Anosognosia in Alzheimer's disease: the role of impairment levels in assessment of insight across domains

The dual-path hypothesis for the emergence of anosognosia in Alzheimer's disease

Although neurocognitive models have been proposed to explain anosognosia in Alzheimer's disease (AD), the neural cascade responsible for its origin in the human brain remains unknown. Here, we build on a mechanistic dual-path hypothesis that brings error-monitoring and emotional processing systems as key elements for self-awareness, with distinct impacts on the emergence of anosognosia in AD. Proceeding from the notion of anosognosia as a dimensional syndrome, varying between a lack of concern about one's own deficits (i.e., anosodiaphoria) and a complete lack of awareness of deficits, our hypothesis states that (i) unawareness of deficits would result from primary damage to the error-monitoring system, whereas (ii) anosodiaphoria would more likely result from an imbalance between emotional processing and error-monitoring. In the first case, a synaptic failure in the error-monitoring system, in which the anterior and posterior cingulate cortices play a major role, would have a negative impact on error (or deficits) awareness, preventing patients from becoming aware of their condition. In the second case, an impairment in the emotional processing system, in which the amygdala and the orbitofrontal cortex play a major role, would prevent patients from monitoring the internal milieu for relevant errors (or deficits) and assigning appropriate value to them, thus biasing their impact on the error-monitoring system. Our hypothesis stems on two scientific premises. One comes from preliminary results in AD patients showing a synaptic failure in the error-monitoring system along with a decline of awareness for cognitive difficulties at the time of diagnosis. Another comes from the somatic marker hypothesis, which proposes that emotional signals are critical to adaptive behavior. Further exploration of these premises will be of great interest to illuminate the foundations of self-awareness and improve our knowledge of the underlying paths of anosognosia in AD and other brain disorders.

Machine learning-based classification of Alzheimer's disease and its at-risk states using personality traits, anxiety, and depression

BACKGROUND

Alzheimer's disease (AD) is often preceded by stages of cognitive impairment, namely subjective cognitive decline (SCD) and mild cognitive impairment (MCI). While cerebrospinal fluid (CSF) biomarkers are established predictors of AD, other non-invasive candidate predictors include personality traits, anxiety, and depression, among others. These predictors offer non-invasive assessment and exhibit changes during AD development and preclinical stages.

METHODS

In a cross-sectional design, we comparatively evaluated the predictive value of personality traits (Big Five), geriatric anxiety and depression scores, resting-state functional magnetic resonance imaging activity of the default mode network, apoliprotein E (ApoE) genotype, and CSF biomarkers (tTau, pTau181, Aβ42/40 ratio) in a multi-class support vector machine classification. Participants included 189 healthy controls (HC), 338 individuals with SCD, 132 with amnestic MCI, and 74 with mild AD from the multicenter DZNE-Longitudinal Cognitive Impairment and Dementia Study (DELCODE).

RESULTS

Mean predictive accuracy across all participant groups was highest when utilizing a combination of personality, depression, and anxiety scores. HC were best predicted by a feature set comprised of depression and anxiety scores and participants with AD were best predicted by a feature set containing CSF biomarkers. Classification of participants with SCD or aMCI was near chance level for all assessed feature sets.

CONCLUSION

Our results demonstrate predictive value of personality trait and state scores for AD. Importantly, CSF biomarkers, personality, depression, anxiety, and ApoE genotype show complementary value for classification of AD and its at-risk stages.

Can a failure in the error-monitoring system explain unawareness of memory deficits in Alzheimer's disease?

Unawareness of memory deficits is an early manifestation in patients with Alzheimer's disease (AD), which often delays diagnosis. This intriguing behavior constitutes a form of anosognosia, whose neural mechanisms remain largely unknown. We hypothesized that anosognosia may depend on a critical synaptic failure in the error-monitoring system, which would prevent AD patients from being aware of their own memory impairment. To investigate, we measured event-related potentials (ERPs) evoked by erroneous responses during a word memory recognition task in two groups of amyloid positive individuals with only subjective memory complaints at study entry: those who progressed to AD within the five-year study period (PROG group), and those who remained cognitively normal (CTRL group). A significant reduction in the amplitude of the positivity error (Pe), an ERP related to error awareness, was observed in the PROG group at the time of AD diagnosis (vs study entry) in intra-group analysis, as well as when compared with the CTRL group in inter-group analysis, based on the last EEG acquisition for all subjects. Importantly, at the time of AD diagnosis, the PROG group exhibited clinical signs of anosognosia, overestimating their cognitive abilities, as evidenced by the discrepancy scores obtained from caregiver/informant vs participant reports on the cognitive subscale of the Healthy Aging Brain Care Monitor. To our knowledge, this is the first study to reveal the emergence of a failure in the error-monitoring system during a word memory recognition task at the early stages of AD. This finding, along with the decline of awareness for cognitive impairment observed in the PROG group, strongly suggests that a synaptic dysfunction in the error-monitoring system may be the critical neural mechanism at the origin of unawareness of deficits in AD.

Cholinergic nucleus 4 grey matter density is associated with apathy in Parkinson's disease

Objective: The generation and maintenance of goal-directed behavior is subserved by multiple brain regions that receive cholinergic inputs from the cholinergic nucleus 4 (Ch4). It is unknown if Ch4 degeneration contributes to apathy in Parkinson's disease (PD). Method: We analyzed data from 106 pre-surgical patients with PD who had brain MRIs and completed the Frontal Systems Behavior Scales (FrSBe). Eighty-eight patients also completed the Beck Depression Inventory-2nd Edition. Cholinergic basal forebrain grey matter densities (GMD) were measured by applying probabilistic maps to T1 MPRAGE sequences processed using voxel-based morphometry methods. We used linear and hierarchical regression modelling to examine the association between Ch4 GMD and the FrSBe Apathy subscale scores. We used similar methods to assess the specificity of this association and potential associations between Ch4 target regions and apathy. Results: Ch4 GMD (p = .021) and Ch123 GMD (p = .032) were significantly associated with Apathy subscale scores on univariate analysis. Ch4 GMD, but not Ch123 GMD, remained significantly associated with apathy when adjusting for age, sex, levodopa equivalent doses, and disease duration. Centromedial amygdala GMD, which receives cholinergic inputs from Ch4, was also associated with apathy. Ch4 GMD was not associated with depression or disinhibition, nor was it associated with executive dysfunction when adjusting for clinical and demographic variables. Conclusions: Ch4 GMD is specifically associated with apathy in PD. Ch4 degeneration results in cholinergic denervation of multiple cortical and limbic regions, which may contribute to the cognitive and emotional-affective processing deficits that underlie the behavioral symptoms of apathy.

Brain functional connectivity alterations associated with neuropsychological performance 6-9 months following SARS-CoV-2 infection

Neuropsychological deficits and brain damage following SARS-CoV-2 infection are not well understood. Then, 116 patients, with either severe, moderate, or mild disease in the acute phase underwent neuropsychological and olfactory tests, as well as completed psychiatric and respiratory questionnaires at 223 ± 42 days postinfection. Additionally, a subgroup of 50 patients underwent functional magnetic resonance imaging. Patients in the severe group displayed poorer verbal episodic memory performances, and moderate patients had reduced mental flexibility. Neuroimaging revealed patterns of hypofunctional and hyperfunctional connectivities in severe patients, while only hyperconnectivity patterns were observed for moderate. The default mode, somatosensory, dorsal attention, subcortical, and cerebellar networks were implicated. Partial least squares correlations analysis confirmed specific association between memory, executive functions performances and brain functional connectivity. The severity of the infection in the acute phase is a predictor of neuropsychological performance 6-9 months following SARS-CoV-2 infection. SARS-CoV-2 infection causes long-term memory and executive dysfunctions, related to large-scale functional brain connectivity alterations.

Detecting Anosognosia from the Prodromal Stage of Alzheimer's Disease

BACKGROUND

Though not originally developed for this purpose, the Healthy Aging Brain Care Monitor (HABC-M) seems a valuable instrument for assessing anosognosia in Alzheimer's disease (AD).

OBJECTIVES

Our study aimed at 1) investigating the validity of the HABC-M (31 items), and its cognitive, psychological, and functional subscales, in discriminating AD patients from controls; 2) exploring whether the HABC-M discrepancy scores between the self-reports of patients/controls in these different domains and the respective ratings provided by their caregivers/informants correlate with an online measure of self-awareness; 3) determining whether the caregiver burden level, also derived from the HABC-M, could add additional support for detecting anosognosia.

METHODS

The HABC-M was administered to 30 AD patients and 30 healthy controls, and to their caregivers/informants. A measure of online awareness was established from subjects' estimation of their performances in a computerized experiment.

RESULTS

The HABC-M discrepancy scores distinguished AD patients from controls. The cognitive subscale discriminated the two groups from the prodromal AD stage, with an AUC of 0.88 [95% CI: 0.78;0.97]. Adding the caregiver burden level raised it to 0.94 [0.86;0.99]. Significant correlations between the HABC-M and online discrepancy scores were observed in the patients group, providing convergent validity of these methods.

CONCLUSIONS

The cognitive HABC-M (six items) can detect anosognosia across the AD spectrum. The caregiver burden (four items) may corroborate the suspicion of anosognosia. The short-hybrid scale, built from these 10 items instead of the usual 31, showed the highest sensitivity for detecting anosognosia from the prodromal AD stage, which may further help with timely diagnosis.

Alterations in metamemory capacity and neural correlates in a subtype of subjective cognitive decline

BACKGROUNDS

Subjective cognitive decline (SCD), one of the important clinical indicators for preclinical Alzheimer's disease (AD), is primarily defined as self-perceived cognitive decline without objective evidence for cognitive impairment. However, the accuracy of their self-evaluation of cognition is unclear. This study sought to investigate the capacity for self-evaluation of own cognitive performance in SCD by applying an objective metamemory paradigm.

METHODS

147 individuals with SCD were classified into four subgroups by their subjective feeling of worse performance than peers or not (P+/-) and whether they have objectively slight cognitive impairment compared to normative data (S+/-). Metamemory scores, the amplitude of the low-frequency fluctuation (ALFF), fractional low-frequency fluctuation amplitude (fALFF), and cortical thickness were compared among four subgroups. Partial correlations between neuropsychological scores and neuroimaging measures were examined, controlling for age, sex, and education years.

RESULTS

SCD S+P- showed the worst performance in short-term delayed recall and the worst metamemory performance, indicated by the highest value in the degree of confidence of short-term delayed recall (DOC-N4) and long-term cued recall (DOC-N6) and the worst value in relative accuracy of judgments of short-term delayed recall (ROJ-N4). ALFF values in the bilateral superior medial frontal and olfactory cortices and the left superior orbitofrontal gyrus cortex were significantly higher in SCD P- compared with SCD P+ groups (all P < 0.05, FWE-corrected, cluster-wise level). A significant S × P interaction effect in the left hippocampus and middle cingulate cortex was found for the fALFF signals (all P < 0.05, FWE-corrected, cluster-wise level). Significant interaction and main effects on cortical thickness were reported. The parahippocampal and posterior cingulate cortices were significantly decreased in SCD S+P- (all P < 0.05).

CONCLUSION

SCD S+P- showed the worst episodic memory performance, altered metamemory capacity (overconfidence and less accuracy of judgment), and altered neuroimaging measures, though they had feelings of similar performance with peers. Our results indicate that metamemory capacity is affected in a subtype of SCD with reduced cortical thickness and intensity of regional spontaneous activity in key areas for metamemory processing.

What Are the Neural Correlates of Impaired Awareness of Social Cognition and Function in Dementia? A Systematic Review

Deficits in social cognition and function are characteristic of dementia, commonly accompanied by a loss of awareness of the presence or extent of these deficits. This lack of awareness can impair social relationships, increase patients' and carers' burden, and contribute to increased rates of institutionalization. Despite clinical importance, neural correlates of this complex phenomenon remain unclear. We conducted a systematic search of five electronic databases to identify functional and structural neuroimaging studies investigating the neural correlates of impaired awareness of social cognition and function in any dementia type. We rated study quality and conducted a narrative synthesis of the results of the eight studies that met the predefined eligibility criteria. Across these studies, deficits in awareness of impairments in social cognition and function were associated with structural or functional abnormalities in the frontal pole, orbitofrontal cortex, temporal pole, middle temporal gyrus, inferior temporal gyrus, fusiform gyrus, amygdala, hippocampus, parahippocampal gyrus, and insula. Several identified regions overlap with established neural correlates of social cognition. More research is needed to understand awareness of social cognition and function and how this becomes impaired in dementia to improve neuroscientific understanding, aid the identification of this problematic symptom, and target interventions to reduce burden and improve care.

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.

Does Your Loved One With Cognitive Symptoms Need to See a Doctor? Check It Online

Widespread access to emerging information and communication technologies (ICT) allows its use for the screening of diseases in the general population. At the initiative of the Spanish Confederation of Associations of Families of People with Alzheimer’s disease and other dementias (CEAFA), a website (http://www.problemasmemoria.com) has been created that provides information about Alzheimer’s disease and includes questionnaires to be completed by family or friends concerned about memory problems of a relative. A cross-sectional, randomized, multicenter study was performed to evaluate feasibility, validity, and user satisfaction with an electronic method of completion vs. the current method of paper-based questionnaires for clinically dementia screening completed by the informants: the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) and the Alzheimer’s disease-8 screening test (AD8). A total of 111 pairs were recruited by seven memory clinics. Informants completed IQCODE and AD8 questionnaires both in their paper and electronic versions. The correlation between paper and electronic versions was significantly positive for IQCODE (r = 0.98; p < 0.001) and AD8 (r = 0.96; p < 0.001). The execution time did not differ significantly, and participants considered their use equally easy. This study shows that an electronic version of the IQCODE and AD8 questionnaires is suitable for its online use via the internet and achieves the same results as the traditional paper versions.

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.

Eliciting Implicit Awareness in Alzheimer’s Disease and Mild Cognitive Impairment: A Task-Based Functional MRI Study

Background

Recent models of anosognosia in dementia have suggested the existence of an implicit component of self-awareness about one’s cognitive impairment that may remain preserved and continue to regulate behavioral, affective, and cognitive responses even in people who do not show an explicit awareness of their difficulties. Behavioral studies have used different strategies to demonstrate implicit awareness in patients with anosognosia, but no neuroimaging studies have yet investigated its neural bases.

Methods

Patients with amnestic mild cognitive impairment and dementia due to Alzheimer’s disease underwent functional magnetic resonance imaging (fMRI) during the execution of a color-naming task in which they were presented with neutral, negative, and dementia-related words (Dementia-Related Emotional Stroop).

Results

Twenty-one patients were recruited: 12 were classified as aware and 9 as unaware according to anosognosia scales (based on clinical judgment and patient-caregiver discrepancy). Behavioral results showed that aware patients took the longest time to process dementia-related words, although differences between word types were not significant, limiting interpretation of behavioral results. Imaging results showed that patients with preserved explicit awareness had a small positive differential activation of the posterior cingulate cortex (PCC) for the dementia-related words condition compared to the negative words, suggesting attribution of emotional valence to both conditions. PCC differential activation was instead negative in unaware patients, i.e., lower for dementia-related words relative to negative-words. In addition, the more negative the differential activation, the lower was the Stroop effect measuring implicit awareness.

Conclusion

Posterior cingulate cortex preserved response to dementia-related stimuli may be a marker of preserved implicit self-awareness.

Long COVID Neuropsychological Deficits after Severe, Moderate, or Mild Infection

There is growing awareness that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, even in its mild or moderate respiratory forms, can include long-term neuropsychological deficits. Standardized neuropsychological, psychiatric, neurological, and olfactory tests were administered to 45 patients 236.51 ± 22.54 days after hospital discharge following severe, moderate, or mild respiratory severity from SARS-CoV-2 infection (severe = intensive care unit hospitalization, moderate = conventional hospitalization, mild = no hospitalization). Deficits were found in all domains of cognition, and the prevalence of psychiatric symptoms was relatively high in the three groups. The severe infection group performed more poorly on long-term episodic memory tests and exhibited greater anosognosia than did the other two groups. Those with moderate infection had poorer emotion recognition, which was positively correlated with persistent olfactory dysfunction. Individuals with mild infection were more stressed, anxious, and depressed. The data support the hypothesis that the virus targets the central nervous system (notably the limbic system) and the notion that there are different neuropsychological phenotypes.

Altered Interplay Among Large-Scale Brain Functional Networks Modulates Multi-Domain Anosognosia in Early Alzheimer’s Disease

Decline in self-awareness is a prevalent symptom in Alzheimer’s disease (AD). Current data suggest that an early breakdown in the brain’s default mode network (DMN) is closely associated with the main symptomatic features in AD patients. In parallel, the integrity of the DMN has been shown to be heavily implicated in retained self-awareness abilities in healthy individuals and AD patients. However, the global contribution to awareness skills of other large-scale networks is still poorly understood. Resting-state functional magnetic resonance imaging (rs-fMRI) scans were acquired and pre-processed from 53 early-stage AD individuals. A group-level independent component analysis was run to isolate and reconstruct four intrinsic connectivity large-scale brain functional networks, namely left and right central executive fronto-parietal networks (FPN), salience network, and anterior and posterior DMN. Hypothesis-driven seed-based connectivity analyses were run to clarify the region-specific underpinnings of multi-domain anosognosia. Multiple regression models were run on large-scale network- and seed-based connectivity maps, including scores of memory, non-memory and total anosognosia obtained via the Measurement of Anosognosia Questionnaire. Memory anosognosia scores were associated with selective lower fronto-temporal connectivity and higher parieto-temporal connectivity. Non-memory anosognosia scores were associated with higher connectivity between the anterior DMN and the cerebellum, between the left medial prefrontal seeds and the contralateral prefrontal cortex, and between the left hippocampal seed and the left insula; lower connectivity was observed between the right prefrontal cortex and the right lingual seed. Lastly, total anosognosia scores were associated with large-scale network alterations, namely reduced left-FPN expression in the left posterior cingulate, reduced right-FPN expression in the left inferior lingual gyrus and adjacent inferior occipital cortex, and increased right-FPN expression in the right anterior cingulate. Seed-based analyses yielded significant connectivity differences only in the connectivity pattern associated with the left hippocampal seed by displaying lower intercommunication with the right prefrontal cortex, but higher connectivity with the left caudate nucleus. These findings support the hypothesis that alterations in functional connectivity of frontal lobe regions involved in executive-related mechanisms represent the neural correlates of domain-specific anosognosia in early AD. Up-regulated connectivity with subcortical structures appears to contribute to changes in the network dynamics interplay and fosters the appearance of anosognosia.

OUP accepted manuscript

Lack of awareness of cognitive impairment (i.e. anosognosia) could be a key factor for distinguishing between neuropsychological post-COVID-19 condition phenotypes. In this context, the 2-fold aim of the present study was to (i) establish the prevalence of anosognosia for memory impairment, according to the severity of the infection in the acute phase and (ii) determine whether anosognosic patients with post-COVID syndrome have a different cognitive and psychiatric profile from nosognosic patients, with associated differences in brain functional connectivity. A battery of neuropsychological, psychiatric, olfactory, dyspnoea, fatigue and quality-of-life tests was administered 227.07 ± 42.69 days post-SARS-CoV-2 infection to 102 patients (mean age: 56.35 years, 65 men, no history of neurological, psychiatric, neuro-oncological or neurodevelopmental disorder prior to infection) who had experienced either a mild (not hospitalized; n = 45), moderate (conventional hospitalization; n = 34) or severe (hospitalization with intensive care unit stay and mechanical ventilation; n = 23) presentation in the acute phase. Patients were first divided into two groups according to the presence or absence of anosognosia for memory deficits (26 anosognosic patients and 76 nosognosic patients). Of these, 49 patients underwent an MRI. Structural images were visually analysed, and statistical intergroup analyses were then performed on behavioural and functional connectivity measures. Only 15.6% of patients who presented mild disease displayed anosognosia for memory dysfunction, compared with 32.4% of patients with moderate presentation and 34.8% of patients with severe disease. Compared with nosognosic patients, those with anosognosia for memory dysfunction performed significantly more poorly on objective cognitive and olfactory measures. By contrast, they gave significantly more positive subjective assessments of their quality of life, psychiatric status and fatigue. Interestingly, the proportion of patients exhibiting a lack of consciousness of olfactory deficits was significantly higher in the anosognosic group. Functional connectivity analyses revealed a significant decrease in connectivity, in the anosognosic group as compared with the nosognosic group, within and between the following networks: the left default mode, the bilateral somatosensory motor, the right executive control, the right salient ventral attention and the bilateral dorsal attention networks, as well as the right Lobules IV and V of the cerebellum. Lack of awareness of cognitive disorders and, to a broader extent, impairment of the self-monitoring brain system, may be a key factor for distinguishing between the clinical phenotypes of post-COVID syndrome with neuropsychological deficits.

"I can do that on my own!" On the relevance of subjective factors to the use of formal support, from the perspective of people with dementia

Our aim was to reach a better insight of the disposition of people living alone with dementia toward the use of care and support services. In biographical narrative interviews, women and men with dementia communicated to us their opinions, needs, and subjectively perceived level of resources regarding their everyday life and care. Both individual and gender-specific differences concerning the use of formal support become evident in their narrations. We offer indications for a future healthcare practice that is specific to dementia. To fully exploit the potential of participatory research, study designs specific to dementia should be developed further.

Anosognosia in Early- and Late-Onset Dementia and Its Association With Neuropsychiatric Symptoms

Background: The symptom anosognosia or unawareness of disease in dementia has mainly been studied in patients with late-onset dementia (LOD, ≥65 years), whereas little is known on whether it is also present in patients with early-onset dementia (EOD, <65 years). We aimed at investigating differences in anosognosia between LOD and EOD, by also studying its association with different clinical variants of EOD and the presence of neuropsychiatric symptoms. Methods: A total of 148 patients, 91 EOD and 57 LOD, were recruited and underwent extended clinical assessment and caregiver interview that included questionnaires aimed at measuring anosognosia and neuropsychiatric symptoms. Differences in anosognosia between EOD and LOD and between subgroups with different clinical variants were investigated, as well as correlation between anosognosia and neuropsychiatric symptoms. A regression analysis was applied to explore the association between anosognosia and development of neuropsychiatric symptoms during disease progression. Results: Median levels of anosognosia were not significantly different between EOD and LOD. Anosognosia increased overtime with disease progression and was higher in frontotemporal dementia patients or, more precisely, in frontotemporal dementia and Alzheimer's disease variants associated with involvement of the frontal lobes. Higher levels of early anosognosia were associated with higher frequency and severity of subsequent neuropsychiatric symptoms, in particular apathy, later in the course of the disease. Conclusion: Anosognosia is a frequent symptom of EOD, occurring in 94.5% of all-cause EOD, and it is associated with higher risk of developing neuropsychiatric symptoms during disease progression. Recognising anosognosia may be helpful for clinicians and families to reduce diagnostic delay and improve disease managment.

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.

Anosognosia in dementia: A review of current assessment instruments

INTRODUCTION

Anosognosia is a common but underrated symptom in dementia and has significant impact on both patients and caregivers. A proper evaluation of anosognosia is therefore desirable. There are three common methods to determine anosognosia: (1) clinical rating, (2) patient-caregiver discrepancies, and (3) prediction of performance discrepancies. Each of them includes different instruments. This review gives an overview of the current instruments used for the assessment of anosognosia in patients with dementia and aims to determine the most suitable instrument for routine use in clinical practice.

METHODS

A search of the literature in PubMed was performed. Furthermore, electronic databases (PsycINFo, ClinicalKey, and Cochrane Library) and reference lists were searched for additional articles.

RESULTS

Forty-six articles were included in this study, comprising 10 clinical rating instruments, 25 patient-caregiver discrepancy instruments, and 14 prediction-performance discrepancy instruments. For every publication, the aims of the study, the included population, the assessment instrument used, the assessed domains, and the psychometric properties of the assessment instruments are described.

CONCLUSIONS

Currently, there is no consensus on the most suitable method to determine anosognosia in dementia. We recommend the Clinical Insight Rating scale and the Abridged Anosognosia Questionnaire-Dementia as the most appropriate for routine use in clinical practice.

Quality of the caregiving relationship and quality of life in mild Alzheimer's dementia

BACKGROUND

The present study aims to investigate the quality of the dyadic relationship between mild Alzheimer patients and their caregivers. The main objective is to evaluate the consistency, agreement and validity of the German version of the Scale for Quality of the Current Relationship in Caregiving (SQCRC). The secondary objective was to examine the association of relationship quality with quality of life (QOL) in patients with mild Alzheimer's disease (AD) and their caregivers.

METHODS

In this study, a sample of 50 patients diagnosed with mild AD and their primary caregivers were included. Participants underwent a full neuropsychological evaluation. The quality of the relationship between persons with AD and their caregivers was assessed using the SQCRC. Furthermore, other scales of relationship quality, well-being of the person with AD, and well-being of the caregiver were used.

RESULTS

The results showed that the SQCRC has a good internal consistency and high validity. Also, relationship quality as rated by the AD patients (r = 0.37, P < 0.1) and their caregivers (r = 0.51, P < 0.1) was significantly correlated with QOL.

CONCLUSIONS

The findings suggest that many persons with mild AD can rate their relationship quality and that the patient's self-rated relationship quality is a substantial predictor of their QOL.

Do you observe what I perceive? The relationship between two perspectives on the ability of people with cognitive impairments to use everyday technology

Objectives: Everyday technologies (ETs) can be challenging to use, particularly for older adults with cognitive impairments. This study evaluated the relationship between the self-perceived ability to use ET and observable performance of self-chosen and familiar, but challenging ETs in people with mild cognitive impairment (MCI) or dementia.Method: A self-perceived report, the Everyday Technology Use Questionnaire (S-ETUQ), and a structured observational tool, the Management of Everyday Technology Assessment (META), assessing the perceived and observed ability to use ET, were used in 41 people with MCI and 38 people with dementia. Correlations were investigated with non-parametric statistical tests.Results: In the dementia group, self-perceived report and observational scores correlated on a significant medium level (R_s=0.44, p = 0.006). In the MCI group, no significant correlation was found.Conclusion: The findings of this study suggest the ability of older adults with cognitive impairments to use ETs can be depicted with self-perceived reports as well as with observations. However, the combination of both approaches is recommended to get a comprehensive picture. While the S-ETUQ provides a broad picture of the use, presence and relevance of technologies in an individual's life, the META describes a specific human-technology interaction in detail. Furthermore, the results suggest people with early dementia retain the ability and insight to accurately reflect on their own ability to use ET, emphasizing the need to include their experiences in research and clinical work.

"What" and "How": A New Perspective for Understanding Unawareness in Alzheimer's Disease Through a Combination of Two Perspectives

OBJECTIVES

Assessments of unawareness in Alzheimer's disease mainly focus on the objects (the "what") of unawareness. A recent person-centered approach proposes to also assess the processes (the "how"). The present study combines 2 approaches to understand this heterogeneity in assessments of unawareness.

METHOD

We recruited 46 participants from 8 nursing homes. They underwent a semi-structured interview and were assessed using a prediction-performance paradigm. Spearman correlations were calculated, and generalized additive models were established.

RESULTS

The 2 approaches are associated through cognitive deficits, confrontation with difficulties and identity changes. Objects (the what), mechanisms, and modes of expression (the how) explain at least 29.6% of the variance of unawareness.

CONCLUSIONS

Unawareness is more than simply being unaware of something; it is a synergy between the objects and processes of arousal and expression. Moreover, unawareness extends beyond the disease to include the self. Considering the entire person seems to be necessary.

"What would you like to achieve?" Goal-Setting in Patients with Dementia in Geriatric Rehabilitation

BACKGROUND

Setting meaningful, individualized rehabilitation goals is an essential part of the rehabilitation process. Even though patients with dementia are a drastically increasing patient group in geriatric rehabilitation, empirical data about meaningful rehabilitation goals and collaborative goal-setting in this target group is missing. Cognitive impairment and lack of insight in current deficits have been discussed as barriers for participation in goal-setting, but require empirical examination. This study investigated the feasibility of a semi-structured versus a structured goal-setting approach and the types of goals, rehabilitation patients with mild to moderate dementia perceive as personally relevant. Insights in acute functional and motor deficits, differentiated by cognitive status were explored.

METHODS

Cohort study in a geriatric rehabilitation center. Semi-structured and ICF-based, structured interviews were applied to explore patients` rehabilitation goals. Patients` insight in deficits was operationalized as the relationship of self-ratings and objective measures of linked clinical assessments for the same functional construct.

RESULTS

Patients (n = 101, MMSE 22 ± 2.6, age 83.9 ± 5.9 years) stated the improvement of mobility-related functions and self-care activities (> 70%) but also psychological well-being such as handling stress or mood (> 38%) as most important rehabilitation goals. The structured interview facilitated goal-setting and provided a broader view of rehabilitation needs. Correlations between self-ratings and clinical assessments were medium to high (rho = 0.29 to 0.83) with highest associations for key motor features. Trend tests identified a significant trend between values of the clinical assessment and categories of self-ratings (p ≤ 0.01) with lower cognitive status derogating this relationship.

CONCLUSIONS

Collaborative goal-setting was feasible, especially when supported by a structured approach and yielded a large spectrum of functional but also psychological rehabilitation needs from the patients` perspective. Patients showed sustained insight in their actual functional impairments, limited in a subgroup of patients with more advanced cognitive impairment.

Neuropsychiatric Symptoms and the Diagnostic Stability of Mild Cognitive Impairment

BACKGROUND

Mild cognitive impairment (MCI) is an intermediate diagnosis between normal cognition (NC) and dementia, including Alzheimer's disease (AD) dementia. However, MCI is heterogeneous; many individuals subsequently revert to NC while others remain stable at MCI for several years. Identifying factors associated with this diagnostic instability could assist in defining clinical populations and determining cognitive prognoses.

OBJECTIVE

The current study examined whether neuropsychiatric symptoms could partially account for the temporal instability in cognitive diagnoses.

METHOD

The sample included 6,763 participants from the National Alzheimer's Coordinating Center Uniform Data Set. All participants had NC at baseline, completed at least two follow-up visits (mean duration: 5.5 years), and had no recent neurological conditions. Generalized linear models estimated by generalized estimating equations examined associations between changes in cognitive diagnoses and symptoms on the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Geriatric Depression Scale (GDS-15).

RESULTS

1,121 participants converted from NC to MCI; 324 reverted back to NC and 242 progressed to AD dementia. Higher symptoms on the GDS-15 and circumscribed symptom domains on the NPI-Q were associated with conversion from NC to MCI and a decreased likelihood of reversion from MCI to NC. Individuals with higher symptoms on NPI-Q Hyperactivity and Mood items were more likely to progress to AD dementia.

DISCUSSION

The temporal instability of MCI can be partially explained by neuropsychiatric symptoms. Individuals with higher levels of specific symptoms are more likely to progress to AD dementia and less likely to revert to NC. Identification and treatment of these symptoms might support cognitive functioning in older adults.

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.

Age, memory loss and perceptions of dementia in South Asian ethnic minorities

BACKGROUND

South Asian older adults are represented less frequently in mainstream mental health services or those for people with dementia. This study aimed to explore in detail the perceptions of dementia (symptoms, causes, consequences, treatments) held by South Asians and to discern how these understandings vary by age and by the self-recognition of memory problems, as these influence help-seeking behaviour.

METHODS

Participants were allocated to three groups: younger adults; older adults; and older adults with subjective memory problems. They completed the semi-structured Barts Explanatory Model Inventory for Dementia schedule, whilst older adults also completed measures of cognition (MMSE), and depression (GDS). Interviews were conducted in English, Gujarati or Urdu.

RESULTS

Groups were similar in identifying unusual forgetting and confusion as the most frequent symptoms; stress and age as the most frequent causes; and talking to your GP/nurse, taking medication, and talking to family and friends as the most frequent treatments. Younger adults more often knew about risk factors and reported practical consequences more than older adults. Older adults with subjective memory problems were more likely to describe sleep related problems or symptoms commonly associated with depression. They more often cited as causes of dementia lack of sleep, side effects of medication and medical reasons, and mentioned religion as a means to cope.

CONCLUSIONS

Findings highlight variability in perceptions of dementia across the South Asian Community and identify specific areas where dementia awareness could be raised in South Asian sub-groups to improve timely diagnosis, treatment outcomes and service access.

Assessment of Patient Self-awareness and Related Neural Correlates in Frontotemporal Dementia and Corticobasal Syndrome

OBJECTIVE

We compared two different methods of assessing self-awareness (clinician-rated vs. self- and caregiver report) in participants with neurodegenerative conditions. Additionally, we examined the contribution of memory dysfunction to assessment of self-awareness.

METHOD

Sixty-seven participants with various neurodegenerative disorders participated in this study. Data were collected on brain volume, neurocognitive function, demographic characteristics, and two measures of patient self-awareness, defined as (1) the discrepancy between patient and caregiver ratings of dysexecutive syndrome and (2) clinician-observed rating of patient insight. Penalized regression with best subset variable selection and 10-fold cross-validation was used to evaluate three neurocognitive frameworks: self-regulation, language, and perspective-taking, each predicting the results from the two methods of self-awareness measurement.

RESULTS

The self-regulation framework was more robustly predictive for both the clinician rating and discrepancy method than language or perspective-taking. Frameworks in which the clinician rating was the criterion were more robust than those with the discrepancy method as criterion. When a measure of memory functioning was added to the framework, there was no appreciable improvement in the prediction of self-awareness.

CONCLUSIONS

A self-regulation neurocognitive framework, consisting of regions of interest and neuropsychological test scores, was more effective in understanding patient self-awareness than perspective-taking or language frameworks. Compared to the discrepancy method, a clinician rating of self-awareness was more robustly associated with relevant clinical variables of regional brain volume and neuropsychological performance, suggesting it may be a useful measure to aid clinical diagnosis.

Neural Correlates of Anosognosia in Alzheimer's Disease and Mild Cognitive Impairment: A Multi-Method Assessment

Patients with Alzheimer's Disease (AD) and Mild Cognitive Impairment (MCI) may present anosognosia for their cognitive deficits. Three different methods have been usually used to measure anosognosia in patients with AD and MCI, but no studies have established if they share similar neuroanatomical correlates. The purpose of this study was to investigate if anosognosia scores obtained with the three most commonly used methods to assess anosognosia relate to focal atrophy in AD and MCI patients, in order to improve understanding of the neural basis of anosognosia in dementia. Anosognosia was evaluated in 27 patients (15 MCI and 12 AD) through clinical rating (Clinical Insight Rating Scale, CIRS), patient-informant discrepancy (Anosognosia Questionnaire Dementia, AQ-D), and performance discrepancy on different cognitive domains (self-appraisal discrepancies, SADs). Voxel-based morphometry correlational analyses were performed on magnetic resonance imaging (MRI) data with each anosognosia score. Increasing anosognosia on any anosognosia measurement (CIRS, AQ-D, SADs) was associated with increasing gray matter atrophy in the medial temporal lobe including the right hippocampus. Our results support a unitary mechanism of anosognosia in AD and MCI, in which medial temporal lobes play a key role, irrespectively of the assessment method used. This is in accordance with models suggesting that anosognosia in AD is primarily caused by a decline in mnemonic processes.

Lack of Accurate Self-appraisal is Equally Likely in MCI from Parkinson's Disease and Alzheimer's Disease

BACKGROUND

How accurate are mild cognitive impairment (MCI) patients in assessing their cognitive and functional deficit is often unclear to the clinician. The accuracy of patient self-appraisal in Parkinson's disease-MCI (PD-MCI) has received less attention than amnestic MCI (a-MCI) often associated with Alzheimer's disease. We evaluated if PD-MCI patients demonstrate accurate self-appraisal of their cognitive deficits compared to patients with amnestic a-MCI or non-amnestic MCI (na-MCI).

METHODS

This cross-sectional cohort study included, 30 PD-MCI, 33 a-MCI, and 17 na-MCI patients. Self-appraisal was assessed by comparing responses of caregivers and patients on a validated self-rating questionnaire of cognitive and functional impairments. All patients completed a full neuropsychological evaluation and depression screening measure. Univariate ANOVA, regression, and correlational analyses were employed to identify group differences in self-appraisal scores and relationships between cognitive and functional impairment, depression measures, and self-appraisal scores.

RESULTS

Self-appraisal scores for PD-MCI did not differ significantly from a-MCI and na-MCI. In the PD-MCI group, higher depression scores were associated with lower self-appraisal scores (i.e, patients assessed cognition as worse than caregivers). In a stepwise regression model with self-appraisal scores as the dependent variable, only the depression score was significant predictor among PD-MCI and accounted for 50% of the variance.

CONCLUSIONS

Our findings suggest that impaired patient self-appraisal is equally likely to occur in PD-MCI as in a-MCI and na-MCI patients. Among PD-MCI, depression was the strongest predictor of impaired patient self-appraisal. Impaired insight into cognitive impairment and depression should be considered in both care and research with PD patients.

Mood and Personality Characteristics are Associated with Metamemory Knowledge Accuracy in a Community-Based Cohort of Older Adults

OBJECTIVES

Emerging work reveals the neuroanatomic changes that compromise metacognition; however, little is known about the impact of premorbid factors. Research suggests that psychological variables influence the perception of cognition, but whether they influence the accuracy of those perceptions (i.e., metacognition) has not been directly examined.

PARTICIPANTS AND METHODS

Using Latent Class Analysis (LCA), we tested for discrete personality (NEOFFI) and mood (STAI, BDI-II, and GDS) classes among a community-based cohort of 151 older adults, enrolled in the NKI-Rockland study. Metamemory was calculated by comparing subjective memory ratings (modified Cognitive Failures Questionnaire) to objective memory (Rey Auditory Verbal Learning Test) to determine the degree to which individuals were overconfident, underconfident, or accurate in their self-assessment. A generalized linear model was used to examine whether metamemory differed across the emergent classes. A one sample t test was used to determine whether the metamemory scores of the emergent classes were statistically significantly different from zero, that is, over or under confident.

RESULTS

Two discrete classes emerged in the LCA: Class 1 was characterized predominantly by high extraversion and conscientiousness and low neuroticism and anxiety; Class 2 was characterized predominantly by low extraversion and conscientiousness and high neuroticism and anxiety. Metamemory differed significantly as a function of Class Membership (F(4,151)=5.42; p<.001), with Class 1 demonstrating accurate metamemory (M=0.21; SD=1.31) and Class 2 demonstrating under-confidence (M=-0.59; SD=1.39) in their memory.

CONCLUSIONS

The significant association between psychological factors and metamemory knowledge accuracy suggests that such characteristics may be important to consider in the conceptualization, assessment, and treatment of metacognitive disturbances. (JINS, 2018, 24, 498-510).

Repressive Coping Does Not Contribute to Anosognosia in First-Diagnosis Patients With Alzheimer Disease

Anosognosia is common in patients with Alzheimer disease (AD) even in early stages. Although neural correlates and the impact of cognitive dysfunctions have been described, possible psychodynamic processes such as a repressive coping style as described in other illnesses, have not been examined. Our study aimed to examine possible psychological influence factors on illness perception embracing a repressive coping style and cognitive functions in AD patients in the diagnostic process. Fifty-four subjects with mild AD diagnosed in our memory clinic were enrolled. Anosognosia was evaluated using a patient-caregiver discrepancy rating. All patients underwent comprehensive neuropsychological testing. In addition, characteristics of a repressive coping style were assessed. In total, 79.6% of our patients showed a lack of awareness at least to some degree. 33.3% of the patients were classified as repressors. Repressors and nonrepressors did not differ in cognition, or the unawareness score. Multivariate regression analysis showed that repressive coping style did not significantly contribute to anosognosia, but that verbal memory and naming ability had a strong influence. Although our data indicate that a high proportion of patients with mild AD show characteristics of repressive coping, this possible defense mechanism had no influence on the awareness of illness-related deficits measured by caregiver patient discrepancy.

Caregiver perception of apathy in persons with mild cognitive impairment or Alzheimer's disease: a longitudinal study

OBJECTIVE

Discrepancy between self- and caregiver apathy ratings was examined longitudinally for persons with mild cognitive impairment or Alzheimer's disease. Particular focus was on the distinction between the positive and negative caregiver bias and its predictive value for a clinical diagnosis of apathy.

METHOD

Apathy rating discrepancy was based on the apathy evaluation scale. Dyads were categorized depending on whether the caregiver reported fewer deficits (positive caregiver bias) or more deficits (negative caregiver bias) than the cognitively impaired person did.

RESULTS

Caregiver ratings and rating discrepancy showed a significant increase from baseline to follow-up. By contrast, self- and clinician ratings showed no change across the two time points. Ratings with a negative caregiver bias remained stable, while those with a positive caregiver bias showed a significant increase in the caregiver ratings but also a significant decrease in the self-ratings. A negative caregiver bias at baseline was significantly related to greater likelihood of having clinical apathy at follow-up, adjusted for an array of control variables.

CONCLUSION

Positive and negative caregiver bias should be distinguished, as they seem to reflect distinct dyadic processes and are relevant for clinical outcome. Furthermore, negative rating discrepancies can be considered a risk factor for developing apathy.

The Structured Interview for Insight and Judgment in Dementia: Development and validation of a new instrument to assess awareness in patients with dementia

INTRODUCTION

Poor insight about their cognitive and functional deficits is highly prevalent in patients with Alzheimer's disease (AD); however, there is a lack of reliable, valid instrumentation to measure this construct. The aim of this study was to develop and validate a semistructured interview to assess insight and judgment in patients with AD and to provide information regarding the assessment of competency and risk in this population.

METHODS

We validated the Structured Clinical Interview for Insight and Judgment in Dementia (SIJID) in a consecutive series of 124 patients with probable AD. The following psychometric properties were evaluated: internal consistency, test-retest reliability, interrater reliability, and convergent and predictive validity.

RESULTS

The SIJID demonstrated high test-retest, interrater reliability and also showed strong discriminant and convergent validity. It showed good predictive validity based on 1-year follow-up information of the patient's clinical outcomes, with a significant association between higher SIJID total scores at baseline, and more severe neuropsychiatric symptoms and more severe caregiver distress at follow-up. Moreover, higher scores of dangerous behaviors at baseline were significantly correlated with a higher frequency of hospitalization and placement in residential care 1 year later.

CONCLUSION

The SIJID is a reliable and valid instrument to assess insight and judgment in patients with AD and is a valuable tool for assessing presence and severity of dangerous behaviors, determining risk, and providing critical information for the assessment of competency.

Functional Status Predicts Awareness in Late-Onset but not in Early-Onset Alzheimer Disease

This study aims to assess whether there are differences between the level of awareness in early-onset Alzheimer disease (EOAD) and late-onset Alzheimer disease (LOAD) and to test its association with quality of life (QOL). A consecutive series of 207 people with Alzheimer disease and their caregivers were selected from an outpatient unit. There were no significant differences in awareness. In LOAD, impairment on awareness was predicted by functional level (β = .37, P < .001), self ( P = .006), and informant report of QOL ( P = .010). The predictors of unawareness in EOAD were self ( P = .002) and informant report of QOL ( P < .001). There is a specific profile of functional deficits underlying awareness in people with LOAD. Additionally, reports of EOAD QOL were more strongly related to awareness than in people with LOAD.

Heterogeneity of Cognitive Anosognosia and its Variation with the Severity of Dementia in Patients with Alzheimer's Disease

Currently, the lack of awareness of deficits, i.e., anosognosia, is a major obstacle in the healthcare circuit that delays the diagnosis of Alzheimer's disease (AD). However, a clear framework is lacking in the literature related to this phenomenon in terms of its definition, mechanisms, and objects. The aim of this study is to assess the different levels of cognitive anosognosia using a prediction-performance procedure and to identify the potential correlates of these levels. A sample of patients with probable AD was divided into three groups according to the severity of dementia (mild (MiD), moderate (MoD), and moderately severe (MSD) dementia), ranked according to the results of the Mini-Mental State Examination. We observed the following three scores: the real score, the prediction score, and the anosognosia score. These scores were calculated based on the prediction-performance task MISAwareness from the Dementia Rating Scale for cognitive processes (i.e., Attention, Initiation, Conceptualization, Construction, and Memory). We obtained a strong plateau effect between the MiD and MoD groups for anosognosia scores for actual performance or prediction for both the level of overall functioning and for specific processes. The sole exception was the result for memory processes. Moreover, the profiles of the patients' responses on the Memory subscale were substantially different and, indeed, opposite from those for the other processes. The main results confirm the multidimensionality of anosognosia and its variability with the stage of dementia and specifically implicate memory processes that indicate a cleavage between memory and other cognitive functions.

Subjective Cognitive Impairment and Affective Symptoms: A Systematic Review

PURPOSE OF STUDY

Subjective cognitive impairment (SCI) has been argued to reflect affective symptoms (i.e., depression and anxiety) rather than actual cognitive issues. Although a number of studies exist that look at the associations between SCI and affective symptoms, no review is available to aggregate this disparate literature. We addressed this gap by conducting a systematic review to better understand the relationships among SCI and affective symptoms among older adults in both community and clinical settings.

DESIGN AND METHODS

We reviewed available literature per the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Weight of evidence (WoE) ratings and narrative synthesis were completed for 58 articles.

RESULTS

A majority of studies focused on community-based samples (n = 40). Approximately half (53%) of the articles reviewed met high WoE criteria for the current review. Cross-sectional findings consistently identified a positive relationship among SCI and affective symptoms. Findings from available longitudinal studies (n = 9) were mixed but suggested a possible reciprocal relationship among SCI and depression. The relationship between SCI and anxiety appeared to be driven by fears over loss of function. Following consultation with health professionals, the association between SCI and anxiety was diminished or eliminated.

IMPLICATIONS

Although SCI is consistently related to affective symptoms in older adults cross-sectionally, more longitudinal work is needed to understand their temporal relationship. Improved measurement of SCI would support a deeper understanding of the impact of SCI on psychological well-being.

Concepts and objects of awareness in Alzheimer’s disease: an updated systematic review

ABSTRACT Objectives To compare and discuss the objects of awareness in Alzheimer’s disease (AD): awareness of cognitive deficits, of functional activities, of social-emotional functioning and behavioral impairment. Methods A search in the PsycINFo, Pilots, PubMed/Medline and ISI electronic databases according to Prisma methodology was performed. We included studies about awareness in people with AD published between 2010 and 2015, with the combination of keywords: “Alzheimer AND awareness of deficits”, “Alzheimer AND anosognosia”, “Alzheimer AND insight”, “dementia AND awareness of deficits”, “dementia AND anosognosia”, “dementia AND insight”. The articles were categorized according to the specific object of awareness. Results Seven hundred and ten records were identified and, after application of the exclusion criteria, 191 studies were retrieved for potential use. After excluding the duplicates, 46 studies were included. Most studies assessed the cognitive domain of awareness, followed by the functional, social-emotional, and behavioral impairment domains. Memory deficits were not sufficient to explain impaired awareness in AD. Longitudinal studies did not find discrepancies between patients and caregivers’ reports, indicating that awareness is not related to cognition. Conflicting findings were observed, including the relation between awareness, mood, severity of disease, and personal characteristics. Conclusions The studies show lack of conceptual consensus and significant methodological differences. The inclusion of samples without differentiation of dementia etiology is associated to symptomatic differences, which affect awareness domains. Awareness in AD is a complex and multidimensional construct. Different objects elicit different levels of awareness.

Effects of anosognosia and neuropsychiatric symptoms on the quality of life of patients with Alzheimer's disease: a 24-month follow-up study

OBJECTIVES

Neuropsychiatric symptoms and anosognosia are known to influence the perceived quality of life of patients (QoL-p) with Alzheimer's disease (AD). This study analysed their impact on patient and caregiver ratings of QoL-p and how these ratings changed in relation to the severity of dementia.

METHODS

A baseline sample of 221 patients and caregivers was followed up over 24 months. Instruments: Neuropsychiatric Inventory (NPI), Anosognosia Questionnaire-Dementia (AQ-D), Quality of life-Alzheimer's Disease (QoL-AD) and the Global Deterioration Scale (GDS). Longitudinal data were analysed using generalized linear models.

RESULTS

In the multivariate analysis, greater anosognosia was always associated with higher ratings of QoL-p among patients, especially at 24 months (p < 0.001), and with more negative ratings among caregivers, especially at baseline (p < 0.001). A higher total NPI score was associated with a more negative rating of QoL-p among caregivers (p < 0.001), and it also had a smaller negative effect on patients' self-ratings (p = 0.001). The neuropsychiatric symptoms (NPI) associated with a more negative view of QoL-p were depression, for patients' self-ratings, and apathy and agitation for caregiver ratings. The discrepancy between patient and caregiver ratings increased in line with the severity of dementia.

CONCLUSION

Neuropsychiatric symptoms had a similarly negative effect on the QoL-p ratings of both patients and caregivers, whereas the effect of anosognosia differed according to the rater (positive for patients, negative for caregivers).

[Geriatric psychiatric home counseling for people with dementia and anosognosia : Results of a model project]

BACKGROUND

Lack of awareness of an illness (anosognosia) is a common symptom in dementia and has a significant impact on the course of the disease. It is associated with dysfunctional interaction with caregivers. Due to unawareness patients are not able to accept diagnostic procedures or medical treatment and refuse any kind of support. Thus, they are not integrated into psychosocial networks and medical support. This has a significant impact on patient-centered care in a domestic environment. In this article a model project with home visits to patients with dementia and anosognosia is described.

METHOD

A total of 55 home visits were carried out. The aim of this project was the integration into the existing healthcare services in order to safeguard the domestic environment. These visits focused on advice and information for the patients and their caregivers initiating the visits. Sociodemographic data of the patient cohort and the satisfaction of the caregiving relatives and general practitioners are presented.

RESULTS

Subjects with dementia were found to be in advanced stages of the disease, caring situations were complex and required assistance. Caregivers showed a substantial burden in accordance with previous reports.

CONCLUSION

New strategies are required to cope with anosognosia in patients with dementia and their caregivers. Even single home visits seem to be sufficient to initiate support for subjects with dementia and their relatives.

The Concept of Missing Incidents in Persons with Dementia

Behavioral symptoms of dementia often present the greatest challenge for informal caregivers. One behavior, that is a constant concern for caregivers, is the person with dementia leaving a designated area such that their whereabouts become unknown to the caregiver or a missing incident. Based on an extensive literature review and published findings of their own research, members of the International Consortium on Wandering and Missing Incidents constructed a preliminary missing incidents model. Examining the evidence base, specific factors within each category of the model were further described, reviewed and modified until consensus was reached regarding the final model. The model begins to explain in particular the variety of antecedents that are related to missing incidents. The model presented in this paper is designed to be heuristic and may be used to stimulate discussion and the development of effective preventative and response strategies for missing incidents among persons with dementia.

Neuropsychological and behavioral disturbance correlates of unawareness of memory impairment in dementia: a population-based study

INTRODUCTION

This study investigated in a community sample associations of 2 different measures of unawareness of memory impairment in dementia with cognitive variables and behavioral and psychological symptoms of dementia.

METHOD

Design--cross-sectional, population-based survey. Settings--community samples (n = 15 022) from 3 world regions (Latin America, China, and India). Participants--829 people with dementia identified from standardized interviews and diagnostic algorithms. Measurements--unawareness of memory deficits was measured in 2 ways: comparison of participant subjective report with either objective performance on memory tests or informant report (IR). Associations were investigated using prevalence ratios and Poisson regressions. Differences in frequency of unawareness were explored with McNemar tests for each region and agreement between variables calculated with Cohen κ.

RESULTS

The unawareness variable based on comparison with performance was associated with cognitive variables, such as fluency (in China) and visuospatial impairments (Latin America and India), and behavioral symptoms, such as mania (Latin America) and hallucinations (China). The unawareness variable based on IR was associated only with behavioral symptoms, such as anxiety (in China and India) and hallucinations and mania (Latin America). Frequency of unawareness was significantly higher in the unawareness variable based on performance in India. Agreement between the 2 unawareness variables was moderate in Latin America and China but only slight in India.

CONCLUSION

Different ways of measuring unawareness are differentially associated with influencing factors. Informant-based unawareness measures may be more subjective and less sensitive than variables taking into account actual performance on cognitive tests.