Longitudinal assessment of awareness in early-stage Alzheimer's disease using comparable questionnaire-based and performance-based measures: a prospective one-year follow-up study

Subjective cognitive decline: Memory complaints, cognitive awareness, and metacognition

Cognitive complaints are common in elderly subjects and are a frequent reason for referral to memory clinics. If the complaints are not associated with objective cognitive impairment, the condition is labelled subjective cognitive decline (SCD). SCD is often considered as a stage antedating objective impairment, and an at-risk condition for subsequent dementia. Recent large-scale studies indicate that a significantly increased risk of clinical progression in subjects with SCD is associated with positivity for Alzheimer's disease (AD) biomarkers, a finding supporting the notion that SCD can be due to different mechanisms not associated with neurodegeneration, including functional cognitive disorders. In this paper we present a selective review of research on the relations among SCD, cognitive awareness, and metacognitive abilities. We propose that longitudinal studies of metacognitive efficiency in SCD may provide useful cues about the risk of progression to dementia and the possible presence of a functional cognitive disorder, with different implications for the management of this prevalent aging-related condition. HIGHLIGHTS: Subjective cognitive decline (SCD), a common cause of referral to memory clinics, can be due to multiple conditions. The predictive value of SCD for progression to Alzheimer's disease (AD) dementia is high in association with AD biomarker positivity. The awareness of cognitive decline is the mechanism responsible for the emergence of SCD and metacognition is the underlying neuropsychological function. The awareness of cognitive decline in clinical patients is usually assessed comparing an informant rating to the patient self-assessment, a method that can be affected by informant bias. While there is strong evidence that awareness starts to decline with the onset of objective cognitive impairment, progressively leading to the anosognosia of AD, the status of metacognitive efficiency in SCD needs to be further investigated. Quantitative, performance-based indexes of metacognitive efficiency may contribute both to the assessment of progression risk and to the management of subjects with functional cognitive disorders.

The relationship between perceived stigma and perceived stress in cognitive decline: a survey of persons with mild cognitive impairment and their caregivers

Introduction

While Alzheimer's disease and other causes of dementia have rapidly become a global health crisis with growing incidence that is unabated, the incidence of Mild Cognitive Impairment (MCI) far exceeds that of Alzheimer's disease. Persons with MCI demonstrate some level of cognitive impairment, but daily functions remain intact and there is no certainty that they will develop dementia. Yet, the possibility conjures a considerable amount of fear and anxiety, further fueled by a vast array of misconceptions and stigma. The pervasive nature of this stigma permeates society and culture at many levels. Persons with MCI who are at higher risk for development of dementia may be especially vulnerable to fear and stigma associated with the diagnosis. Based on this premise, the primary aim of this study was to examine the relationship between perceived stigma and perceived stress in persons with MCI and their care partners, including the relationship between income and the study variables. The secondary aim was to examine the effect of a combined cognitive rehabilitation and wellness program on these perceptions.

Methods

Thirty participants were recruited from Mayo Clinic's Health Action to Benefit Independence and Thinking (HABIT) program. MCI (n = 15) and care partner (n = 15) participants completed the Stigma Impact Scale (SIS) and the Perceived Stress Scale (PSS) before and after the HABIT program.

Results

Average SIS and PSS scores decreased in the MCI, care partner, and combined groups, both pre- and post-HABIT. Linear regression was used to assess the relationship between perceived stigma and stress, controlling for income. A significant relationship was found between perceived stigma and perceived stress both pre and post-HABIT.

Discussion

The results suggest a relationship exists between perceived stigma and perceived stress in persons with MCI and their care partners, and an educational program such as HABIT may strengthen this relationship by informing participants of potential challenges that occur in cognitive decline. Understanding these relationships may provide an opportunity to provide tools for this vulnerable population.

Changes in awareness of condition in people with mild-to-moderate dementia: Longitudinal findings from the IDEAL cohort

OBJECTIVES

Awareness of difficulties shown by people with dementia is known to vary, but few studies have explored changes in awareness over time. Investigating this could further the understanding of surrounding concepts and reasons for impaired awareness. Recognising emerging or diminishing awareness could facilitate discussions about diagnosis and appropriate post-diagnostic support.

METHODS

Using longitudinal data from the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort, awareness in community-dwelling people with mild-to-moderate dementia was assessed at three timepoints over 2 years. A validated checklist was used to evaluate awareness of difficulties associated with dementia. We examined changes in awareness for people with low awareness at baseline, and used case-matching to describe differences in characteristics between people who gained awareness, and those who continued with low awareness.

RESULTS

At baseline, 83 people from a sample of 917 showed low awareness. The majority of those remaining in the study at later timepoints had gained awareness, some as late as four or more years after diagnosis. Case-matched comparisons revealed few distinguishing characteristics: cases with stable low awareness had similar or better cognitive and functional ability than those who gained and retained awareness at 12 and 24 months, but may have had more co-morbidities.

CONCLUSIONS

Self-reported awareness of difficulties can change and may increase over time in people with mild-to-moderate dementia. There may be individual reasons for ongoing low awareness, not explained by cognitive or functional ability. This challenges the view that a single record of low awareness represents a fixed disease-related symptom, and highlights the complex, individual and dynamic nature of awareness.

Awareness for People With Alzheimer’s Disease: Profiles and Weekly Trajectories

Objective: To understand awareness and fluctuations of awareness in Alzheimer’s disease (AD), it is fruitful to consider the objects of awareness, e.g., cognitive functioning or recognition of the disease, as well as the mechanisms and modes of expression underlying awareness. With a holistic and discourse-centered approach, we aimed to identify different awareness profiles and test whether these profiles were stable or whether transitions from one profile to another occurred over short time intervals.

Methods: Twenty-eight residents of nursing homes with a diagnosis of AD participated in four semistructured interviews at biweekly intervals. These interviews were cluster analyzed to determine profiles of awareness. A Markov chain was applied to model their fluctuation.

Results: Five awareness profiles were observed that differed in terms of objects and underlying processes. Awareness proved to be quite stable for four of the five profiles. Interindividual variability in awareness was also observed through numerous different trajectories that were identified.

Discussion: Self-awareness and disease awareness are characterized by profiles that vary subtly between individuals. Fluctuations in awareness underscore the need to employ assessment intervals that closely reflect daily life in institutions.

The Association Between Impaired Awareness and Depression, Anxiety, and Apathy in Mild to Moderate Alzheimer's Disease: A Systematic Review

Objectives: Impaired awareness of cognitive and functional deficits is a common feature of Alzheimer's disease (AD). Although a lack of awareness has been suggested to be a protective factor against experiencing affective symptoms, such as depression, anxiety, and apathy which are common in AD, there is conflicting evidence about the links between them. This systematic review examines the evidence for an association between impaired awareness and depressive, anxiety, and apathy symptoms in mild to moderate AD. Method: We searched four databases (OvidMedline, Embase, PsycInfo, and PsycArticles) using terms encompassing awareness, apathy, depression, anxiety, and mild-moderate AD. We included studies that assessed the relationship between awareness and depressive symptoms, anxiety symptoms, or apathy. We assessed included papers for quality and report results using a narrative approach, prioritizing high quality studies. Results: We identified 1,544 articles, and twenty-seven studies fulfilled inclusion criteria (high-quality = 15; moderate-quality = 12). Most high-quality studies reported that impaired awareness in early-stage AD is cross-sectionally linked with fewer depressive symptoms and anxiety symptoms (correlation ranged from -0.3 to -0.7), but with more apathy. Conclusions: High-quality studies suggested that in people with early AD, impaired awareness is related to fewer depressive and anxiety symptoms and to more apathy. Future research should focus on elucidating causality among impaired awareness and these symptoms in AD.

Awareness of dementia and coping to preserve quality of life: a five-year longitudinal narrative study

Purpose

To examine how people (<65 years) with young-onset dementia (YOD) express awareness of dementia and how they seem to handle awareness as a strategy to preserve quality of life over time.

Method

A longitudinal qualitative study with individuals with YOD was performed with interviews every 6 months over 5 years for a maximum of 10 interviews. The interviews were analysed by modified grounded theory adapted to narrative inquiry.

Results

Awareness is a complex, multidimensional concept. Awareness of dementia is predisposed by personality, life history and established coping styles. The main coping styles during dementia—live in the moment, ignore the dementia, and make the best of it—seem to be rather consistent throughout disease progression. Transitions in the life situation may change the individual’s awareness of dementia.

Conclusion

Unawareness of dementia may have an important adaptive function for preserving quality of life. Increasing awareness of dementia must be approached with reflexivity and great sensitivity.

Evolution of anosognosia in alzheimer's disease and its relationship to amyloid

OBJECTIVE

Unawareness, or anosognosia, of memory deficits is a challenging manifestation of Alzheimer's disease (AD) that adversely affects a patient's safety and decision-making. However, there is a lack of consensus regarding the presence, as well as the evolution, of altered awareness of memory function across the preclinical and prodromal stages of AD. Here, we aimed to characterize change in awareness of memory abilities and its relationship to beta-amyloid (Aβ) burden in a large cohort (N = 1,070) of individuals across the disease spectrum.

METHODS

Memory awareness was longitudinally assessed (average number of visits = 4.3) and operationalized using the discrepancy between mean participant and partner report on the Everyday Cognition scale (memory domain). Aβ deposition was measured at baseline using [18F]florbetapir positron emission tomographic imaging.

RESULTS

Aβ predicted longitudinal changes in memory awareness, such that awareness decreased faster in participants with increased Aβ burden. Aβ and clinical group interacted to predict change in memory awareness, demonstrating the strongest effect in dementia participants, but could also be found in the cognitively normal (CN) participants. In a subset of CN participants who progressed to mild cognitive impairment (MCI), heightened memory awareness was observed up to 1.6 years before MCI diagnosis, with memory awareness declining until the time of progression to MCI (-0.08 discrepant-points/yr). In a subset of MCI participants who progressed to dementia, awareness was low initially and continued to decline (-0.23 discrepant-points/yr), reaching anosognosia 3.2 years before dementia onset.

INTERPRETATION

Aβ burden is associated with a progressive decrease in self-awareness of memory deficits, reaching anosognosia approximately 3 years before dementia diagnosis. ANN NEUROL 2020;87:267-280.

"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.

Antecedents and consequences of unawareness of memory impairment in dementia

OBJECTIVE

To assess the prevalence, antecedents, and consequences of unawareness of memory impairment in dementia.

METHOD

Persons (n = 1,862) from a geographically defined community without dementia at enrollment subsequently underwent clinical classification (248 with dementia, 611 with mild cognitive impairment, 1,003 with no cognitive impairment), memory testing, and self-appraisal of memory. Memory performance was regressed on self-appraised memory, and the residuals served as an index of memory awareness. After clinical classification, participants completed brief cognitive testing at 3-year intervals for up to 15 years.

RESULTS

When unawareness was defined as a score at or below thresholds ranging from the 15th to 25th percentiles, it was more common in dementia (67%-83%) and mild cognitive impairment (15%-33%) than in no cognitive impairment (2%-6%; all p < .001). A continuous measure of awareness (M = 0.00, SD = 0.61) was reduced by 0.37-unit in mild cognitive impairment (SE = 0.04, p < .001) and 1.04-unit in dementia (SE = 0.06), p < .001) compared with those without cognitive impairment, and these associations were weaker in Black persons than White persons (estimate for dementia by race = 0.37, SE = 0.12, p = .003; estimate for mild cognitive impairment by race = 0.30, SE = 0.08, p < .001). Higher premorbid neuroticism was associated with better memory awareness in dementia. Higher memory awareness was not related to mortality in mild cognitive impairment or dementia but had a marginal association with slower cognitive decline in mild cognitive impairment.

CONCLUSIONS

Unawareness of memory impairment is a common manifestation of dementia, particularly in White persons, but is not strongly related to adverse disease outcomes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Integrating the Constructs of Anosognosia and Metacognition: a Review of Recent Findings in Dementia

The current review integrates recent findings regarding the construct of self-awareness in dementia from both clinical and cognitive perspectives. We present the predominant theoretical models of awareness and summarize both traditional and emerging approaches to assessing awareness from clinical and meta-cognitive perspectives. In this review, we focus primarily on findings from recent studies in anosognosia and meta-cognition in the context of neurodegenerative disease with special emphasis on Alzheimer's disease and frontotemporal dementia. Emerging trends in the study of awareness, including examination of the longitudinal course of anosognosia, and investigation of the neural substrates underlying meta-cognitive abilities are addressed. Finally, the practical importance of studying and assessing awareness from both theoretical and clinical angles is emphasized.

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.

Temporal course and pathologic basis of unawareness of memory loss in dementia

OBJECTIVE

To characterize the natural history and neuropathologic basis of unawareness of memory loss in late-life dementia.

METHODS

Analyses are based on 2,092 older persons from 3 longitudinal clinical-pathologic cohort studies who had no memory or cognitive impairment at baseline. Annual evaluations included clinical classification of dementia plus self-rating and performance testing of memory. At death, there was a uniform neuropathologic examination to quantify 7 dementia-related pathologies.

RESULTS

In the full group, memory ratings were modestly correlated with memory performance (intercepts r = 0.26, p < 0.001; slopes r = 0.23, p < 001) and so we regressed each person's memory performance on their memory ratings, and the residuals provided longitudinal indicators of memory awareness. In a subset of 239 persons who developed dementia, episodic memory awareness was stable until a mean of 2.6 years before dementia onset (95% credible interval -2.7, -1.6); thereafter, memory awareness declined rapidly (mean annual change -0.32, 95% credible interval -0.37, -0.28). Older age at baseline was associated with later onset of memory unawareness. In a subset of 385 persons who died and underwent neuropathologic examination, transactive response DNA-binding protein 43 (TDP-43) pathology, tau tangles, and gross cerebral infarcts were related to decline in memory awareness. In the absence of these pathologies, no decline in memory awareness was evident. Results were similar in subgroups with and without dementia.

CONCLUSIONS

Awareness of memory impairment typically begins to decline about 2-3 years before dementia onset and is associated with postmortem evidence of TDP-43 pathology, tangles, and gross cerebral infarcts.

Longitudinal changes in awareness over 36 months in patients with mild Alzheimer's disease

BACKGROUND

Longitudinal changes in awareness in dementia have been studied with short follow-up time and mostly in small patient groups (including patients with moderate dementia). We investigated awareness in patients with mild Alzheimer's disease (AD) over 36 months and studied if a decline in awareness was associated with decline in cognition and increase in neuropsychiatric symptoms.

METHODS

Awareness was measured on a categorical scale in 95 AD patients (age ≥50 years, Mini-Mental State Examination (MMSE) score ≥20). Awareness was rated at three time points (follow-up at 12 and 36 months) where MMSE, Neuropsychiatric Inventory (NPI-Q), and Cornell scale for Depression in Dementia also were applied.

RESULTS

At 12 months, 26% had lower awareness rating as compared to baseline and at 36 months lower awareness ratings were found in 39%. At both visits, 16% had higher awareness rating as compared to baseline. Patients with lower awareness at 36 months as compared to baseline had a more rapid increase in NPI-Q score (p = 0.002) over 36 months as compared to patients with stable or improved awareness over 36 months. A more rapid decline in MMSE score was observed for patients with lower awareness at 36 months (as compared to baseline) but only when compared to patients in whom awareness improved over time.

CONCLUSIONS

The results show essentially no clear relationship between cognitive decline over three years and awareness. In some cases, awareness remained stable or even improved despite significant cognitive decline. In the subgroup where awareness declined over time, overall ratings of neuropsychiatric symptoms declined more rapidly than in the remaining patients.

Clinical correlates of awareness for balance, function, and memory: evidence for the modality specificity of awareness

Awareness in dementia is increasingly recognized not only as multifactorial, but also as domain specific. We demonstrate differential clinical correlates for awareness of daily function, awareness of memory, and the novel exploration of awareness of balance. Awareness of function was higher for participants with mild cognitive impairment (aMCI and non-aMCI) than for those with dementia (due to Alzheimer disease; AD and non-AD), whereas awareness of memory was higher for both non-aMCI and non-AD dementia patients than for those with aMCI or AD. Balance awareness did not differ based on diagnostic subgroup. Awareness of function was associated with instrumental activities of daily living and caregiver burden. In contrast, awareness of balance was associated with fall history, balance confidence, and instrumental activities of daily living. Clinical correlates of awareness of memory depended on diagnostic group: associations held with neuropsychological variables for non-AD dementia, but for patients with AD dementia, depression and instrumental activities of daily living were clinical correlates of memory awareness. Together, these data provide support for the hypothesis that awareness and dementia are not unitary and are, instead, modality specific.

Consciência do déficit na doença de Alzheimer: diferenças entre os domínios cognitivo e funcional

OBJETIVOS: Revisar sistematicamente desenhos de estudo, instrumentos de avaliação e fatores relacionados ao comprometimento dos domínios cognitivo e funcional da consciência do déficit em pessoas com doença de Alzheimer (DA). MÉTODO: Pesquisa nas bases de dados PubMed e ISI de estudos sobre consciência do déficit na DA publicados entre 2008 e 2013. As palavras-chave utilizadas foram: "dementia", "Alzheimer", "awareness", "awareness of memory" e "awareness of functioning", "deficits", "cognition". RESULTADOS: Os 10 artigos selecionados utilizaram os conceitos "falta de consciência do déficit", "anosognosia", "insight", "falta de consciência das dificuldades cognitivas" e "consciência limitada das deficiências". A etiologia do comprometimento da consciência do déficit foi relacionada a fatores biológicos como gravidade clínica da doença, associações neuroanatômicas, alterações neuropsiquiátricas e fatores psicológicos e sociais. O desenho de estudo mais utilizado foi o corte transversal. No domínio cognitivo, a memória e as funções executivas foram as duas principais funções investigadas. No domínio funcional, foram encontradas associações com a disfunção executiva, declínio da interação social, depressão e a influência do desempenho ocupacional. CONCLUSÕES: As distintas hipóteses etiológicas, a operacionalização variável do conceito e a falta de instrumentos de avaliação padronizados impossibilitam a obtenção de resultados homogêneos. Essas dificuldades comprometem a compreensão e a investigação dos domínios cognitivo e funcional.

Consciência da doença na demência do tipo Alzheimer: uma revisão sistemática de estudos longitudinais

OBJETIVOS: Avaliar as definições, métodos de avaliação e hipóteses etiológicas utilizadas em estudos longitudinais sobre consciência da doença na demência do tipo Alzheimer. MÉTODO: Pesquisa, nas bases de dados Medline, ISI, Lilacs e SciELO, de estudos longitudinais sobre consciência da doença na demência do tipo Alzheimer entre 1999 e 2009. As palavras-chave utilizadas foram: "Alzheimer", "dementia", "anosognosia", "awareness of deficit", "awareness of disease", "insight" e "longitudinal study". Os artigos examinados foram classificados conforme as hipóteses etiológicas encontradas. RESULTADOS: Os nove artigos selecionados foram divididos em duas áreas: hipóteses etiológicas biológicas e hipóteses etiológicas psicossociais. Os termos "falta de consciência dos déficits", "consciência do déficit", "insight" e "negação do déficit de memória" são utilizados nos estudos como sinônimos do termo "anosognosia", mesmo sendo, conceitualmente, diferentes. O método de avaliação mais utilizado foi o uso de questionários de discrepância entre os relatos dos pacientes e cuidadores. CONCLUSÕES: Os estudos longitudinais apresentam hipóteses etiológicas heterogêneas, além da inexistência de um padrão conceitual e metodológico de avaliação. Essas dificuldades impossibilitam a obtenção de resultados homogêneos, o que gera a necessidade de aprofundamento dos estudos na área.

Three trail making tests for use in neuropsychological assessments with brief intertest intervals

Practice effects in serial neuropsychological assessment have led to the use of alternate forms to measure change in cognitive functioning. The construct validity of three variants of the Trail Making Test was explored over a 3-week period in a sample of 158 undergraduate students. Using confirmatory factor analysis, a two-factor (sequencing-shifting) model was identified to best represent the data. Latent means structural analysis indicated the absence of order effects, lending support for the construct validity of the three tests. The study provides evidence that the three tests can be offered as potential alternative instruments in serial assessment.

Awareness of memory functioning in early Alzheimer's disease: lessons from a comparison with healthy older people and young adults

To compare awareness of memory in people with early Alzheimer's disease (AD) with older and younger control groups in order to clarify the contributions of disease and ageing. Twenty-one individuals with early AD, 32 older people (OP) and 32 younger people (YP) estimated their performance before and following each of four tests of memory. Those with AD significantly overestimated performance prior to testing, confirming the presence of unawareness for prediction. Their estimates were adjusted for age in a similar way to those of OP, who predicted their performance accurately. Younger people significantly underestimated their performance. Following memory tests, YP and those with AD significantly adjusted their ratings towards greater accuracy but on average those with AD still overestimated. There were variations in post-test ratings from over to under prediction in all three groups. Heightened awareness post-performance may open possibilities of cognitive rehabilitation to consolidate momentary into more long-term awareness, whilst the operation of possible psychosocial influences suggests that emotion oriented interventions to increase acceptance and decrease shame might be helpful.