Anosognosia for memory impairment in Alzheimer's disease

The Breakfast and Dressing Conflict Task: Preliminary Evidence of Its Validity to Measure Online Self-Awareness After Acquired Brain Injury

IMPORTANCE

Impaired self-awareness (SA) of deficits after an acquired brain injury (ABI) severely affects patients' independence in activities of daily living (ADLs). However, any assessment tool permits an exhaustive evaluation of SA in the context of ADLs.

OBJECTIVE

To study the validity of the Breakfast and Dressing Conflict Task (BD Conflict Task) to assess online SA (awareness of performance in the context of a given task) in patients with ABI; to study its interactions with offline SA (general awareness); and to test the validity of a simplified measure of performance monitoring, the ADL Conflict-Monitoring Index.

DESIGN

Convergent validity and correlational study.

SETTING

Research laboratory, hospitals, and homes.

PARTICIPANTS

Thirty patients with ABI and 28 neurologically healthy controls.

OUTCOMES AND MEASURES

Using the BD Conflict Task, measures of emergent awareness, self-regulation, anticipatory awareness, and self-evaluation were assessed and their convergent validity and relationship with offline SA were analyzed. The ADL Conflict-Monitoring Index was calculated, and its convergent validity was tested.

RESULTS

The online SA variables of the BD Conflict Task showed convergent validity with traditional online SA measures. Offline SA correlated with emergent and anticipatory awareness in the Breakfast Task. The ADL Conflict-Monitoring Index proved to be a valid measure of patients' performance monitoring.

CONCLUSIONS AND RELEVANCE

These preliminary findings suggest that the BD Conflict Task is a valid tool to assess online SA in patients with ABI and provide further understanding of the online SA-offline SA interaction. Furthermore, the ADL Conflict-Monitoring Index may be a valid and easy-to-use monitoring measure in clinical settings. Plain-Language Summary: Patients with acquired brain injury (ABI) and reduced awareness of their cognitive deficits face problems performing activities of daily living (ADLs) and may show signs of unsafe behaviors. Being aware of one's own abilities involves anticipating problems before starting a task, detecting and correcting errors during the task, and evaluating performance afterward. This study provides preliminary validity for the Breakfast and Dressing Conflict Task, a new tool that assesses aspects of self-awareness simultaneously in the context of familiar and significant ADLs. Furthermore, the tool simplifies the assessment of detecting and correcting errors with an easy-to-use index, making it suitable for use in clinical settings.

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.

Altered metamemory precedes cognitive impairment in subjective cognitive decline with positive amyloid-beta

Subjective cognitive decline (SCD) as an indicator of preclinical Alzheimer's disease (AD) may precede mild cognitive impairment (MCI) over several decades. Self-reported cognitive decline as a typical clinical manifestation is critical in preclinical AD. Metacognition represents a person's ability to accurately assess cognition. Our study aimed to examine (1) the alternations of metamemory in a cohort across the Alzheimer's continuum, (2) the association between metamemory and cognition, and (3) the relationship of cortical thickness in four regions of interest (ROI) with metamemory scores. Six hundred ninety-seven participants were classified as 79 AD dementia, 161 aMCI, 261 SCD, and 196 cognitively unimpaired (CU) individuals, in which 418 participants aged above 65, 131 participants with Aβ+ after receiving positron emission tomography, and 602 participants received sMRI. The degree of confidence (DOC) was measured by calculating discrepancies between judgments and memory performance. We assessed the relationships between DOC tertiles and cognition and analyzed the screening power, then investigated the partial correlation between DOC and ROIs, controlled by age, sex, and cognition. In the Aβ+ subgroup, SCD showed significantly higher DOC scores than the CU group. There was an increasing trend of overconfidence with the decline of cognition across the AD spectrum (P for trend < 0.001). After adjusting for age, sex, and education, the lower degree of confidence-long-term delay recall (DOC-LD) tertiles were associated with lower odds ratio in SCD, aMCI, and AD in the Aβ+ subgroup (all P for trend < 0.05). The area under the curves of DOC scores for screening SCD from CU in the Aβ+ subgroup was better than that in all participants and the age ≥65 subgroup. Partial correlation showed that in the Aβ+ subgroup, DOC-SD (degree of confidence-short-term delay recall) was negatively correlated with the anterior cingulate cortex; DOC-LD was negatively correlated with the cortices of parahippocampal, anterior cingulate, posterior cingulate, and medial orbitofrontal. In individuals with Aβ+, SCD exhibited a detectable metamemory alternation before objective cognitive impairment could be tested, indicated by the overestimation in the memory performance. The pattern of an increasing trend of overconfidence across SCD, aMCI, and AD dementia supports the view of a continuum in Alzheimer's disease.

In Vivo Parieto-Occipital White Matter Metabolism Is Correlated with Visuospatial Deficits in Adult DM1 Patients

Myotonic dystrophy type 1 (DM1) is a genetic disorder caused by a (CTG) expansion in the DM protein kinase (DMPK) gene, representing the most common adult muscular dystrophy, characterized by a multisystem involvement with predominantly skeletal muscle and brain affection. Neuroimaging studies showed widespread white matter changes and brain atrophy in DM1, but only a few studies investigated the role of white matter metabolism in the pathophysiology of central nervous system impairment. We aim to reveal the relationship between the metabolic profile of parieto-occipital white matter (POWM) as evaluated with proton MR spectroscopy technique, with the visuoperceptual and visuoconstructional dysfunctions in DM1 patients. MR spectroscopy (3 Tesla) and neuropsychological evaluations were performed in 34 DM1 patients (19 F, age: 46.4 ± 12.1 years, disease duration: 18.7 ± 11.6 years). The content of neuro-axonal marker N-acetyl-aspartate, both relative to Creatine (NAA/Cr) and to myo-Inositol (NAA/mI) resulted significantly lower in DM1 patients compared to HC (p-values < 0.0001). NAA/Cr and NAA/mI correlated with the copy of the Rey-Osterrieth complex figure (r = 0.366, p = 0.033; r = 0.401, p = 0.019, respectively) and with Street’s completion tests scores (r = 0.409, p = 0.016; r = 0.341, p = 0.048 respectively). The proportion of white matter hyperintensities within the MR spectroscopy voxel did not correlate with the metabolite content. In this study, POWM metabolic alterations in DM1 patients were not associated with the white matter morphological changes and correlated with specific neuropsychological deficits.

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

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

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.

Awareness of Cognitive Decline in Patients With Alzheimer's Disease: A Systematic Review and Meta-Analysis

Background: Identifying a poor degree of awareness of cognitive decline (ACD) could represent an early indicator of Alzheimer's disease (AD). Objectives: (1) to understand whether there is evidence of poor ACD in the pre-dementia stages of AD; (2) to summarize the main findings obtained investigating ACD in AD; (3) to propose a conceptual framework. Data Sources: We searched Scopus, Pubmed, and the reference lists for studies published up to August 2020. Original research articles must report a measure of ACD and included individuals with AD dementia, or prodromal AD (or MCI), or being at risk for AD. Data Synthesis: All studies covering preclinical, prodromal, and AD dementia were systematically reviewed. We intended to perform a meta-analysis of empirical studies on preclinical AD or prodromal AD (or MCI), to compare ACD between clinical groups. Due to the paucity of literature on preclinical AD, meta-analysis was only possible for prodromal AD (or MCI) studies. Results: We systematically reviewed 283 articles, and conducted a meta-analysis of 18 articles on prodromal AD (or MCI), showing that ACD was not significantly different between patients with amnestic and non-amnestic MCI (SMD = 0.09, p = 0.574); ACD was significantly poorer in amnestic MCI (SMD = -0.56, p = 0.001) and mild AD (SMD = -1.39, p < 0.001) than in controls; ACD was also significantly poorer in mild AD than in amnestic MCI (SMD = -0.75, p < 0.001), as well as poorer than in non-amnestic MCI (SMD = -1.00, p < 0.001). We also discuss key findings on ACD in AD, such as its neural and cognitive correlates. Conclusions and Implications: We propose that patients may be complaining of their initial subtle cognitive changes, but ACD would soon start to decrease. The individual would show mild anosognosia in the MCI stage, and severe anosognosia in dementia. The evaluation of ACD (comparing self-report to cognitive scores or to informant-report) could be useful to guide the clinician toward a timely diagnosis, and in trials targeting early-stage AD.

Insight into memory and functional abilities in individuals with amnestic mild cognitive impairment

OBJECTIVE

Accurate insight into one's abilities facilitates engagement in rehabilitation and implementation of compensatory strategies. In this study, self-awareness, self-monitoring, and a new self-updating construct of insight were examined in amnestic mild cognitive impairment (aMCI).

METHOD

Individuals with aMCI and healthy older adults (HOAs) completed a list-learning task in a laboratory setting, and a naturalistic task of everyday functioning in a campus apartment along with other standardized neuropsychological tests. Participants made predictions about performance on the memory and functional tasks prior to task experience (self-awareness), immediately after task experience (self-monitoring), and after a delay (self-updating).

RESULTS

Individuals with aMCI performed more poorly than HOAs on the memory task and other neuropsychological tests but not the functional task. For both the memory and functional task, performance predictions and prediction accuracy measures revealed that the aMCI group exhibited intact self-awareness, self-monitoring, and self-updating. Prediction accuracy measures showed some association with an executive composite but not a memory composite.

DISCUSSION

Participants with aMCI demonstrated intact self-awareness, self-monitoring, and self-updating for a memory and functional task despite exhibiting poorer performance on neurocognitive tests compared to HOAs. These findings suggest that, even as memory in aMCI degrades, executive abilities may help sustain insight into difficulties, enabling adoption of cognitive strategies to support difficulties.

The Petrified Self 10 Years After: Current Evidence for Mnemonic anosognosia

Lack of awareness about disease, its symptoms and consequences, also termed anosognosia, is a common feature of Alzheimer's disease (AD). It has been hypothesized that memory disorder may be a key contributing factor to anosognosia, with people with AD not being able to update their personal information about performance and relying on older consolidated material about ability. This potentially outdated sense of self has been named, as a metaphor, the petrified self. In the current review, evidence from the past 10 years in relation to this concept is critically appraised. In particular, focus is given to empirical evidence produced on anterograde memory deficits about performance, the profile of autobiographical retrograde memory loss and the role of frontal lobes in anosognosia in AD. Finally, wider consequences of this metaphor for the understanding of selfhood in dementia are discussed.

"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.

In the here and now: Short term memory predictions are preserved in Alzheimer's disease

According to neuropsychological models of anosognosia, there is a failure to transfer on-line awareness of dysfunction into a more generalised long term belief about memory function in Alzheimer's disease. This failure results in specific metamemory deficits for global predictions: patients overestimate their performance before the task but are able to monitor their memory performance after having experienced the task. However, after a delay, they are still not able to make accurate predictions. As previous work has mainly focused on long-term memory, the present study investigates this issue in short-term and working memory. Using both global and item-by-item metacognitive judgements in a digit span task, we showed that Alzheimer's disease patients are as accurate as older adults in monitoring their performance despite impaired memory. When they have the opportunity to test themselves, or when they have already performed the task, patients are able to use feedback to adjust their metacognitive judgements. Overall, these results show that even for a relatively complex task, patients with Alzheimer's disease are aware of their difficulties in the here-and-now.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Response bias and response monitoring: Evidence from healthy older adults and patients with mild Alzheimer's disease

Patients with Alzheimer's disease (AD) often exhibit an abnormally liberal response bias in recognition memory tests, responding "old" more frequently than "new." Investigations have shown patients can to shift to a more conservative response bias when given instructions. We examined if patients with mild AD could alter their response patterns when the ratio of old items is manipulated without explicit instruction. Healthy older adults and AD patients studied lists of words and then were tested in three old/new ratio conditions (30%, 50%, or 70% old items). A subset of participants provided estimates of how many old and new items they saw in the memory test. We demonstrated that both groups were able to change their response patterns without the aid of explicit instructions. Importantly, AD patients were more likely to estimate seeing greater numbers of old than new items, whereas the reverse was observed for older adults. Elevated estimates of old items in AD patients suggest their liberal response bias may be attributed to their reliance on familiarity. We conclude that the liberal response bias observed in AD patients is attributable to their believing that more of the test items are old and not due to impaired meta-memorial monitoring abilities.

Relating pessimistic memory predictions to Alzheimer's disease brain structure

Patients with Alzheimer's disease (AD) show impairment of episodic memory and related metacognitive processes. The present study examined subjective metacognitive judgments preceding objective memory retrieval and investigated the neural correlates of pessimistic predictions for successfully retrieved memories in AD patients. AD patients and healthy older (HO) participants provided predictive judgments on their recognition performance before retrieval of famous (semantic) and recently learned (episodic) names. Correlations between gray matter volume (GMV) in T1 images and behavioral scores were examined with multivariate (partial least square - PLS) and univariate (general linear model - GLM) analyses in AD patients. AD patients showed a significant proportion of successful name recognition preceded by pessimistic prediction in episodic memory. PLS revealed that the behavioral pattern in AD patients was related with a mainly right lateralized pattern of GMV decrease including medial temporal lobe and posterior cingulate cortex (PCC), but also right ventrolateral prefrontal cortex (VLPFC). GLM further confirmed that pessimistic prediction negatively correlated with GMV in VLPFC. Thus, impaired monitoring processes (possibly influenced by inaccurate beliefs) allowing inferences about one's own memory performance are primarily related to decrease GMV in VLPFC in AD patients.

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.

Awareness of cognitive deficits and clinical competence in mild to moderate Alzheimer's disease: their relevance in clinical practice

Awareness of cognitive deficits and clinical competence were investigated in 79 mild to moderate Alzheimer's disease patients. Awareness was assessed by the anosognosia questionnaire for dementia, and clinical competence by specific neuropsychological tests such as trail making test-A, Babcock story recall test, semantic and phonemic verbal fluency. The findings show that 66 % of the patients were aware of memory deficits, while the 34 % were unaware. Deficit in awareness correlated with lower scores on the Mini Mental State Examination test that, in the score range from 24.51 to 30 and from 19.50 to 24.50, appeared to be a significant predictor of level of awareness. None of the AD patients had fully preserved clinical competence, only 7 patients (9 %) had partially preserved clinical competence and 72 patients (91 %) had completely lost clinical competence. All the patients with partially preserved clinical competence (9 %) were aware of their memory deficit. The study indicates that neuropsychological tests used for the assessment of executive functions are not suitable for investigating clinical competence. Therefore, additional and specific tools for the evaluation of clinical competence are necessary. Indeed, these might allow clinicians to identify AD patients who, despite their deficits in selected functions, retain their autonomy of choice as well as recognize those patients who should proceed to the nomination of a legal representative.

Clinical correlates of unawareness of deficits among patients with dementia due to Alzheimer's disease

BACKGROUND

To investigate the associations between unawareness of deficits and clinical correlates, including apathy and depression, among patients with dementia due to Alzheimer's disease (AD).

METHODS

Fifty-five patients with AD were enrolled. Unawareness of memory deficits and psychosis or behavior problems was assessed. The Apathy Evaluation Scale informant version and the Cornell Scale for Depression in Dementia (CSDD) were used to measure apathy and depression, respectively.

RESULTS

In all, 32 (57.2%) and 27 (49.1%) participants were identified as being unaware of memory deficits and psychosis or behavior problems, respectively. Unawareness of memory deficits was associated with lower scores on the Mini-Mental State Examination (MMSE) and higher scores on the CSDD. Unawareness of psychosis or behavior problems was associated with lower scores on the MMSE.

CONCLUSION

Unawareness of deficits among patients with AD was common. The 2 domains of unawareness showed different characteristics and may possibly present different etiologies.

O insight no transtorno bipolar: uma revisão sistemática

Objetivos Realizar uma revisão sistemática para compreender que fatores estão relacionados a uma maior ou menor consciência de morbidade no transtorno bipolar (TB), como o insight varia em função do estado afetivo e estabelecer uma comparação com outros transtornos mentais. Métodos Realizou-se uma revisão sistemática da literatura científica sobre o insight em pacientes com TB. Foram buscados estudos clínicos originais sobre o tema nas bases de dados Medline, ISI e SciELO. Os termos de busca empregados foram: “insight” OR “awareness” AND “bipolar” OR “mania” OR “manic”. Resultados Foram selecionados 55 artigos. O insight no TB parece ser mais prejudicado do que na depressão unipolar, porém menos do que na esquizofrenia. Com relação ao TB, um menor nível de insight está relacionado à presença de sintomas psicóticos e de alterações cognitivas. Além disso, um comprometimento do insight está associado a uma menor adesão ao tratamento. Por outro lado, uma maior preservação do insight pode estar associada a maior ideação suicida. Finalmente, a fase maníaca cursa com um nível inferior de insight quando comparada à fase depressiva ou de eutimia. Conclusão No TB, o insight está significativamente prejudicado, especialmente na mania. Diversos fatores clínicos parecem influenciar o nível de insight.

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.

Alzheimer's disease can spare local metacognition despite global anosognosia: revisiting the confidence-accuracy relationship in episodic memory

Alzheimer's disease (AD) can impair metacognition in addition to more basic cognitive functions like memory. However, while global metacognitive inaccuracies are well documented (i.e., low deficit awareness, or anosognosia), the evidence is mixed regarding the effects of AD on local or task-based metacognitive judgments. Here we investigated local metacognition with respect to the confidence-accuracy relationship in episodic memory (i.e., metamemory). AD and control participants studied pictures of common objects and their verbal labels, and then took forced-choice picture recollection tests using the verbal labels as retrieval cues. We found that item-based confidence judgments discriminated between accurate and inaccurate recollection responses in both groups, implicating relatively spared metamemory in AD. By contrast, there was evidence for global metacognitive deficiencies, as AD participants underestimated the severity of their everyday problems compared to an informant's assessment. Within the AD group, individual differences in global metacognition were related to recollection accuracy, and global metacognition for everyday memory problems was related to task-based metacognitive accuracy. These findings suggest that AD can spare the confidence-accuracy relationship in recollection tasks, and that global and local metacognition measures tap overlapping neuropsychological processes.

What Do Cognitive Complaints in a Sample of Memory Clinic Outpatients Reflect?

Conflicting evidence exists concerning the value of cognitive complaints in the course of assessing cognitive performance in individuals. The present study examines whether cognitive complaints are differentially related to cognitive functioning in groups with different diagnoses. 169 older outpatients (76 years on average) were divided into three groups and diagnosed with subjective cognitive complaints, mild cognitive impairment, or dementia. They were then administered a self-rating questionnaire on cognitive complaints, with semantic fluency and global cognitive functioning being assessed as cognitive measures. Multiple regression analyses revealed that, after controlling for depression, age, sex, and education, global cognitive functioning was not related to cognitive complaints. Semantic fluency was related to cognitive complaints depending on the group. Results suggest that cognitive complaints reflect, in part, actual cognitive performance.