained a significant predictor of recall. There was no statistically significant interaction between working memory and health literacy. Findings from this study indicate that working memory and health literacy were associated with successful recall of the warning signs of stroke in older adults. Further studies are needed to determine if programs that include cognitive and literacy assessments could identify older adults who need additional support to learn and recall the signs of stroke.

Keywords: health literacy, older adults, recall, stroke, working memory


Stroke is the third most common cause of death worldwide and a significant cause of chronic disability (Roger et al., 2011). Older age is a risk factor for stroke; hence, the number of older adults with stroke will increase as our population ages (Kleindorfer et al., 2009). It is well documented that optimal outcomes after stroke are associated with receiving guideline-driven care in designated stroke centers, including the administration of reperfusion therapies (Adams et al., 2007; Chandratheva, Lasserson, Geraghty, & Rothwell, 2010; Donnan, Fisher, Macleod, & Davis, 2008; Gropen et al., 2006; Kleindorfer et al., 2009; Lees et al., 2010; Saver et al., 2010; Zaheer, Robinson, & Mistri, 2011). In the last decade, great progress has been made in the development and implementation of public education campaigns emphasizing the need for seeking early treatment to assess eligibility for reperfusion therapy after stroke. Despite these efforts, it is estimated that only 3%-4% of all persons with ischemic stroke arrive at the hospital in time to receive reperfusion therapies, due in part to delay in seeking care (Moser et al., 2006; Sprigg, Machili, Otter, Wilson, & Robinson, 2009). Although previous studies have examined the reasons for delay in seeking immediate care at the time of a stroke, few factors are consistently associated with delay behavior (Giles, Flossman, & Rothwell, 2006; Kleindorfer et al., 2009; Sprigg et al., 2009).

Successfully recalling the signs of stroke when it occurs is the first necessary step in seeking immediate treatment. Working memory and health literacy are important variables that predict successful recall of stored information in other settings (Morrow et al., 2006) and may be critical in predicting the recall of the warning signs of stroke when the individual is experiencing them. Working memory is defined as the temporary storage and management of information that is required to carry out cognitive tasks such as learning, reasoning, and comprehending. Importantly, working memory is limited in capacity, in other words, in the amount of information that an individual can hold and manipulate at any one time (Baddeley, 1992; Was & Woltz, 2007). Research demonstrates that, as people age, working memory capacity declines (Salthouse, 2010). The presentation of health information can overburden a capacity-limited working memory because learning new information requires that older adults engage in increased mental effort (Velanova, Lustig, Jacoby, & Buckner, 2007).

In addition to declining working memory capacity among older adults, navigating through the healthcare system requires that individuals possess a minimal set of skills that allows them to effectively engage in healthcare encounters. These skills have been described as an individual's degree of "health literacy." Healthy People 2010 defines health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (Cutilli & Bennett, 2009, p. 2). Furthermore, it is known that both working memory (Salthouse, 2010) and health literacy decline (Baker, Gazmararian, Sudano, & Patterson, 2000) with advancing age.

Although much is known about how these factors independently influence older adults' ability to recall information, research investigating the effect of the interaction between working memory and health literacy on recall of information related to stroke is less well understood. Therefore, the purpose of the current study was to investigate working memory and health literacy, factors that have the potential to influence the recall of the signs of stroke in older adults. The successful recall of the signs of stroke could initiate prompt action to seek care and prevent the deleterious effects of stroke. Knowing if limitations in working memory and health literacy place the individual at greater risk for the inability to recall signs of stroke may alter the manner in which health messages are delivered to older adults.


Study Setting, Sample, and Measures

This descriptive pilot study was conducted at two senior citizen centers in the metropolitan New York City area. Study approval was obtained through the university's Human Subjects Protection Program and from the directors of the senior citizen centers. A convenience sample of 58 community dwelling adults was recruited, and all participants provided informed consent. To be included in the study, participants had to be 65 years old or older and can speak and read English. Exclusion criteria were (a) symptoms of depression, as indicated by a score greater than 6 on the Short Form of the Geriatric Depression Scale (Brown & Schinka, 2005); (b) signs of dementia indicated by a score of <24 on the Folstein Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975); (c) inadequate near vision as measured by visual screening using the standardized Rosenbaum Pocket screen greater than 20/50 (Horton & Jones, 1997); and (d) a self-reported history of stroke. Demographic information on age, gender, income, race, and years of schooling were obtained. Income was measured on a 4-point scale where increasing numbers indicates greater economic stress (0 = exceeds expenses, 1 = meets expenses, 2 = barely meets expenses, and 3 = does not meet expenses).

Study participants were individually tested by the study principal investigator and asked to read a two-page public service brochure that listed the five warning signs of stroke and actions that should be taken if a person experiences any of the signs (American Heart and Stroke Association, 2007). The five warning signs of stroke listed on the brochure are (a) sudden numbness or weakness of the face, arm, and leg, especially on one side of the body; (b) sudden confusion and trouble in speaking or understanding; (c) sudden trouble seeing in one or both eyes; (d) sudden trouble in walking, dizziness, loss of balance, or coordination; (e) sudden severe headache with no known cause. Participants were given as much time as needed to read the brochure and ask questions. Upon completion of the learning session, the brochures were collected. Participants were not told that they would be asked to recall the signs of stroke at the end of the study visit.

Following the learning session, working memory capacity was measured using the Wechsler Adult Intelligence Scale-III Working Memory Index, which is composed of three subtests, Mental Arithmetic (test-retest reliability = .86), Digits Span Forward (DSF), and Digits Span Backward (DSB; test-retest reliability = .83), and Letter-Number Sequencing (test-retest reliability = .75; Wechsler, 1997). Mental Arithmetic is a series of problems that must be solved mentally. Scores can range from 0 to 22. In DSF, the investigator recites a series of numbers and the participant repeats the numbers in the same order. In DSB, the investigator recites a series of numbers and the participant recites the numbers in reverse order. In both DSF and DSB, the numbers increase by one in each set of two. Therefore, as time goes on, the task becomes more difficult, requiring the individual to hold and, in the case of DSB, give back in the opposite order, the same digits. The range of scores combining DSF and DSB, the Digit Span raw score, is 0-30. The Letter-Number Sequencing subtest is a mix of numbers and letters. Participants are asked to order the randomly given letters and numbers sequentially. To perform this task, participants must remember the numbers and letters and recite them in sequential order. For example, if the numbers and letters were F3A, the correct response would be 3AF, the numbers first in order and then the letters in alphabetical order. The range on this task is 0-21. The Working Memory Index was created by first transforming each of the subtest scores to Z scores and then calculating the mean. This process allows for the comparison of scores obtained from different measures (Howell, 2008). The working memory testing took approximately 60 minutes to complete.

After the working memory testing, the Short Test of Functional Health Literacy in Adults (S-TOFHLA) was used to assess health literacy (Baker, Williams, Parker, Gazmararian, & Nurss, 1999). The test takes approximately 7 minutes to complete and is intended to determine participants' ability to read and understand health-related passages (Levinthal, Morrow, Tu, Wu, & Murray, 2008; Parker, Baker, Williams, & Nurss, 1995). The test requires participants to read a sentence and answer questions that measure their understanding. That is, participants are required to "fill in the blank" using a word from a list of options. The S-TOFHLA scores range from 0 to 36, with higher scores indicating better health literacy. Scores are divided into three levels of health literacy: adequate level of health literacy or can read and interpret most health texts (23-36), marginal health literacy or has difficulty reading and interpreting health texts (17-22), and inadequate health literacy or unable to read and interpret health texts (0-16; Baker et al., 1999).The S-TOFHLA is a widely used tool since the 1980s with previous studies documenting the reliability of the test at .97 (Baker et al., 1999). The test is shown to have high internal consistency (Cronbach's [alpha] = .98 for all items combined) and validity (r = .91).

The participant's ability to recall the warning signs of stroke were individually tested after the completion of all study-related data collection. There was, on average, a 1-hour lag time between participants' reading of brochure and request for recall. Participants were asked to recall the warning signs of stroke using the question, "What are the five warning signs of stroke?" Cues were not given at any point during the recall task, and there was no time limit to complete the task. With respect to recall testing, data were reported and coded as correct only if responses contained the key words listed on the brochure or if they contained alternative words or phrases that were closely associated with the key phrases in the brochure. For example, words and phrases that were coded as correct included "loss of feeling" for numbness, "can't move my arm" for extremity weakness, "problems walking" for loss of balance or coordination, "blurred vision" for trouble seeing, "slurred speech" for trouble speaking, and "migraine" for headache. At the completion of the study, participants were given the public service stroke brochure for future reference.


Participant Population

Fifty-eight participants were recruited for this study. There were no exclusions for dementia (MMSE scores) or depression (Geriatric Depression Scale scores). Two participants did not meet study criteria because of self-reported macular degeneration and problems with near vision and were given appropriate community referral for follow-up. Fifty-six participants completed the study. Demographic data were analyzed using descriptive statistics. Values are reported as means and standard deviations where indicated. The mean age of participants was 80.4 years. This was also a relatively well-educated group with a mean educational level of 14.2 years of education. A very small number of participants did not finish high school (n = 4, 7.1%), whereas 50% of participants completed at least some college (n = 28). All of the participants were White. Baseline characteristics of the sample are summarized in Table 1.

Recall of the Signs of Stoke

Recall of the signs of stroke was tested at the completion of the study when the participants were asked to list as many of the five signs of stroke as they could remember. The time between reading the list and later recall varied between 60 and 90 minutes. The mean number of the signs of stroke recalled was 2.9 ([+ or -] 1.33) with a range of 0-5 (Figure 1).

Working Memory

The mean score on the Mental Arithmetic subtest of the Working Memory Index was 10.71 (SD = 3.70) with a range of 6-21. The subtests DSF and DSB were combined to create the Digit Span raw score (Kaufman & Lichtenberger, 1999). The mean Digit Span raw score was 15.0 (SD = 4.10), with a range of 9-26. The Letter-Number Sequencing subtest mean score was 5.5 (SD = 2.86), with a range of 0-16. The reliability of the composite working memory score was calculated using the three Z-scored working memory scales using the reliability function in the SPSS statistical program. The composite working memory score range was -1.21 to 2.88 (SD = .88) and indicated good reliability ([alpha] = .86).

Health Literacy

The mean health literacy score (assessed with S-TOFHLA) was 25.4 (SD = 11.08) and ranged from 5 to 36, with a median score of 33. On this scale, a score of 23-36 represents adequate health literacy. A median score of 33 in this study reflects that over 50% of the sample had high health literacy.

Working Memory Index, Health Literacy, and Recall of Signs of Stroke

Correlations between the demographic variables (age, gender, educational attainment in years of formal schooling, self-reported income to meet expenses, and number of chronic illnesses) and working memory capacity, health literacy, and information recall of the five signs of stroke are found in Table 2. Recall was associated with working memory (r = .38, p < .01), health literacy(r = .44, p < .01), education (r = .36, p < .01), and dementia (r = .54, p < .01). Working memory was positively associated with education (r = .58, p < .01), income that meets expenses (r = -.34, p < .05), health literacy (r = .57, p < .01), and age (r = -.33, p < .05). Health literacy was also significantly related to educational attainment (r = .46, p < .01).

An important relationship that was examined was the interaction between working memory and health literacy on the recall of the signs of stroke. Therefore, linear regression was performed to examine the best predictor of recall of the warning signs of stroke given health literacy and working memory. This analysis indicated that health literacy remained significantly associated with recall of signs of stroke ([beta] = .56, p < .01; Table 3). It was hypothesized that there might be an interaction between working memory and health literacy on the recall of the signs of stroke, but this was not the case. However, the data indicate that there were no individuals who were 1 standard deviation above the mean with respect to working memory that were low on health literacy. Therefore, there is a restriction of range, that is, there are no individuals in this sample who scored high on working memory and low on health literacy (Figure 1). Interestingly, with additional regression analysis considering working memory, health literacy and dementia together, both health literacy ([beta] = .28, p < .05) and dementia ([beta] = .44, p < .01) were significantly associated with recall of signs of stroke (Table 4).


This study explored the associations between changes in cognition associated with cognitive aging, specifically working memory, health literacy, and recall of the five signs of stroke among community-dwelling older adults. The results of this study demonstrate that working memory and health literacy were significantly associated with recall of the signs of stroke. In regression analysis, including each variable and the interaction between health literacy and working memory, only health literacy remained a significant predictor of the recall of the warning signs of stroke. When the MMSE (dementia) was included in regression, health literacy remained a significant predictor of recall, but interestingly, dementia was more strongly associated with recall. The results provide support to the idea that working memory, health literacy, and dementia are important factors to consider when delivering stroke-related health information to older adults.


Research investigating working memory has shown that varying degrees of task difficulty or the amount of cognitive load that an individual experiences may influence the amount of information that can be held in mind at any one time (Smiler, Gagne, & Stine-Morrow, 2003). Advancing age is associated with declines in working memory capacity or the amount of information that can be held (stored) and manipulated (Bialystok & Craik, 2006). In a literature review, it was determined that no one had investigated the extent to which working memory capacity and health literacy influence recall of the signs of stroke among older adults.

An additional consideration in understanding the recall of health information is an individual's degree of health literacy. Health literacy is defined as the understanding of basic health information and the services needed to make appropriate health decisions (Nielsen-Bohlman, Panzer, & Kindig, 2004). The results of this study suggest that, in community dwelling older adults, health literacy is associated with the recall of signs of stroke.

In this study, educational levels were relatively high. Previous research indicates that education is an indicator of health literacy and is highly correlated with an individual's functional ability and reading level (Williams, Davis, Parker, & Weiss, 2002; Wolf et al., 2007). However, it has been reported that educational level alone cannot accurately predict ability to interpret information (Schwartzberg, VanGeest, & Wang, 2005). Interestingly, the data indicate that, although participants were screened for dementia and were determined not to have dementia, as indicated by a score of less than 24 on the MMSE, the MMSE was nonetheless significantly associated with recall and that MMSE predicted recall when considered together with working memory and health literacy. The relationship between dementia, as measured by MMSE, and the recall of the signs of stroke in community-dwelling older adults has not been previously reported and is worthy of further investigation.

Ultimately, the inability to recall signs of stroke may represent delays in seeking care. Previous studies related to delays in seeking care have not been consistently associated with gender, age, education, or employment (Azzimondi et al., 1997; Bouckaert, Lemmens, & Thijs, 2009; Teuschl & Brainin, 2010). Mixed results have been reported for income, ethnicity, and living alone (Kim, Ahn, Kim, & Hong, 2010; Menon, Pandey, & Morgenstern, 1998a, 1998b; Smith et al., 1998). Stronger associations have been reported for time of day and day of week (Smith et al., 1998; Wester, Radberg, Lundgren, & Peltonen, 1999). One study reported that patients with known risk factors such as hypertension, previous stroke, or transient ischemic attack and those with severe symptoms were more likely to seek immediate care (Ayala et al., 2003; Moser et al., 2006). Taken together, these results indicate that few factors are consistently associated with delay in seeking care. The current study provides support for the idea that the complex interplay of cognitive factors and health literacy before experiencing stroke may contribute to delays in seeking care.


The generalizability of the study is limited as only elders in senior centers in urban centers were recruited. The sample also limits the generalizability of findings to other ethnicities and persons with lower income and education. Furthermore, it is possible that the higher average age in this study influenced the finding that the MMSE, a measure of dementia, was a predictor of recall. In younger populations, MMSE scores are not as strong a predictor of recall as working memory (Friedman, Yelland, & Robinson, 2012; Palladino & De Beni, 1999). In this study, we did not differentiate between transient ischemic attack and stroke and we did not test whether working memory or health literacy was associated with recall of the actions to take (i.e., calling 9-1-1) if the signs of transient ischemic attack or stroke were indeed identified. Although this study specifically focused on working memory, we recognize that memory is complex and that other cognitive factors such as (but not limited to) speed of processing, attention, and comprehension are important and could be examined in larger future studies.


The failure to recall important health messages can lead to disability impacting quality of life and causing increases in the cost of caring for seniors (National Center for Chronic Disease Prevention and Health Promotion, 2004). Despite numerous community educational programs that have focused on the signs of stroke, the problem in delay in seeking care persists (Giles et al., 2006; Kleindorfer et al., 2009; Sprigg et al., 2009). The results of this study provide new data to support the notion that working memory and health literacy are associated with recall of the signs of stroke in older adults. The study provides a foundation for future research efforts examining the content and the manner in which we deliver and evaluate health messages about transient ischemic attack and stroke.


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Questions or comments about this article may be directed to Christine A. Ganzer, PhD RN, at She is an assistant professor at Hunter College, New York, NY.

Kathleen C. Insel, PhD RN, is an associate professor at University of Arizona, Tucson, AZ.

Leslie S. Ritter, PhD RN FAAN, is a professor at College of Nursing and Department of Neurology, William M. Feinberg Endowed Chair for Stroke Research, University of Arizona, Tucson, AZ.

The authors declare no conflicts of interest.

DOI: 10.1097/JNN.0b013e3182666231
Demographics and Descriptive Statistics of
the Sample (N = 56)

Variable               M (SD)       Range

Age, years           80.4 (7.95)    68-99
Education, years     14.2 (3.46)    8-22
Female, %            70
White, %            100
MMSE                 27.4 (1.72)    24-30
GDS-SF               0.98 (1.27)     0-4
S-TOFHLA            25.46 (11.08)   5-36

Note. MMSE = Mini-Mental State Examination; GDS-SF =
Geriatric Depression Scale-Short Form; S-TOFHLA =
Short Test of Functional Health Literacy Adults.

TABLE 2. Zero Order Correlations

Variables    Recall    S-TOFHLA   WMI       Age      Education   MMSE

S-TOFHLA      .44 **
WMI           .38 **    .57 **
Age          -.05      -.16       -.33 *
Education     .36 **    .46 **     .58 **   -.33 *
MMSE          .54 **    .38 **     .53 **   -.21      .50 **
Income       -.25      -.21       -.34 **    .09     -.36 **     -.24
Chronic       .18       .11        .07       .28 *   -.01         .06

Variables    Income

Chronic        -.07

Note. S-TOFHLA = Short Test of Functional Health Literacy Adults;
WMI = Working Memory Index; MMSE = Mini-Mental State Examination;
Chronic = number of chronic illnesses.

* p < .05. **p < .01.

Simultaneous Regression With S-TOFHLA and Working Memory Index

Variable                  B       SE        Beta       t Score

S-TOFHLA                 0.067   .025       .56         2.72 **
Working Memory Index    -1.078   .891      -.72        -1.21
S-TOFHLA x Working       0.041   .026       .83         1.58
 Memory Index

Note. S-TOFHLA = Short Test of Functional Health Literacy Adults.

** p < .01.

TABLE 4. Regression With STOFHLA and Working Memory Index and MMSE

Variable                   B       SE       Beta       t Score

S-TOFHLA                  0.034   .016       -.013       2.040
Working Memory Index     -0.020   .224        .278      -0.088
MMSE                      0.343   .102        .444       3.363

Note. S-TOFHLA = Short Test of Functional Health Literacy
Adults; MMSE = Mini-Mental State Examination.

** p < .01.
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