Self-awareness in Mild Cognitive Impairment: Quantitative evidence from systematic review and meta-analysis

Impact of AI-Powered Solutions in Rehabilitation Process: Recent Improvements and Future Trends

Rehabilitation is an important and necessary part of local and global healthcare services along with treatment and palliative care, prevention of disease, and promotion of good health. The rehabilitation process helps older and young adults even children to become as independent as possible in activities of daily life and enables participation in useful living activities, recreation, work, and education. The technology of Artificial Intelligence (AI) has evolved significantly in recent years. Many activities related to rehabilitation have been getting benefits from using AI techniques. The objective of this review study is to explore the advantages of AI for rehabilitation and how AI is impacting the rehabilitation process. This study aims at the most critical aspects of the rehabilitation process that could potentially take advantage of AI techniques including personalized rehabilitation apps, rehabilitation through assistance, rehabilitation for neurological disorders, rehabilitation for developmental disorders, virtual reality rehabilitation, rehabilitation of neurodegenerative diseases and Telerehabilitation of Cardiovascular. We presented a survey on the newest empirical studies available in the literature including the AI-based technology helpful in the Rehabilitation process. The novelty feature included but was not limited to an overview of the technological solutions useful in rehabilitation. Seven different categories were identified. Illustrative examples of practical applications were detailed. Implications of the findings for both research and practice were critically discussed. Most of the AI applications in these rehabilitation types are in their infancy and continue to grow while exploring new opportunities. Therefore, we investigate the role of AI technology in rehabilitation processes. In addition, we do statistical analysis of the selected studies to highlight the significance of this review work. In the end, we also present a discussion on some challenges, and future research directions.

Anosognosia in Alzheimer's Pathology: Validation of a New Measure

OBJECTIVE

Two studies were performed to validate a brief measure of cognitive insight and compare it to an empirical model - the Cognitive Awareness Model (CAM).

METHOD

A pilot study included 31 (52% male; Mage = 69.42) patients from an outpatient neuropsychological assessment clinic. Seven patients were diagnosed with likely Alzheimer's dementia (AD), 15 mild cognitive impairment (MCI), and 9 no diagnosis (i.e., cognitively normal; CN). The Cognitive Coding Form (CCF) and several other measures were administered. Study 2 entailed archival data extraction of 240 patients (80 CN, 80 MCI, and 80 AD; 53.3% female; Mage = 72.8) to examine whether the CCF predicts memory (Wechsler Memory Scale - IV) and executive functioning (Trail-Making Test B).

RESULTS

The pilot study found preliminary evidence of convergent and discriminant validity for the 8-item CCF. Study 2 confirmed that both patient-reported cognitive concerns (F(2,237) = 10.40, p < .001, ω2 = .07, power = .99) and, more strongly, CCF informant-patient discrepancy scores (F(2,237) = 24.52, p < .001, ω2 = .16, power = .99) can distinguish CNs from those with MCI and AD. A regression indicated that depression (5.5%; β = -.38, p < .001) and TMT-B (13%; β = -.43, p < .001), together accounted for 18.5% of the variance in insight (R2 = .19, F(2,219) = 26.10, p < .001), supporting the CAM.

CONCLUSIONS

These studies establish an efficient measure of insight with high clinical utility and inform the literature on the role of insight in predicting performance in those with Alzheimer's pathology.

Olfactory and cognitive decrements in 1991 Gulf War veterans with gulf war illness/chronic multisymptom illness

BACKGROUND

Gulf War illness (GWI)/Chronic Multisymptom Illness (CMI) is a disorder related to military service in the 1991 Gulf War (GW). Prominent symptoms of GWI/CMI include fatigue, pain, and cognitive dysfunction. Although anosmia is not a typical GWI/CMI symptom, anecdotally some GW veterans have reported losing their sense smell shortly after the war. Because olfactory deficit is a prodromal symptom of neurodegenerative diseases like Parkinson's and Alzheimer's disease, and because we previously reported suggestive evidence that deployed GW veterans may be at increased risk for Mild Cognitive Impairment (MCI) and dementia, the current study examined the relationship between olfactory and cognitive function in deployed GW veterans.

METHODS

Eighty deployed GW veterans (mean age: 59.9  ±7.0; 4 female) were tested remotely with the University of Pennsylvania Smell Identification Test (UPSIT) and the Montreal Cognitive Assessment (MoCA). Veterans also completed self-report questionnaires about their health and deployment-related exposures and experiences. UPSIT and MoCA data from healthy control (HC) participants from the Parkinson's Progression Markers Initiative (PPMI) study were downloaded for comparison.

RESULTS

GW veterans had a mean UPSIT score of 27.8  ± 6.3 (range 9-37) and a mean MoCA score of 25.3  ± 2.8 (range 19-30). According to age- and sex-specific normative data, 31% of GW veterans (vs. 8% PPMI HCs) had UPSIT scores below the 10th percentile. Nearly half (45%) of GW veterans (vs. 8% PPMI HCs) had MoCA scores below the cut-off for identifying MCI. Among GW veterans, but not PPMI HCs, there was a positive correlation between UPSIT and MoCA scores (Spearman's ρ = 0.39, p < 0.001). There were no significant differences in UPSIT or MoCA scores between GW veterans with and without history of COVID or between those with and without Kansas GWI exclusionary conditions.

CONCLUSIONS

We found evidence of olfactory and cognitive deficits and a significant correlation between UPSIT and MoCA scores in a cohort of 80 deployed GW veterans, 99% of whom had CMI. Because impaired olfactory function has been associated with increased risk for MCI and dementia, it may be prudent to screen aging, deployed GW veterans with smell identification tests so that hypo- and anosmic veterans can be followed longitudinally and offered targeted neuroprotective therapies as they become available.

Know thyself: Executive functioning and sex predict self-appraisal of functional abilities in community-dwelling older adults

Objective: The capacity for accurate self-appraisals of age-related changes in cognitive and functional abilities is integral to the maintenance of independence in later life, yet there is little understanding of the factors that place nondemented older adults at risk for poor self-awareness. This study examined the potential contributions of executive functioning (EF), crystallized intelligence (IQ-Cr), and sex in predicting congruence between performance and self-appraisals of instrumental activities of daily living (IADL) in a group of community-dwelling older adults. Method: A group of 150 nondemented, community-dwelling older adults (White and majority highly educated) completed measures of EF and IQ-Cr. Participants also completed five timed IADL tasks and self-appraised their performance relative to others of similar age. Results: Sex [F(1,148)  =  7.75, p = .006, ηp2 = .05] and EF [(F(1,147) = 5.30, p = .02, ηp2 = .04)], but not IQ-Cr, predicted the relationship between performance and self-appraisals, such that those with lower EF and those of male sex overestimated their performance more than those with higher EF and females. Conclusions: Findings indicate that having average to below average EF abilities and being of male sex are risk factors for less accurate self-report of IADL abilities and as such might represent important considerations when assessing IADL abilities via self-report among largely independent, community-dwelling older adults.

Metacognitive Differences in Amnestic Mild Cognitive Impairment and Healthy Cognition: A Cross-Sectional Study Employing Online Measures

This study aimed to examine metacognitive abilities in individuals diagnosed with amnestic mild cognitive impairment (aMCI) by using online metacognitive measures during cognitive tasks. A total of 100 participants were enrolled, all aged 50 or older (mean age = 61.98; SD = 6.27), and with a minimum of six years of education (mean = 14.95; SD = 2.94). The sample included 50 individuals with aMCI (34 females) and 50 healthy controls (HC) (33 females). Both groups underwent metacognitive versions of memory tasks (Doors and People) and executive functions tasks (Wisconsin Card Sorting Test). Metacognition was assessed through confidence ratings given after each answer (referred to as metacognitive monitoring) and the accuracy of the participants' decisions to include or exclude answers from their final scores (known as metacognitive control). The results showed that although individuals with aMCI were aware of their cognitive limitations-evidenced by their lower confidence ratings across all tasks-they still exhibited overconfidence relative to their actual performance. Moreover, they included a greater number of incorrect answers in their final scores compared to the healthy control group. These findings suggest that while individuals with aMCI retain some level of awareness, their self-evaluations appear to lack precision. This observation was consistent across both types of cognitive tasks. The results underscore the need for additional research to better understand metacognition in MCI as well as the interplay between metacognitive monitoring and control.

Brain Volumes and Metacognitive Deficits in Knowledge of Self, Task and Strategies in Mathematics: A Preliminary Pilot One-Year Longitudinal Study in aMCI Patients Compared to Healthy Controls

Metacognitive knowledge has been little investigated in aMCI patients. The aim of this study is to examine whether there are specific deficits in knowledge of self, task and strategies in mathematical cognition, due its importance for everyday functioning, mainly due to its importance for financial capacity in old age. A total of 24 patients with a diagnosis of aMCI and one-to-one 24 matched individuals (similar age, education and gender) were examined at three time points in a year with a number of neuropsychological tests and a slightly modified version of the Metacognitive Knowledge in Mathematics Questionnaire (MKMQ). We analyzed longitudinal MRI data regarding various brain areas for the aMCI patients. Results indicated that the aMCI group differed in all MKMQ subscale scores at the three time points compared to healthy controls. Correlations were found only for metacognitive avoidance strategies and left and right amygdala volumes at baseline, while after twelve months correlations were found for avoidance and right and left parahippocampal volumes. These preliminary results highlight the role of specific brain regions that could be used as indices in clinical practice for the detection of metacognitive knowledge deficits that are found in aMCI.

Everyday function profiles in prodromal stages of MCI: Prospective cohort study

INTRODUCTION

The nature and course of limitations in everyday function in the early clinical stages of cognitive decline is not well known.

METHODS

We compared complex everyday functional profiles at baseline in 59 community-dwelling older individuals with normal cognitive performance who went on to develop incident mild cognitive impairment (MCI) ("pre-MCI") with 284 older individuals who remained cognitively normal over follow-up.

RESULTS

The mean number of limitations on complex everyday function at baseline was 3.1 ± 3.0 in the 59 pre-MCI cases and 2.0 ± 2.4 in the 284 normal controls (P = .003). Pre-MCI cases had limitations in traveling, entertaining, remembering appointments, and hobbies compared to normal controls. A progressive increase in mild limitations on complex everyday function preceded the incidence of MCI (mean change: pre-MCI 1.9 ± 3.6 vs normal controls 0.5 ± 2.7, P < .001).

DISCUSSION

Prodromal stages of MCI are associated with progressive mild limitations in complex activities of daily living.

An application study-subjective cognitive decline Questionnaire9 in detecting mild cognitive impairment (MCI)

Objective: Subjective cognitive decline (SCD) complaints as the early manifestation of mild cognitive impairment (MCI) may be harbingers of objective cognitive decline. SCD-questinnaire9 (SCD-Q9) is developed to investigate the early sign for MCI. However, few studies have reported its power for discriminating MCI from healthy controls (HCs). Therefore, this study aims to investigate the discrimination power of SCD-Q9 as a brief screening tool for early detection of SCD in MCI.Methods: 84 HCs and 205 people with MCI were recruited. Their demographic information and scores of SCD-Q9 were compared. A binary logistic regression model was used to analyze the potential affecting factors of MCI, and the Receiver Operating Characteristic analysis was applied to test the discrimination powers of those factors, including SCD-Q9.Results: (1) Single and total scores of SCD-Q9 were all lower in the MCI group than those in the HC group. (2) Ageing, lower education and higher total scores of SCD-Q9 were associated with MCI. (3) Area Under the Curves (AUC) of SCD-Q9 for discriminating MCI from HC group was 0.815 and when integrating age and education, the AUC improved slightly and reached 0.839. Additionally, the sensitivity and specificity were 68.8% and 85.7%, respectively when a cut-off value of 3 was applied. Conclusions: SCD-Q9 may be able to detect the subjective cognitive decline in MCI early, but it may be used together with other screening questionnaires to improve its sensitivity and further verification of its power is needed.

Correlates of subjective and objective everyday functioning in middle-aged and older adults with human immunodeficiency virus

People with human immunodeficiency virus (HIV) (PWH) are at an increased risk for impaired everyday functioning and they may also experience poor awareness of their functional status. This study identified factors associated with (1) subjective and objective instrumental activities of daily living (IADLs) and (2) awareness of functional capacity in PWH. In this cross-sectional study, 236 PWH completed a neurobehavioral assessment, including self-report and performance-based measures of IADLs. Multiple regressions were performed to identify demographic, personality, and cognitive factors contributing to subjective and objective evaluation of everyday functioning, as well as discrepancy between self-report and performance-based measures of IADLs. Results indicated that increased depression was associated with worsened self-report of everyday functioning but not performance of IADLs. Cognitive function and age were associated with IADL performance. Most participants (58.1%) demonstrated a discrepancy between self-report and actual performance of IADLs. Worse processing speed was correlated with greater discrepancy. Inaccurate self-reporters had worse overall cognitive functioning and lower levels of personality traits, including openness, conscientiousness, and agreeableness. In conclusion, self-report and actual performance of IADLs in PWH is influenced by different factors. Self-report may be more affected by psychological variables, such as mood and personality, while actual performance is more sensitive to age and cognitive function.

Self-Awareness of Cognitive Efficiency, Cognitive Status, Insight, and Financial Capacity in Patients with Mild AD, aMCI, and Healthy Controls: An Intriguing Liaison with Clinical Implications?

Objectives: This study compares objective measures of cognitive performance with subjective perception of specific performance on neuropsychological tests examining basic cognitive domains, including, for the first time, financial capacity. Additionally, differences in assessment between single- and multiple-domain aMCI, mild AD, and healthy elderly regarding insight are examined. Methods: Participants completed a number of neuropsychological tests and the Legal Capacity for Property Law Transactions Assessment Scale (LCPLTAS). After every test, participants were asked to complete the Clinical Insight Rating scale (CIR) and to self-evaluate their performance by comparing it to what they considered as average for people of their age and educational level. Results: These preliminary findings show significant differences in the self-assessment patterns of the four groups in measures of verbal memory, visuospatial perception and memory, executive functions, tests of attention, and financial capacity. Mild AD expressed the highest overestimations, followed by single- and multiple-domain aMCI as well as controls. Accuracy of self-report is not uniform across groups and functional areas. Conclusions: Unawareness of memory deficits in both MCI subtypes is contradictory to subjective memory complaints as being an important component for clinical diagnosis. Financial capacity is overestimated in MCI and mild AD, a finding that has a plethora of clinical and legal implications.

Differential Patterns of Domain-Specific Cognitive Complaints and Awareness Across the Alzheimer's Disease Spectrum

Background: Characterizing self- and informant-reported cognitive complaints, as well as awareness of cognitive decline (ACD), is useful for an early diagnosis of Alzheimer's disease (AD). However, complaints and ACD related to cognitive functions other than memory are poorly studied. Furthermore, it remains unclear which source of information is the most useful to distinguish various groups on the AD spectrum. Methods: Self- and informant-reported complaints were measured with the Everyday Cognition questionnaire (ECog-Subject and ECog-StudyPartner) in four domains (memory, language, visuospatial, and executive). ACD was measured as the subject-informant discrepancy in the four ECog scores. We compared the ECog and ACD scores across cognitive domains between four groups: 71 amyloid-positive individuals with amnestic AD, 191 amnestic mild cognitive impairment (MCI), or 118 cognitively normal (CN), and 211 amyloid-negative CN controls, selected from the ADNI database. Receiver operating characteristic curves analysis was performed to evaluate the accuracy of the ECog and ACD scores in discriminating clinical groups. Results: Self- and informant-reported complaints were generally distributed as follows: memory, language, executive, and visuospatial (from the most severe to the least severe). Both groups of CN participants presented on average more memory and language complaints than their informant. MCI participants showed good agreement with their informants. AD participants presented anosognosia in all domains, but especially for the executive domain. The four ECog-StudyPartner sub-scores allowed excellent discrimination between groups in almost all classifications and performed significantly better than the other two classifiers considered. The ACD was excellent in distinguishing the participants with AD from the two groups of CN participants. The ECog-Subject was the least accurate in discriminating groups in four of the six classifications performed. Conclusion: In research, the study of complaint and anosognosia should not be reduced solely to the memory domain. In clinical practice, non-amnestic complaints could also be linked to Alzheimer's disease. The presence of an informant also seems necessary given its accuracy as a source of information.

Ability of older adults to recognize cognitive changes and its relationship with mental health: a cross-sectional study

INTRODUCTION

With rising age, the incidence of physical and mental problems increases. Physiological and social changes occur across the lifespan that can affect an individual's health and ability. The present study was aimed to determine older adult's ability to recognize cognitive changes and its relation with mental health status.

MATERIALS AND METHODS

A descriptive correlational design was used to recruit 423 older adults who were referred to health centers in Tabriz, Iran in 2019 to receive primary health care. A systematic random sampling method was used for selecting participants. Data collection tools included a demographic-social questionnaire, General Health Questionnaire for assessing mental health (with 4 subscales) and a questionnaire of ability to recognize cognitive changes (with 8 sub-scales). Data were analyzed using descriptive statistics and inferential statistics.

RESULTS

The mean score of mental health of the older adults was 56.35 (8.40) which shows moderately impaired mental health. The most impaired aspect of mental health detected was the social function dimension 13.20 (2.67). The average of the total ability score was 41.19 (4.78) and the physical strength dimension had the highest average of 9.08 (1.80) and the empowerment obligation dimension had the lowest average of 3.06 (1.08). There was significant relationship between dimensions of depression (r = 0.21, p < 0.001), anxiety (r = 0.1, p = 0.04) and social functioning (r = 0.17), p < 0.001) with the ability to recognize cognitive changes of the older adults.

CONCLUSION

Negative mood states and social functioning were associated with the ability to recognize cognitive changes in this population of older adults. This sample exhibited moderately impaired mental health status and relatively large burdens of untreated affective symptoms. Although causality cannot be determined with this cross-sectional design, use of social programs to keep older adults mentally active, as well as cognitive rehabilitation programs could be tested with longitudinal designs for their impact on cognitive change recognition.

Effects of dyadic discrepancy in awareness of mild cognitive impairment on changes in care partner's burden over time

Objectives:This study explored interpersonal aspects of coping with mild cognitive impairment (MCI), focusing on how shared illness representations between persons with MCI (PwMCI) and their care partners (CPs) are associated with CP perceived burden.Method:Longitudinal data from a purposive sample of 69 MCI care dyads were analyzed using descriptive statistics, t-tests, intraclass correlations, and regression analyses.Results: CP perceived their PwMCI's deficits in MCI-related functions as more negative than PwMCI rated themselves, but the extent of the discrepancy varied across cognitive and behavioral abilities. The discrepancy in dyadic appraisal of PwMCI functioning was associated significantly with CP burden.Conclusion: The findings highlight the value of shared PwMCI and CP perspectives on cognitive functioning for MCI management and psychological adjustment.

Cognitive function in patients undergoing cystectomy for bladder cancer – results from a prospective observational study

Background:

Impaired cognitive function of bladder cancer patients plays a role in coping with the kind of urinary diversion and may impact perioperative morbidity. In this study we therefore aimed to assess the prevalence of mild cognitive impairment in patients undergoing radical cystectomy. Secondary objectives included correlation of common cognition tests, assessment of the admitting physician, and perioperative complication rates.

Methods:

Patients undergoing radical cystectomy for bladder cancer were prospectively screened by neuropsychological tests including cognition tests [DemTect (Dementia Detection test), MMSE (Mini-Mental State Examination), clock drawing test] prior to surgery. Besides, clinical characteristics and perioperative outcomes were documented. Frequency of mild cognitive impairment as assessed by DemTect was correlated with the results of MMSE and clock drawing test, the occurrence of anxiety and depression, the assessment of the admitting physician, and perioperative complication rates as calculated by Spearman rank correlation coefficient. Comparative analysis (parametric and nonparametric) of patient characteristics (nonpathological versus pathological DemTect suggestive of mild cognitive impairment) was performed.

Results:

A total of 51 patients (80% male, median age 69 years) were analyzed. DemTect was suspicious of mild cognitive impairment in 27% (14/51) of patients, whereas MMSE and clock drawing test showed pathological results only in 10/51 and 6/51 patients, respectively. We found no correlation between mild cognitive impairment and anxiety/depression status. In all, 5/20 patients (25%) with suspicious DemTect results were considered suitable for a continent diversion neobladder by the admitting physician. Suspicious DemTect results were predictive for higher perioperative complication rates (29% versus 5%). Study limitations include small sample size and missing long-term follow-up.

Conclusions:

Mild cognitive impairment was observed in more than a quarter of radical cystectomy patients prior to surgery. Preoperative assessment should be supplemented by neuropsychological testing such as the DemTect as mild cognitive impairment is often underestimated and associated with significantly higher perioperative complication rates.

Prospective Metamemory Monitoring of Episodic Visual Memory in Community-Dwelling Older Adults with Subjective Cognitive Decline and Mild Cognitive Impairment

OBJECTIVE

Metamemory tasks have been utilized to investigate anosognosia in older adults with dementia, though previous research has not systematically compared memory self-awareness in prodromal dementia groups. This represents an important oversight given that remedial and interventional efforts may be most beneficial before individuals' transition to clinical dementia. We examine differences in memory self-awareness and memory self-monitoring between cognitively healthy elderly controls and prodromal dementia groups.

METHODS

Participants with subjective cognitive decline despite intact objective neuropsychological functioning (SCD; n = 82), amnestic mild cognitive impairment (aMCI; n = 18), nonamnestic mild cognitive impairment (naMCI; n = 38), and normal cognitive functioning (HC; n = 120) were recruited from the Einstein Aging Study for a cross-sectional study. Participants completed an experimental visual memory-based global metamemory prediction task and subjective assessments of memory/cognition and self-awareness.

RESULTS

While, relative to HC, memory self-awareness and memory self-monitoring were preserved for delayed memory performance in SCD and aMCI, these processes were impaired in naMCI. Furthermore, results suggest that poor metamemory accuracy captured by our experimental task can be generalized to everyday memory problems.

CONCLUSIONS

Within the framework of the Cognitive Awareness Model, our findings provide preliminary evidence that poor memory self-awareness/self-monitoring in naMCI may reflect an executive or primary anosognosia, with implications for tailored rehabilitative interventions.

The Seven Selves of Dementia

The self is a complex and multifaceted phenomenon, encompassing a variety of cognitive processes and psychosocial influences. Considering this, there is a multiplicity of "selves," the current review suggesting that seven fundamental self-processes can be identified that further our understanding of the experience of dementia. These include (1) an embodied self, manifest as corporeal awareness; (2) an agentic self, related to being an agent and influencing life circumstances; (3) an implicit self, linked to non-conscious self-processing; (4) a critical self, which defines the core of self-identity; (5) a surrogate self, based on third-person perspective information; (6) an extended self, including external objects or existences that are incorporated into the self; and, finally, (7) an emergent self, a property of the self-processes that give rise to the sense of a unified self. These are discussed in relation to self-awareness and their use in making sense of the experience of dementia.

White matter network disruption and cognitive correlates underlying impaired memory awareness in mild cognitive impairment

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Episodic memory deficits are insufficient for explaining memory anosognosia in MCI.

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Reasoning ability can be used as a basis for identifying memory anosognosia in MCI.

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Memory anosognosia in MCI is a white matter disconnection syndrome.

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Frontal-subcortical and callosal fibers are linked to memory anosognosia in MCI.

Decreased awareness of memory declines in mild cognitive impairment (MCI) has been linked to structural or functional changes in a wide gray matter network; however, the underlying white matter pathway correlations for the memory awareness deficits remain unknown. Moreover, consistent findings have not been obtained regarding the cognitive basis of disturbed awareness of memory declines in MCI. Due to the methodological drawbacks (e.g., correlational analysis without controlling confounders related to clinical status, a problem related to the representativeness of the control group) of previous studies on the aforementioned topic, further investigation is required. To addressed the research gaps, this study investigated white matter microstructural integrity and the cognitive correlates of memory awareness in 87 older adults with or without mild cognitive impairment (MCI). The patients with MCI and healthy controls (HCs) were divided into two subgroups, namely those with normal awareness (NA) and poor awareness (PA) for memory deficit, according to the discrepancy scores calculated from the differences between subjective and objective memory evaluations. Only the results for HCs with NA (HC-NA) were compared with those for the two MCI groups (i.e., MCI-NA and MCI-PA). The three groups were matched on demographic and clinical variables. An advanced diffusion imaging technique—diffusion spectrum imaging—was used to investigate the integrity of the white matter tract. The results revealed that although the HC-NA group outperformed the two MCI groups on several cognitive tests, the two MCI groups exhibited comparable performance across different neuropsychological tests, except for the test on reasoning ability. Compared with the other two groups, the MCI-PA group exhibited lower integrity in bilateral frontal-striatal fibers, left anterior thalamocortical radiations, and callosal fibers connecting bilateral inferior parietal regions. These results could not be explained by gray matter morphometric differences. Overall, the results indicated that mnemonic anosognosia was not sufficient to explain the memory awareness deficits observed in the patients with MCI. Our brain imaging findings also support the concept of anosognosia for memory deficit as a disconnection syndrome in MCI.

Anosognosia in Mild Cognitive Impairment: Lack of Awareness of Memory Difficulties Characterizes Prodromal Alzheimer's Disease

While anosognosia is often present in Alzheimer's disease, the degree of awareness of cognitive difficulties in the earlier stages, such as Mild Cognitive Impairment (MCI), is less clear. Using a questionnaire and Feeling-of-Knowing tasks, the aims of this study were (1) to test the hypothesis that anosognosia is present specifically in prodromal AD stage in patients that, owing to a more severe AD neuropathology, will rapidly progress to overt dementia and (2) to assess the neural bases of self-awareness for memory functioning. A group of 44 patients with amnestic MCI and a group of 29 healthy older participants (CTRL) performed two Feeling-of-Knowing tasks (episodic and semantic FOK) and responded to the Functional Memory Scale (MARS), also completed by one of their relatives. They underwent FDG-PET and structural MRI. The participants were followed clinically for 4 years. At the end of follow-up, 23 patients with MCI developed Alzheimer's disease (converters) and 21 patients still presented symptoms of MCI without progression (non-converters). The analyses focused on the data from inclusion stratified according to clinical status 4 years later (converters, non-converters, CTRL). On the episodic FOK task, converters patients overestimated their ability to later recognize unrecalled words and they showed prediction accuracy (Hamann coefficient) at the level of chance. No difficulty was observed in any group with the semantic FOK task. On the MARS, converters patients had a higher anosognosia score than non-converters patients and CTRL, which did not differ from each other. Correlations between self-awareness scores and neuroimaging data using small volume correction analyses in a priori regions of interest in converters indicated that inaccurate episodic FOK judgments was related to changes in brain areas that might support interpretation of retrieved content for judging the likelihood of recognition. For the MARS, the association between anosognosia and decreased gray matter density of the left inferior prefrontal cortex in converters might indicate poor inhibition over outdated personal knowledge. In amnestic MCI, anosognosia could be an early sign of neurodegeneration in brain areas that would support control mechanisms over memory representations.

Neuropsychological Correlates of Anosognosia for Objective Functional Difficulties in Older Adults on the Mild Cognitive Impairment Spectrum

OBJECTIVE

To examine the neuropsychological correlates of anosognosia for instrumental activities of daily living (IADLs) in older adults with mild cognitive impairment (MCI) and mild dementia.

METHOD

Participants (n = 103; age range = 54-88, 52% female) with MCI and mild dementia were recruited from neurology and geriatrics clinics for cross-sectional analysis. They completed neuropsychological tests along with subjective and performance-based assessments of six IADLs: financial management, driving, grocery shopping, nutrition evaluation, telephone use, and medication management. For each IADL, participants were classified as having anosognosia when there was objective difficulty but no subjective complaints.

RESULTS

Depending on functional domain, 13-39% of the sample had objective IADL difficulty, and of those, 65-93% lacked insight into these deficits. Binomial logistic regression models controlling for demographic variables revealed that measures of global cognition, executive function, visual attention, and verbal memory predicted classification of anosognosia, and these relationships varied across IADLs. In contrast, basic auditory attention, working memory, depressive symptoms, nor cognitive reserve were significantly related to anosognosia for any IADL.

CONCLUSION

Results support the Conscious Awareness Model, which theorizes that accurate metacognitive output is reliant on attentional, memory, and executive functioning systems. Findings from this study suggest that anosognosia for different IADLs may arise from breakdowns at varying points in this model, explaining both inter- and intra-patient variability in self-awareness of functional deficits.

Retrospective metamemory monitoring of semantic memory in community-dwelling older adults with subjective cognitive decline and mild cognitive impairment

In neurodegenerative conditions, better memory/cognitive awareness, indexed by greater "metamemory monitoring accuracy", is linked to stronger cognitive remediation outcomes. Differences in metamemory monitoring accuracy in predementia conditions, which could inform treatment effectiveness, have not been systematically investigated. We utilized a retrospective confidence judgment (RCJ) task for general knowledge recognition in community-dwelling older adults: 106 cognitively healthy (HC), 68 subjective cognitive decline (SCD) despite intact neuropsychological function, 14 amnestic mild cognitive impairment (aMCI), and 31 non-amnestic mild cognitive impairment (naMCI). Participants gave confidence ratings after making recognition responses to general knowledge questions. Recognition accuracy, confidence levels, and absolute and relative RCJ accuracy (i.e., metamemory monitoring accuracy) were analysed. Compared to HC and SCD, absolute RCJ accuracy was significantly poorer in both MCI groups but relative RCJ accuracy was significantly poorer in naMCI, but not aMCI. This novel result may be driven by lower confidence for correct recognition responses in naMCI and suggests that poorer RCJ accuracy in naMCI may be attributable to poorer performance monitoring. We discuss results in relation to the possibility that individuals in distinct preclinical dementia conditions, who have different levels of memory/cognitive awareness, may differentially benefit from cognitive remediation strategies tailored to their levels of memory/cognitive awareness.

Wayfinding Strategies and Spatial Anxiety in Older Adults With and Without Alzheimer's Disease

Persons with Alzheimer's disease (AD) often experience problems finding their way (i.e., wayfinding) even in familiar locations. One possible explanation for wayfinding impairments in persons with AD is that they use different wayfinding strategies than persons without AD; and these strategies may be ineffective. The current study examined differences in wayfinding strategies and spatial anxiety in older adults with and without early-stage AD, as well as the effect gender has on both variables. Older adults with normal cognition (n = 50) and adults with early stage AD (n = 38) completed a demographic survey, cognitive tests, the Wayfinding Strategies Scale, and the Spatial Anxiety Scale. Results indicated that adults with normal cognition used significantly more orientation strategies (t [85] = 2.54, p = 0.013) than adults with AD, and men (n = 37) used significantly more orientation strategies than women (n = 51; t [85] = 2.41, p = 0.018). Participants with AD rated their spatial anxiety significantly higher than adults with normal cognition (n = 51; t [84] = -3.89, p < 0.001). Orientation strategy use was inversely related to spatial anxiety (r = -0.434, p < 0.001). These findings suggest that persons with early-stage AD may use fewer wayfinding strategies and have higher wayfinding-related anxiety compared to adults without AD. [Research in Gerontological Nursing, 13(2), 91-101.].

Changes in Activity Participation Among Older Adults With Subjective Cognitive Decline or Objective Cognitive Deficits

Participation in daily activities is crucial for healthy aging. There is limited research on participation of older adults with subjective cognitive decline (SCD), defined as the experience of cognitive deficits with no evidence of objective cognitive deficits. Therefore, this study examined perceived changes in participation in this population, and compared it to perceived changes reported by individuals with objective cognitive deficits. The study aimed to: (1) examine the reported changes in activity participation of older with SCD; (2) investigate differences in the reported changes in participation between individuals with SCD and those with mild or severe objective cognitive deficits; (3) examine the relationship between activity participation, subjective memory, and objective cognitive status; and (4) explore whether subjective memory explains additional variance in activity participation after accounting for age and objective cognitive deficits. Participants were 115 older adults (60+), divided into three groups based on their Montreal Cognitive Assessment (MoCA) scores: (1) SCD (MoCA≥26; n = 66); (2) mild objective cognitive deficits (MoCA = 20-25; n = 34); and (3) severe objective cognitive deficits (MoCA ≤ 19; n = 15). The Activity Card Sort was used to measure participation in instrumental activities of daily living, social, and leisure activities. The Multifactorial Memory Questionnaire-Ability subscale was used to assess subjective memory. We found that individuals with SCD, mild cognitive deficits and severe cognitive deficits reported participation withdrawal to a level of 80, 70, and 58% of their past participation, respectively. A significant between group difference was found on participation [χ2(2) = 16.44, p < 0.01], with the SCD group reporting higher participation than the other two groups. Participation significantly correlated with both cognitive status (r = 0.40, p < 0.01) and subjective memory (r = 0.45, p < 0.05). A regression analysis revealed that subjective memory contributed significantly to the explained variance in participation, beyond that accounted for by objective cognitive deficits and age. Our findings demonstrate the important role of subjective memory problems in activity participation of older adults, even in the absence of objective cognitive deficits.

Discrepancy in the perception of symptoms of cognitive decline between older adults and their family members: results of the Toyama dementia survey

Background

Early consultation is important to delay the onset of dementia. The present study aimed to explore the reasons for delaying a consultation of dementia while focusing on the differences in the perception of cognitive decline between older adults and their family members.

Methods

A group of 663 older adults aged ≥65 years and living with family members in Toyama Prefecture was surveyed. The questionnaires included items that measured changes in cognitive function noticed by older adults and their family members, and the Revised Hasegawa Dementia Scale (HDS-R). The degrees of consistency on the perception of mental changes that accompanied cognitive decline were measured using the Kappa statistic.

Results

Both older adults and their family members were well aware of “forgetfulness” as a symptom of cognitive decline. Only the perception of “loss of appetite” at the late stage of cognitive decline was consistent between older adults and their family (κ = 0.707). When older adults often noticed their own forgetfulness, their mean HDS-R score was 22.7, whereas that of the family members was 14.7. The combinations of perception of forgetfulness by older adults and their family members, and the mean HDS-R scores were unaware/unaware (mean HDS-R score = 27.0), aware/unaware (mean HDS-R score = 24.9), aware/aware (mean HDS-R score = 15.5), and unaware/aware (mean HDS-R score = 13.0).

Conclusions

There were discrepancies in the perception of cognitive decline between older adults and their family members. Cognitive decline had progressed by the time that family members had noticed the symptom of forgetfulness in their older adult relatives. The perception gap regarding cognitive decline deters consultation of dementia.

Participant and study partner prediction and identification of cognitive impairment in preclinical Alzheimer's disease: study partner vs. participant accuracy

BACKGROUND

Preclinical Alzheimer's disease (AD) clinical trials require participants to enroll with a study partner, a person who can attend visits and report changes in the participant's cognitive ability. Whether study partners, compared to participants themselves, provide added information about participant cognition in preclinical AD trials is an open question. We tested the hypothesis that study partners provide meaningful information related to participant cognition cross-sectionally and longitudinally, and assessed whether amyloid status modified observed effects.

METHODS

We assessed participant and study partner Everyday Cognition (ECog) scores and participant Alzheimer's Disease Assessment Scale 13-item cognitive subscale (ADAS13) data from 335 cognitively normal participant-partner dyads in the AD Neuroimaging Initiative. We used random forest and linear mixed effects (LME) models to predict ADAS13 scores as a function of participant and/or study partner ECog scores over time. LME models were adjusted for potential confounding factors, including APOE4 status, amyloid status, baseline age, years of education, and sex. Random forest models were split into the above factors, as well as race/ethnicity and other available neuropsychological battery test scores.

RESULTS

In random forest models predicting ADAS13 12 months from baseline, we observed no difference in the estimated mean variable importance (eMVI) associated with baseline study partner ECog compared to the baseline participant ECog (eMVI = 0.15, 95%CB 0.13, 0.16 for partner; eMVI = 0.15, 95%CB 0.14, 0.16 for participant). In models predicting ADAS13 48 months after baseline, the eMVI associated with baseline study partner ECog was slightly lower than that associated with baseline participant ECog (eMVI = 0.21, 95%CB 0.20, 0.22 for partner; eMVI = 0.24, 95%CB 0.22, 0.25 for participant). In cross-sectional models, study partner eMVI was twice as large as participant eMVI at 12 months (eMVI = 0.20, 95%CB 0.19, 0.21 for partner; eMVI = 0.09, 95%CB 0.09, 0.10 for participant) and three times as large at 48 months (eMVI = 0.38, 95%CB 0.36, 0.39 for partner; eMVI = 0.13, 95%CB 0.12, 0.14 for participant). We did not observe qualitative differences by amyloid status.

CONCLUSIONS

While baseline participant reports reasonably predict subsequent cognitive change, informants perform better at cross-sectionally recognizing cognitive status as observation time grows. The study partner requirement may be essential to ensure trial data integrity, especially in longer trials.

Memory awareness disruptions in amnestic mild cognitive impairment: comparison of multiple awareness types for verbal and visuospatial material

Successful memory is normally accompanied by explicit awareness of retrieval and confidence in the accuracy of the retrieval product. Prior findings suggest that these features of metamemory can be dissociated from retrieval accuracy in Amnestic Mild Cognitive Impairment (aMCI). However, the literature on this question contains variable and conflicting results, likely because of differences in experimental conditions. We sought to systematically evaluate memory awareness disruptions in aMCI using multiple measures and stimulus formats within the same individuals. Memory awareness was tested with global predictions and postdictions, judgments of learning, confidence level ratings, and modified feeling-of-knowing ratings in tasks of visuospatial and verbal memory. These tests were administered to 14 individuals with aMCI and 15 healthy, age-matched controls. Memory awareness accuracy was calculated as the correspondence between subjective judgments and memory performance.Individuals with aMCI demonstrated impaired global and trial-level retrospective task awareness for visuospatial and verbal stimuli. Additionally, modified feeling-of-knowing awareness was impaired selectively for verbal stimuli. Statistical effect sizes for global awareness impairments were comparable to impairments in several objective neuropsychological memory assessments.Memory awareness (metamemory) disruptions in aMCI were most evident for a subset of subjective judgment types and task input modalities. These findings advance understanding of the nature of memory impairments in aMCI and support the utility of incorporating memory awareness testing to better characterize memory integrity in older adults.

Subjective memory complaints are not increased in type 2 diabetes: A matched cohort study

Type 2 diabetes is associated with several cognitive syndromes but whether this generates subjective complaints remains unclear. In an age- and sex-matched study, subjective memory complaints were neither more prevalent nor more severe in those with type 2 diabetes, despite them having lower Mini-Mental State Examination scores.

Functional Neural Correlates of Anosognosia in Mild Cognitive Impairment and Alzheimer's Disease: a Systematic Review

Functional neuroimaging techniques (i.e. single photon emission computed tomography, positron emission tomography, and functional magnetic resonance imaging) have been used to assess the neural correlates of anosognosia in mild cognitive impairment (MCI) and Alzheimer's disease (AD). A systematic review of this literature was performed, following the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement, on PubMed, EMBASE, and PsycINFO databases. Twenty-five articles met all inclusion criteria. Specifically, four brain connectivity and 21 brain perfusion, metabolism, and activation articles. Anosognosia is associated in MCI with frontal lobe and cortical midline regional dysfunction (reduced perfusion and activation), and with reduced parietotemporal metabolism. Reduced within and between network connectivity is observed in the default mode network regions of AD patients with anosognosia compared to AD patients without anosognosia and controls. During initial stages of cognitive decline in anosognosia, reduced indirect neural activity (i.e. perfusion, metabolism, and activation) is associated with the cortical midline regions, followed by the parietotemporal structures in later stages and culminating in frontotemporal dysfunction. Although the current evidence suggests differences in activation between AD or MCI patients with anosognosia and healthy controls, more evidence is needed exploring the differences between MCI and AD patients with and without anosognosia using resting state and task related paradigms.

Interaction between memory impairment and depressive symptoms can exacerbate anosognosia: a comparison of Alzheimer's disease with mild cognitive impairment

OBJECTIVE

To investigate the effects of interactions between memory impairment, depressive symptoms, and anosognosia.

METHODS

Anosognosia for memory impairment was assessed in 118 patients with Alzheimer's disease (AD), 47 patients with mild cognitive impairment (MCI), and 17 non-diagnosed controls (NC) using a questionnaire and evaluation of the anosognosia score as the discrepancy between ratings of the patient and a relative. Demographic characteristics, such as the relationship of the patient with the relative and the activities of daily living (ADL) were evaluated. Memory impairment was evaluated with the Rivermead Behavioral Memory Test (RBMT), depressive symptoms were evaluated using the Geriatric Depression Scale (GDS) 15 items version.

RESULTS

In the MCI group, a stepwise multiple regression analysis showed an interaction between RBMT and GDS scores, and simple slope analysis indicated that scores for RBMT at low GDS (-1 standard deviation) were positively correlated with self-rated memory impairment. In the AD group, the relationship of the patient with the relative, ADL, and GDS and RBMT scores were associated with the anosognosia score.

CONCLUSION

Patients with MCI who have no depressive symptoms may be able to more accurately evaluate their memory impairment than those who have depressive symptoms and patients with AD. The evaluation by relatives, depressive symptoms or ADL of patients may distort evaluation of anosognosia for memory impairment in patients with AD or MCI. It seems necessary to include not only depression scale scores but also results of objective memory tests in the patients' medical information for the correct assessment of anosognosia.

Virtual Reality as a Possible Tool for the Assessment of Self-Awareness

The absence of self-awareness is a crucial aspect in the symptomatology of various neurodegenerative disorders. This characteristic becomes relevant due to the strong implications it has on the patient’s quality of life, on the effects that functional dependence has on the caregiver and on the efficacy of the therapy. Faced with a construct as complex as self-awareness, there are in the literature investigations on different aspects of this phenomenon, such as the creation of cognitive models, the study of the neural substrate and the research of appropriate assessment methods that can reliably detect this function. With regard to the assessment methods, there are methodologies in the literature that provide complementary information. The first modality is a quantitatively online measurement based on the discrepancy between the estimate of the patient of his performance and his actual performance, but often neglecting the ecological validity and the real functioning of the subject. The second kind collecting subjective information on the actual daily functioning of the patient resulting from clinical observation or interviews with the subject and caregivers, but obtaining offline information on the functioning of the subject, liable to bias that may imply an overestimation or underestimation of subject’s ability. The absence of acknowledged metacognitive functional assessment with normative data to evaluate awareness winks at the emerging and increasingly consistent use of virtual reality (VR) also in the context of cognitive research and clinical assessment. This article aims to make a theoretical proposal regarding the use of this innovative and promising tool as a supplement to the assessment methods of self-awareness.

Differences in self-awareness of functional deficits between amnestic single- and multidomain mild cognitive impairment

INTRODUCTION

Prior research examining self-awareness of deficits in those with mild cognitive impairment (MCI) has been inconsistent, suggesting that preservation of insight at this disease stage may be conditional on the domain(s) examined as well as individual characteristics. The current study is the first to examine differences in objective performance and self-awareness of difficulties between older adults with amnestic single- (MCI-ASD) and multidomain MCI (MCI-AMD) across six instrumental activities of daily living (IADLs).

METHOD

Seventy-five individuals (M_age = 73.9 years, range = 55-88 years; 56% female) with MCI-ASD (n = 30) and MCI-AMD (n = 45) were recruited primarily from a hospital-based memory disorders clinic. Participants were administered self-report and objective measures assessing six functional domains: financial management, driving, telephone use, nutrition evaluation, grocery shopping, and medication management. Self-awareness discrepancy scores were calculated for each of these IADLs, and participants were classified as either "overestimating ability" or "accurately/underestimating ability."

RESULTS

Individuals with MCI-AMD performed significantly worse on objective measures of financial management, driving, and nutrition evaluation than those with MCI-ASD. Across MCI subtypes, participants were most likely to lack awareness of their difficulties in nutrition evaluation (31%), financial management (25%), and driving (23%) domains. Individuals with MCI-AMD were significantly more likely than those with MCI-ASD to overestimate performance on driving and telephone use domains.

CONCLUSION

Individuals with MCI-AMD are more likely than those with MCI-ASD to have impairment in their everyday function and to lack awareness into their IADL difficulties. When possible, clinicians should obtain objective measures in combination with detailed informant reports of functional abilities in order to evaluate capacity to independently engage in various daily activities. Finally, level of self-awareness varies across IADL domains, providing further evidence that insight is not a unitary construct.

Increasing Inaccuracy of Self-Reported Subjective Cognitive Complaints Over 24 Months in Empirically Derived Subtypes of Mild Cognitive Impairment

OBJECTIVES

Although subjective cognitive complaints (SCC) are an integral component of the diagnostic criteria for mild cognitive impairment (MCI), previous findings indicate they may not accurately reflect cognitive ability. Within the Alzheimer's Disease Neuroimaging Initiative, we investigated longitudinal change in the discrepancy between self- and informant-reported SCC across empirically derived subtypes of MCI and normal control (NC) participants.

METHODS

Data were obtained for 353 MCI participants and 122 "robust" NC participants. Participants were classified into three subtypes at baseline via cluster analysis: amnestic MCI, mixed MCI, and cluster-derived normal (CDN), a presumptive false-positive group who performed within normal limits on neuropsychological testing. SCC at baseline and two annual follow-up visits were assessed via the Everyday Cognition Questionnaire (ECog), and discrepancy scores between self- and informant-report were calculated. Analysis of change was conducted using analysis of covariance.

RESULTS

The amnestic and mixed MCI subtypes demonstrated increasing ECog discrepancy scores over time. This was driven by an increase in informant-reported SCC, which corresponded to participants' objective cognitive decline, despite stable self-reported SCC. Increasing unawareness was associated with cerebrospinal fluid Alzheimer's disease biomarker positivity and progression to Alzheimer's disease. In contrast, CDN and NC groups over-reported cognitive difficulty and demonstrated normal cognition at all time points.

CONCLUSIONS

MCI participants' discrepancy scores indicate progressive underappreciation of their evolving cognitive deficits. Consistent over-reporting in the CDN and NC groups despite normal objective cognition suggests that self-reported SCC do not predict impending cognitive decline. Results demonstrate that self-reported SCC become increasingly misleading as objective cognitive impairment becomes more pronounced. (JINS, 2018, 24, 842-853).

Mild cognitive impairment and prospective memory: translating the evidence into neuropsychological practice

OBJECTIVE

There has been a recent rapid development of research characterizing prospective memory performance in mild cognitive impairment (MCI) in older age. However, this body of literature remains largely separated from routine clinical practice in neuropsychology. Furthermore, there is emerging evidence of effective interventions to improve prospective memory performance. Therefore, our objective in this article was to offer a clinical neuropsychological perspective on the existing research in order to facilitate the translation of the evidence-base into clinical practice.

METHOD

By conducting a critical review of the existing research related to prospective memory and MCI, we highlight how this data can be introduced into clinical practice, either within diagnostic assessment or clinical management.

CONCLUSIONS

Prospective memory is impaired in older adults with MCI, with a pattern of performance that helps with differential diagnosis from healthy aging. Clinical neuropsychologists are encouraged to add prospective memory assessment to their toolbox for diagnostic evaluation of clients with MCI. Preliminary findings of prospective memory interventions in MCI are promising, but more work is required to determine how different approaches translate to increasing independence in everyday life.

Anosognosia in mild Alzheimer's disease is correlated with not only neural dysfunction but also compensation

BACKGROUND

Anosognosia in Alzheimer's disease (AD) is a complicated, non-unitary phenomenon. In a clinical setting, patients with mild AD often preserve their awareness partially. We hypothesized that compensation, as well as neural dysfunction, could be correlated with anosognosia in mild AD.

METHODS

The severity of anosognosia was evaluated using the Anosognosia Questionnaire for Dementia in 37 subjects with mild AD or mild cognitive impairment due to AD. The subjects also underwent single-photon emission computed tomography with N-isopropyl-p-[¹²³ I]iodoamphetamine. Correlation between the severity of anosognosia and perfusion was assessed, and anosognosia (+) and (-) groups were compared.

RESULTS

The severity of anosognosia was relatively mild; the mean Anosognosia Questionnaire for Dementia score was 6.76 ± 14.16. Subjects were divided into two groups: anosognosia (+) (n = 11) and anosognosia (-) (n = 26). In the single-photon emission computed tomography data analysis, the severity of anosognosia was correlated with both lower regional cerebral blood flows of the right prefrontal cortex and higher regional cerebral blood flows of the parietal cortex, especially the left temporo-parietal junction.

CONCLUSIONS

Our results suggest that anosognosia in mild AD could be correlated with compensation as well as neural dysfunction. We speculate that this compensation may be related to the retrieval of outdated autobiographical memory.

The Proactive Self in Space: How Egocentric and Allocentric Spatial Impairments Contribute to Anosognosia in Alzheimer's Disease

In addition to impairments in episodic and spatial memory, anosognosia (i.e., loss of awareness of the deficient aspect of own cognitive functioning) may be considered an important cognitive marker of Alzheimer's disease (AD). However, although a growing body of interesting models have been proposed to explain this early symptom, what is still missing is a unifying framework of all the characteristic signs occurring in patients with AD that may guide the search for its causal neuropathological process and, ultimately, the etiological process. This contribution will first show how anosognosia may be related to the above-mentioned episodic and spatial memory impairment through a unifying framework of all these characteristic signs, i.e., the continuous interaction between different spatial representations. Second, we hypothesize that a break in the interaction between different spatial representations, as we suggest occurs in AD, may contribute significantly both to the early impairments in spatial and episodic memory, and to a deficient self-awareness since it may interfere with the capacity of the brain to detect predictive errors.

Subjective Memory Impairment and Gait Variability in Cognitively Healthy Individuals: Results from a Cross-Sectional Pilot Study

BACKGROUND

Increased stride time variability has been associated with memory impairment in mild cognitive impairment. Subjective memory impairment (SMI) is considered the earliest clinical stage of Alzheimer's disease (AD). The association between increased stride time variability and SMI has not been reported.

OBJECTIVE

This study aims to examine the association of stride time variability while performing single and dual tasking with SMI in cognitively healthy individuals (CHI).

METHODS

A total of 126 CHI (15 without SMI, 69 with SMI expressed by participants, 10 with SMI expressed by participant's relative, and 32 with SMI expressed by both participants and their relatives) were included in this cross-sectional study. The coefficient of variation (CoV) of stride time and walking speed were recorded under usual condition and while counting backwards. Age, gender, body mass index, number of drugs taken daily, use of psychoactive drugs, fear of falling, history of previous falls, and walking speed were used as covariates.

RESULTS

The multiple linear regression models showed that greater CoV of stride time while counting backwards, but not while single tasking, was associated with a participant's relative SMI (p = 0.038).

CONCLUSION

This study found a specific association between SMI expressed by a participant's relative and a greater CoV of stride time (i.e., worse performance) while dual tasking, suggesting that the association between gait variability and memory may be present in the earliest stages of memory impairment. Thus, gait variability under dual-task in individuals with SMI expressed by their relatives can be a potential biomarker of AD.

Anosognosia predicts default mode network hypometabolism and clinical progression to dementia

Objective

To identify the pathophysiologic mechanisms and clinical significance of anosognosia for cognitive decline in mild cognitive impairment.

Methods

We stratified 468 patients with amnestic mild cognitive impairment into intact and impaired awareness groups, determined by the discrepancy between the patient and the informant score on the Everyday Cognition questionnaire. Voxel-based linear regression models evaluated the associations between self-awareness status and baseline β-amyloid load, measured by [¹⁸F]florbetapir, and the relationships between awareness status and regional brain glucose metabolism measured by [¹⁸F]fluorodeoxyglucose at baseline and at 24-month follow-up. Multivariate logistic regression tested the association of awareness status with conversion from amnestic mild cognitive impairment to dementia.

Results

We found that participants with impaired awareness had lower [¹⁸F]fluorodeoxyglucose uptake and increased [¹⁸F]florbetapir uptake in the posterior cingulate cortex at baseline. In addition, impaired awareness in mild cognitive impairment predicted [¹⁸F]fluorodeoxyglucose hypometabolism in the posterior cingulate cortex, left basal forebrain, bilateral medial temporal lobes, and right lateral temporal lobe over 24 months. Furthermore, participants with impaired awareness had a nearly 3-fold increase in likelihood of conversion to dementia within a 2-year time frame.

Conclusions

Our results suggest that anosognosia is linked to Alzheimer disease pathophysiology in vulnerable structures, and predicts subsequent hypometabolism in the default mode network, accompanied by an increased risk of progression to dementia. This highlights the importance of assessing awareness of cognitive decline in the clinical evaluation and management of individuals with amnestic mild cognitive impairment.

Involvement of the Cingulate Cortex in Anosognosia: A Multimodal Neuroimaging Study in Alzheimer's Disease Patients

BACKGROUND

Anosognosia is a frequent symptom of Alzheimer's disease (AD), but its neural substrates remain in question.

OBJECTIVE

In this study, we combined neuroimaging with a neuropsychological evaluation to assess neural substrates of anosognosia.

METHODS

We prospectively recruited 30 patients with probable early-stage AD and matched healthy controls. Participants underwent MRI, FDG-PET, and a neuropsychological evaluation that includes an assessment of anosognosia. In the AD group, correlations between the anosognosia score, neuroimaging modalities, and neuropsychological performance were performed.

RESULTS

Atrophy and hypometabolism were correlated with the anosognosia score in the left dorsal anterior cingulate cortex. The anosognosia score was also correlated with atrophy of the cerebellar vermis, the left postcentral gyrus, and the right fusiform gyrus. No relation was found between anosognosia and the neuropsychological assessment.

DISCUSSION

Structural and metabolic alteration in the dorsal anterior cingulate cortex seems to be associated with a diminution of awareness in patients with early-stage AD.

Self-Awareness for Memory Impairment in Amnestic Mild Cognitive Impairment: A Longitudinal Study

AIM

To assess memory impairment insight as a predictor of dementia and Alzheimer's disease (AD) in amnestic mild cognitive impairment (MCI).

METHODS

To verify whether the awareness of memory impairment assessed by Geriatric Depression Scale (GDS) was associated with the risk of progression to dementia and AD in a cohort of MCI, we used a Cox regression model adjusted for age, sex, education, subtypes of amnestic MCI, Mini-Mental State Examination, Cumulative Illness Rating Scale severity index, and apolipoprotein E genotype.

RESULTS

During a follow-up of 27.7 (20.8) months, 205 (63.3%) of 324 patients with amnestic MCI progressed to dementia, including 141 to AD. No association was found in the unadjusted, partially adjusted (for sociodemographic variables), and fully adjusted multivariate Cox analysis between the awareness of memory impairment and the progression to dementia and AD.

DISCUSSION

Awareness or anosognosia of memory deficits, identified by GDS, is not useful to predict progression to dementia of patients with amnestic MCI.

Awareness, apathy, and depression in Alzheimer's disease and mild cognitive impairment

INTRODUCTION

Results from studies on awareness disorders in Alzheimer's disease (AD) are controversial because the methodologies, the "objects" of awareness, and the patients' pathologic stage all vary. Our study aimed to compare scores and correlates of awareness according to the stage of the disease and the assessment method.

METHODS

We compared 20 mild AD patients to 20 mild cognitive impairment (MCI) patients, using the Patient Competency Rating Scale (PCRS; patient vs. caregiver report) and the Self-Consciousness Scale (rating scale). All patients underwent cognitive, psycho-affective and behavioral assessments (global cognition, executive functions, episodic memory, anxiety-depression, and apathy measures).

RESULTS

Groups were matched for age, education, and gender. They were comparable on the depression, anxiety, apathy and awareness scales (ps > .05), and differed for all cognitive variables (p < .05). Using the median split approach, greater apathy and lower depression were associated with poorer awareness on the Self-Consciousness Scale (respectively: odds ratio [OR] = 4.8, p = .03; OR = 4.84, p = .04), and the PCRS (only apathy: OR = 9.3, p = .003). Greater apathy plus lower depression were associated with poorer awareness in both scales (PCRS: OR = 40.5, p = .005; Self-consciousness scale: OR = 28, p = .012).

CONCLUSION

These results evidence comparable awareness between AD and MCI patients. The correlates were more affective and behavioral than cognitive, independently from assessment method.

Early Functional Limitations in Cognitively Normal Older Adults Predict Diagnostic Conversion to Mild Cognitive Impairment

OBJECTIVES

To examine whether specific types of early functional limitations in cognitively normal older adults are associated with subsequent development of mild cognitive impairment (MCI), as well as the relative predictive value of self versus informant report in predicting diagnostic conversion to MCI.

DESIGN

As a part of a longitudinal study design, participants underwent baseline and annual multidisciplinary clinical evaluations, including a physical and neurological examination, imaging, laboratory work, and neuropsychological testing.

SETTING

Data used in this study were collected as part of longitudinal research at the University of California, Davis Alzheimer's Disease Center.

PARTICIPANTS

Individuals diagnosed as having normal cognition at study baseline who had an informant who could complete informant-based ratings and at least one follow-up visit (N = 324).

MEASUREMENTS

Participants and informants each completed the Everyday Cognition Scale (ECog), an instrument designed to measure everyday function in six cognitively relevant domains.

RESULTS

Self- and informant-reported functional limitations on the ECog were associated with significantly greater risk of diagnostic conversion to MCI (informant: hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.3-3.2, P = .002), with self-report having a slightly higher hazard (HR = 2.3, 95% CI = 1.4-3.6, P < .001). When controlling for baseline cognitive abilities, the effect remained significant for self- and informant-reported functional limitations.

CONCLUSION

Deficits in everyday memory and executive function domains were the strongest predictors of diagnostic conversion to MCI. Detection of early functional limitations may be clinically useful in assessing the future risk of developing cognitive impairment in cognitively normal older adults.

Recommendations for the Use of ICT in Elderly Populations with Affective Disorders

Objective: Affective disorders are frequently encountered among elderly populations, and the use of information and communication technologies (ICT) could provide an added value for their recognition and assessment in addition to current clinical methods. The diversity and lack of consensus in the emerging field of ICTs is however a strong limitation for their global use in daily practice. The aim of the present article is to provide recommendations for the use of ICTs for the assessment and management of affective disorders among elderly populations with or without dementia.

Methods: A Delphi panel was organized to gather recommendations from experts in the domain. A set of initial general questions for the use of ICT in affective disorders was used to guide the discussion of the expert panel and to analyze the Strengths, Weaknesses, Opportunities, and Threats (SWOT) of employing ICT in elderly populations with affective disorders. Based on the results collected from this first round, a web survey was sent to local general practitioners (GPs) and to all interns in psychiatry in France.

Results: The results of the first round revealed that ICT may offer very useful tools for practitioners involved in the diagnosis and management of affective disorders. However, the results of the web survey showed the interest to explain better to current and upcoming practitioners the utility of ICT especially for people living with dementia.

Long-term trajectories of self-reported cognitive function in a cohort of older survivors of breast cancer: CALGB 369901 (Alliance)

BACKGROUND

The number of survivors of breast cancer aged ≥65 years (“older”) is growing, but to the authors' knowledge, little is known regarding the cognitive outcomes of these individuals.

METHODS

A cohort of cognitively intact older survivors with nonmetastatic, invasive breast cancer was recruited from 78 sites from 2004 through 2011; approximately 83.7% of the survivors (1280 survivors) completed baseline assessments. Follow‐up data were collected at 6 months and annually for up to 7 years (median, 4.1 years). Cognitive function was self‐reported using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ‐C30); scores ranged from 0 to 100, with a higher score indicating better function. Group‐based trajectory modeling determined trajectories; women were assigned to a trajectory group based on the highest predicted probability of membership. Multinomial logistic regression evaluated the association between receipt of chemotherapy (with or without hormonal treatment) and trajectory group.

RESULTS

Survivors were aged 65 to 91 years; approximately 41% received chemotherapy. There were 3 cognitive trajectories: “maintained high” (42.3% of survivors); “phase shift” (50.1% of survivors), with scores slightly below but parallel to maintained high; and “accelerated decline” (7.6% of survivors), with the lowest baseline scores and greatest decline (from 71.7 [standard deviation, 19.8] to 58.3 [standard deviation, 21.9]). The adjusted odds of being in the accelerated decline group (vs the maintained high group) were 2.1 times higher (95% confidence interval, 1.3‐3.5) for survivors who received chemotherapy (with or without hormonal therapy) versus those treated with hormonal therapy alone. Greater comorbidity and frailty also were found to be associated with accelerated decline.

CONCLUSIONS

Trajectory group analysis demonstrated that the majority of older survivors maintained good long‐term self‐reported cognitive function, and that only a small subset who were exposed to chemotherapy manifested accelerated cognitive decline. Future research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline. Cancer 2016;122:3555–3563. © 2016 American Cancer Society

Among older survivors of breast cancer who were followed for up to 7 years, approximately 42% reported maintaining high cognitive function, but receipt of chemotherapy (with or without hormonal therapy) appeared to double the odds of being in the group that reported accelerated cognitive decline (vs maintaining high function), compared with receiving hormonal treatment alone. Further research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline.