A diagnostic formulation for anosognosia in Alzheimer's disease

Prevalence of sleep disturbances in people with mild cognitive impairment: A systematic review and meta-analysis

This review was performed to determine sleep disturbance prevalence in individuals with mild cognitive impairment (MCI). The MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science databases were systematically searched from inception to January 20, 2024. Fifty-two studies fulfilling the eligibility criteria were included. However, six of these studies were excluded from data synthesis due to poor methodological quality. The subjective sleep disturbance prevalence among all individuals with MCI was 35.8 % (95 % CI: 31.9-39.7) across 44 studies, and the objective sleep disturbance prevalence was 46.3 % (95 % CI: 36.3-56.3) across 6 studies. Five studies examined TST and WASO, while three assessed SE. Among all potential objective assessments of sleep disturbance prevalence, only TST, WASO, and SE could be meta-analyzed in MCI because of the limited number of studies available. The estimated sleep disturbance prevalence differed significantly according to measurement method, geographical region, and research design. However, the data source did not significantly influence prevalence estimates. In meta-regression analysis, publication year, participant age, percentage of females, and study quality did not predict prevalence. As subjective and objective sleep disturbances are common in people with MCI, effective intervention strategies should be developed to alleviate them.

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.

Awareness of episodic memory and meta-cognitive profiles: associations with cerebrospinal fluid biomarkers at the preclinical stage of the Alzheimer's continuum

Introduction

The lack of cognitive awareness, anosognosia, is a clinical deficit in Alzheimer's disease (AD) dementia. However, an increased awareness of cognitive function, hypernosognosia, may serve as a marker in the preclinical stage. Subjective cognitive decline (SCD) might correspond to the initial symptom in the dynamic trajectory of awareness, but SCD might be absent along with low awareness of actual cognitive performance in the preclinical stage. We hypothesized that distinct meta-cognitive profiles, both hypernosognosia and anosognosia, might be identified in preclinical-AD. This research evaluated the association between cerebrospinal fluid (CSF) AD biomarkers and the awareness of episodic memory, further exploring dyadic (participant-partner) SCD reports, in the preclinical Alzheimer's continuum.

Methods

We analyzed 314 cognitively unimpaired (CU) middle-aged individuals (mean age: 60, SD: 4) from the ALFA+ cohort study. Episodic memory was evaluated with the delayed recall from the Memory Binding Test (MBT). Awareness of episodic memory, meta-memory, was defined as the normalized discrepancy between objective and subjective performance. SCD was defined using self-report, and dyadic SCD profiles incorporated the study partner's report using parallel SCD-Questionnaires. The relationship between CSF Aβ42/40 and CSF p-tau181 with meta-memory was evaluated with multivariable regression models. The role of SCD and the dyadic contingency was explored with the corresponding stratified analysis.

Results

CSF Aβ42/40 was non-linearly associated with meta-memory, showing an increased awareness up to Aβ-positivity and a decreased awareness beyond this threshold. In the non-SCD subset, the non-linear association between CSF Aβ42/40 and meta-memory persisted. In the SCD subset, higher Aβ-pathology was linearly associated with increased awareness. Individuals presenting only study partner's SCD, defined as unaware decliners, exhibited higher levels of CSF p-tau181 correlated with lower meta-memory performance.

Discussion

These results suggested that distinct meta-cognitive profiles can be identified in preclinical-AD. While most individuals might experience an increased awareness associated with the entrance in the AD continuum, hypernosognosia, some might be already losing insight and stepping into the anosognosic trajectory. This research reinforced that an early anosognosic profile, although at increased risk of AD-related decline, might be currently overlooked considering actual diagnostic criteria, and therefore its medical attention delayed.

Multi-modal Neuroimaging Phenotyping of Mnemonic Anosognosia in the Aging Brain

BACKGROUND

Unawareness is a behavioral condition characterized by a lack of self-awareness of objective memory decline. In the context of Alzheimer's Disease (AD), unawareness may develop in predementia stages and contributes to disease severity and progression. Here, we use in-vivo multi-modal neuroimaging to profile the brain phenotype of individuals presenting altered self-awareness of memory during aging.

METHODS

Amyloid- and tau-PET (N = 335) and resting-state functional MRI (N = 713) imaging data of individuals from the Anti-Amyloid Treatment in Asymptomatic Alzheimer's Disease (A4)/Longitudinal Evaluation of Amyloid Risk and Neurodegeneration (LEARN) Study were used in this research. We applied whole-brain voxel-wise and region-of-interest analyses to characterize the cortical intersections of tau, amyloid, and functional connectivity networks underlying unawareness in the aging brain compared to aware, complainer and control groups.

RESULTS

Individuals with unawareness present elevated amyloid and tau burden in midline core regions of the default mode network compared to aware, complainer or control individuals. Unawareness is characterized by an altered network connectivity pattern featuring hyperconnectivity in the medial anterior prefrontal cortex and posterior occipito-parietal regions co-locating with amyloid and tau deposition.

CONCLUSIONS

Unawareness is an early behavioral biomarker of AD pathology. Failure of the self-referential system in unawareness of memory decline can be linked to amyloid and tau burden, along with functional network connectivity disruptions, in several medial frontal and parieto-occipital areas of the human brain.

Examining the role of participant and study partner report in widely-used classification approaches of mild cognitive impairment in demographically-diverse community dwelling individuals: results from the Einstein aging study

Objective

The role of subjective cognitive concerns (SCC) as a diagnostic criterion for MCI remains uncertain and limits the development of a universally (or widely)-accepted MCI definition. The optimal MCI definition should define an at-risk state and accurately predict the development of incident dementia. Questions remain about operationalization of definitions of self- and informant-reported SCCs and their individual and joint associations with incident dementia.

Methods

The present study included Einstein Aging Study participants who were non-Hispanic White or Black, free of dementia at enrollment, had follow-up, and completed neuropsychological tests and self-reported SCC at enrollment to determine MCI status. Informant-reported SCC at baseline were assessed via the CERAD clinical history questionnaire. Self-reported SCC were measured using the CERAD, items from the EAS Health Self-Assessment, and the single memory item from the Geriatric Depression Scale. Cox proportional hazards models examined the association of different operationalizations of SCC with Petersen and Jak/Bondi MCI definitions on the risk of dementia, further controlling for age, sex, education, and race/ethnicity. Time-dependent sensitivity and specificity at specific time points for each definition, and Youden's index were calculated as an accuracy measure. Cox proportional hazards models were also used to evaluate the associations of combinations of self- and informant-reported SCC with the risk of incident dementia.

Results

91% of the sample endorsed at least one SCC. Youden's index showed that not including SCC in either Jak/Bondi or Petersen classifications had the best balance between sensitivity and specificity across follow-up. A subset of individuals with informants, on average, had a lower proportion of non-Hispanic Blacks and 94% endorsed at least one self-reported SCC. Both informant-reported and self-reported SCC were significantly associated with incident dementia.

Conclusion

Our findings suggest that the SCC criterion may not improve the predictive validity for dementia when included in widely-employed definitions of MCI. Consistent with some prior research, informant-reported SCC was more related to risk of incident dementia than self-reported SCC. Given that requiring informant report as a diagnostic criterion may unintentionally exclude health disparate groups, additional consideration is needed to determine how best to utilize informant-report in MCI diagnosis.

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.

Influence of affective states on informant impression of neuropsychiatric symptoms in people living with MCI

Objectives: Alzheimer's disease (AD) and mild cognitive impairment (MCI) are often accompanied by neuropsychiatric symptoms (NPS; e.g. depression/apathy/irritability) causing challenges for people living with dementia/caregivers and predicting worse disease progression. Accurately assessing NPS is critical to research on AD/MCI. However, there are limitations to both self-reports and clinician evaluations; the field often relies on informants to assess NPS. Informants' perception of NPS are influenced by disease and caregiver factors that may lead to biased assessments. We aimed to assess the relationship between participants self-reported affective states (valence/arousal) and informant-reported NPS.Methods: Data from a double-blinded intervention design (primarily testing neurostimulation's effect on NPS) were used to examine the relationship between participant-reported affective states and informant-reported NPS over 1 month. Forty participants (24 females) with MCI and NPS (mean age = 71.7, SD = 7) were enrolled along with informants (primarily spouses/partners) who regularly interact with participants. NPS assessment occurred weekly and at pre- and post-intervention, and participant-reported affective states were assessed at 14 timepoints.Results: Generalized Estimating Equations showed that participant levels of arousal, but not valence, were significantly related to corresponding informant-reported NPS at weekly (arousal: B= -0.59, SE = 0.27, Wald's χ2 = 4.61, p=.032; valence: B = 0.17, SE = 0.19, Wald's χ2 = 0.80, p=.37) and pre-/post- (arousal: B= -4.00, SE = 1.58, Wald's χ2 = 6.42, p=.011; valence: B= -3.34, SE = 1.80, Wald's χ2 = 3.43, p=.06) assessments.Conclusion: The findings indicate that informant-reported NPS may be more strongly influenced by arousal, and informants may be less attuned to valence in people living with MCI.

Awareness of diagnosis predicts changes in quality of life in individuals with mild cognitive impairment and mild stage dementia

BACKGROUND AND OBJECTIVE

This observational study examined how awareness of diagnosis predicted changes in cognition and quality of life (QOL) 1 year later in older adults with normal cognition and dementia diagnoses.

RESEARCH DESIGN AND METHODS

Older adults (n = 259) with normal cognition, mild cognitive impairment (MCI), or mild stage Alzheimer's disease (AD) completed measures of diagnostic awareness, cognition, and multiple domains of QOL. We compared 1-year change in cognition and QOL by diagnostic group and diagnostic awareness.

RESULTS

Patients who were unaware of their diagnosis at baseline showed average decreases in both satisfaction with daily life (QOL-AD; paired mean difference (PMD) = -0.9, p < 0.05) and physical functioning (SF-12 PCS; PMD = -2.5, p < 0.05). In contrast, patients aware of their diagnosis at baseline showed no statistically discernable changes in most QOL domains (all p > 0.05). Of patients aware of their diagnosis at baseline (n = 111), those who were still aware (n = 84) showed a decrease in mental functioning at follow up (n = 27; SF-12 MCS). Change in MoCA scores in patients unaware of their diagnosis was similar to that in patients aware of their diagnosis, -1.4 points (95% CI -2.6 to -0.6) and -1.7 points (95% CI -2.4 to -1.1) respectively.

DISCUSSION AND IMPLICATIONS

Awareness of one's diagnosis of MCI or AD, not the severity of cognitive impairment, may predict changes in patients' mental functioning, expectations of their memory, satisfaction with daily life, and physical functioning. The findings may help clinicians anticipate the types of threats to wellbeing that a patient might encounter and identify key domains for monitoring.

Impaired Awareness in People with Severe Alcohol-Related Cognitive Deficits Including Korskoff's Syndrome: A Network Analysis

BACKGROUND

Impaired awareness of one's own functioning is highly common in people with Korsakoff's syndrome (KS). However, it is currently unclear how awareness relates to impairments in daily functioning and quality of life (QoL).

METHODS

We assessed how impaired awareness relates to cognitive, behavioral, physical, and social functioning and QoL by applying a network analysis. We used cross-sectional data from 215 patients with KS or other severe alcohol-related cognitive deficits living in Dutch long-term care facilities (LTCFs).

RESULTS

Apathy has the most central position in the network. Higher apathy scores relate positively to reduced cognition and to a greater decline in activities of daily living and negatively to social participation and the use of antipsychotic drugs. Impaired awareness is also a central node. It is positively related to a higher perceived QoL, reduced cognition and apathy, and negatively to social participation and length of stay in the LTCF. Mediated through apathy and social participation, impaired awareness is indirectly related to other neuropsychiatric symptoms.

CONCLUSIONS

Impaired awareness is closely related to other domains of daily functioning and QoL of people with KS or other severe alcohol-related cognitive deficits living in LTCFs. Apathy plays a central role. Network analysis offers interesting insights to evaluate the interconnection of different symptoms and impairments in brain disorders such as KS.

Metacognitive Improvements Following Cognitive Stimulation Therapy for People with Dementia: Evidence from a Pilot Randomized Controlled Trial

OBJECTIVES

Impaired self-awareness is a common feature of dementia, with considerable clinical impact. Some therapeutic strategies such as cognitive stimulation and psychotherapy have been suggested to mitigate loss of awareness. Nevertheless, evidence of intervention improving awareness of deficits is scarce. The present study aims to explore the impact of a Brazilian adapted version of Cognitive Stimulation Therapy (CST-Brasil), an evidence-based psychosocial intervention for people with dementia (PwD), on the level of awareness, reporting here a secondary outcome of a pilot randomized controlled trial.

METHODS

47 people with mild to moderate dementia attending an out-patient unit were randomly allocated to CST (n = 23) or treatment as usual (TAU) (n = 24) across 7 weeks, in a pilot randomized controlled trial. Awareness was measured before and after the intervention.

RESULTS

Results indicated that people in both groups increased in overall awareness of the disease, but only those receiving CST exhibited improvements of awareness of cognitive ability.

CONCLUSIONS

These findings suggest that CST may also improve metacognitive abilities in PwD, which could potentially be applied to other settings with beneficial effects.

CLINICAL IMPLICATIONS

Considering the negative impacts of anosognosia, CST-led improvements in awareness have the potential to benefit PwD and their caregivers.

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.

Monocytosis in the acute phase of SARS-CoV-2 infection predicts the presence of anosognosia for cognitive deficits in the chronic phase

Reduced awareness of neuropsychological disorders (i.e., anosognosia) is a striking symptom of post-COVID-19 condition. Some leukocyte markers in the acute phase may predict the presence of anosognosia in the chronic phase, but they have not yet been identified. This study aimed to determine whether patients with anosognosia for their memory deficits in the chronic phase presented specific leukocyte distribution in the acute phase, and if so, whether these leukocyte levels might be predictive of anosognosia.

First, we compared the acute immunological data (i.e., white blood cell differentiation count) of 20 patients who displayed anosognosia 6–9 months after being infected with SARS-CoV-2 (230.25 ± 46.65 days) versus 41 patients infected with SARS-Cov-2 who did not develop anosognosia. Second, we performed an ROC analysis to evaluate the predictive value of the leukocyte markers that emerged from this comparison.

Blood circulating monocytes (%) in the acute phase of SARS-CoV-2 infection were associated with long-term post-COVID-19 anosognosia. A monocyte percentage of 7.35% of the total number of leukocytes at admission seemed to predict the presence of chronic anosognosia 6–9 months after infection.

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.

Associations of fall history and fear of falling with multidimensional cognitive function in independent community-dwelling older adults: findings from ORANGE study

BACKGROUND

Falls and fear of falling (FoF) inhibit healthy longevity and have been suggested to be associated with cognitive function. However, the domains of cognitive function that are associated with them remain controversial. It is speculated that clarifying this will help in the assessment of health status and interventions in the community.

AIM

To analyse the associations between fall history and FoF and multidimensional cognitive function in independent community-dwelling older adults.

METHODS

The data from 9759 (73.3 ± 5.4 years, 59.9% women) older individuals enrolled in the cross-sectional ORANGE study were analysed. Simple questions were used to assess fall history in the past year and current FoF. Assessments of multidimensional cognitive function were performed using the National Center for Geriatrics and Gerontology-Functional Assessment Tool (NCGG-FAT) to evaluate memory, attention, executive function, and processing speed. The independent associations of fall history and FoF with multidimensional cognitive function were assessed using multivariate linear regressions adjusted for potential confounding variables.

RESULTS

A total of 18.3% and 35.4% of participants presented with fall history and FoF, respectively. Fall history (p = 0.008) and FoF (p = 0.002) were significantly associated with memory. FoF, but not fall history was associated with attention (p = 0.004), executive function (p < 0.01), and processing speed (p < 0.01).

CONCLUSION

In independent community-dwelling older adults, fall history was associated only with the memory domain; in contrast, fear of falling was associated with multidimensional cognitive function. This study provides weak evidence suggesting the need to assess falls and FoF in all situations involving independent community-dwelling older adults.

Automated Vehicles for People With Dementia: A "Tremendous Potential" That "Has Ways to go"-Reports of a Qualitative Study

BACKGROUND AND OBJECTIVES

The prospect of automated vehicles (AVs) has generated excitement among the public and the research community about their potential to sustain the safe driving of people with dementia. However, no study to date has assessed the views of people with dementia on whether AVs may address their driving challenges.

RESEARCH DESIGN AND METHODS

This mixed-methods study included two phases, completed by nine people with dementia. Phase I included questionnaires and individual semistructured interviews on attitudes toward using different types of AVs (i.e., partially or fully automated). Interpretative phenomenological analysis was used to assess participants' underlying reasons for and against AV use. The participants' identified reasons against AV use informed the focus group discussions in Phase II, where participants were asked to reflect on potential means of overcoming their hesitancies regarding AV use.

RESULTS

The results showed that people with dementia might place higher levels of trust in fully automated compared to partially automated AVs. In addition, while people with dementia expressed multiple incentives to use AVs (e.g., regaining personal freedom), they also had hesitations about AV use. These hesitancies were based on their perceptions about AVs (e.g., cost), their own abilities (i.e., potential challenges operating an AV), and driving conditions (i.e., risk of driving in adverse weather conditions).

DISCUSSION AND IMPLICATIONS

The findings of this study can help promote the research community's appreciation and understanding of the significant potential of AVs for people with dementia while elucidating the potential barriers of AV use by people with dementia.

Apathy Is the Best Dimension to Consider for Awareness Assessment in Alzheimer’s Disease

Previous studies have reported the major role of apathy in awareness assessment among Alzheimer’s patients using the patient-caregiver discrepancy method, whatever the awareness dimension assessed. Using the Apathy Evaluation Scales among other awareness scales, we report that apathy is the sole awareness dimension distinguishing healthy controls (25), mild (57) and moderate-to-moderately-severe (11) Alzheimer’s patients. A linear regression showed that the Mini-Mental State Examination score used as a risk factor for non-awareness was the only factor associated with awareness of apathy and was the best predictor. This suggests that apathy is the most discriminant dimension for awareness assessment in Alzheimer’s disease.

Everyday Functioning in a Community-Based Volunteer Population: Differences Between Participant- and Study Partner-Report

Introduction: Impaired awareness in dementia caused by Alzheimer's disease and related disorders made study partner-report the preferred method of measuring interference in "instrumental activities of daily living" (IADL). However, with a shifting focus toward earlier disease stages and prevention, the question arises whether self-report might be equally or even more appropriate. The aim of this study was to investigate how participant- and study partner-report IADL perform in a community-based volunteer population without dementia and which factors relate to differences between participant- and study partner-report. Methods: Participants (N = 3,288; 18-97 years, 70.4% females) and their study partners (N = 1,213; 18-88 years, 45.8% females) were recruited from the Dutch Brain Research Registry. IADL were measured using the Amsterdam IADL Questionnaire. The concordance between participant- and study partner-reported IADL difficulties was examined using intraclass correlation coefficient (ICC). Multinomial logistic regressions were used to investigate which demographic, cognitive, and psychosocial factors related to participant and study partner differences, by looking at the over- and underreport of IADL difficulties by the participant, relative to their study partner. Results: Most A-IADL-Q scores represented no difficulties for both participants (87.9%) and study partners (89.4%). The concordance between participants and study partners was moderate (ICC = 0.55, 95% confidence interval [CI] = [0.51, 0.59]); 24.5% (N = 297) of participants overreported their IADL difficulties compared with study partners, and 17.8% (N = 216) underreported difficulties. The presence of depressive symptoms (odds ratio [OR] = 1.31, 95% CI = [1.12, 1.54]), as well as memory complaints (OR = 2.45, 95% CI = [1.80, 3.34]), increased the odds of participants overreporting their IADL difficulties. Higher IADL ratings decreased the odds of participant underreport (OR = 0.71, 95% CI = [0.67, 0.74]). Conclusion: In this sample of community-based volunteers, most participants and study partners reported no major IADL difficulties. Differences between participant and study partner were, however, quite prevalent, with subjective factors indicative of increased report of IADL difficulties by the participant in particular. These findings suggest that self- and study partner-report measures may not be interchangeable, and that the level of awareness needs to be considered, even in cognitively healthy individuals.

Hyperconnectivity Associated with Anosognosia Accelerating Clinical Progression in Amnestic Mild Cognitive Impairment

The incidence and prevalence of anosognosia are highly variable in amnestic mild cognitive impairment (aMCI) patients. The study aims to explore the neuropathological mechanism of anosognosia in aMCI patients using two different but complementary technologies, including ¹⁸F-flortaucipir positron emission tomography and resting state functional magnetic resonance imaging. The study found that anosognosia was related to higher tau accumulation in the left medial orbitofrontal cortex (OFC), left posterior cingulate cortex, and right precuneus in aMCI patients. Intrinsic functional connectivity analyses found significant correlations between anosognosia index and hypoconnectivity between the left medial OFC and left middle temporal gyrus (MTG), right precuneus and left lingual gyrus. Longitudinally, the connectivity of these brain regions as well as the right precuneus and right cuneus showed hyperconnectivity in aMCI patients with anosognosia. The anosognosia index was also correlated with AD pathological markers (i.e., Aβ, t-tau, and p-tau) and brain glucose metabolism in aMCI patients. In conclusion, anosognosia in aMCI patients is associated with the dysfunction of medial OFC-MTG circuit and the precuneus-visual cortex circuit and accelerates clinical progression to AD dementia.

Can Automated Vehicles Be Useful to Persons Living With Dementia? The Perspectives of Care Partners of People Living With Dementia

Background and Objectives

Driving cessation is a complex challenge with significant emotional and health implications for people with dementia, which also affects their family care partners. Automated vehicles (AVs) could potentially be used to delay driving cessation and its adverse consequences for people with dementia and their care partners. Yet, no study to date has investigated whether care partners consider AVs to be potentially useful for people with dementia.

Research Design and Methods

This mixed-methods study assessed the views of 20 former or current family care partners of people with dementia on AV use by people with dementia. Specifically, questionnaires and semistructured interviews were used to examine care partners’ acceptance of AV use by people with dementia and their views about the potential usefulness of AVs for people with dementia.

Results

The results demonstrated that care partners identified possible benefits of AV use by people with dementia such as their anticipated higher social participation. However, care partners also voiced major concerns around AV use by people with dementia and reported significantly lower levels of trust in and perceived safety of AVs if used by the person with dementia in their care compared to themselves. Care partners’ concerns about AV use by people with dementia included concerns around the driving of people with dementia that AVs are not designed to address; concerns that are specific to AVs but are not relevant to the nonautomated driving of people with dementia; and concerns that arise from existing challenges around the nonautomated driving of people with dementia but may be exacerbated by AV use.

Discussion and Implications

Findings from this study can inform future designs of AVs that are more accessible and useful for people with dementia.

Subjective cognitive decline: opposite links to neurodegeneration across the Alzheimer's continuum

Subjective memory decline is associated with neurodegeneration and increased risk of cognitive decline in participants with no or subjective cognitive impairment, while in patients with mild cognitive impairment or Alzheimer's-type dementia, findings are inconsistent. Our aim was to provide a comprehensive overview of subjective memory decline changes, relative to objective memory performances, and of their relationships with neurodegeneration, across the clinical continuum of Alzheimer's disease. Two hundred participants from the Imagerie Multimodale de la maladie d'Alzheimer à un stade Précoce (IMAP+) primary cohort and 731 participants from the Alzheimer's Disease Neuroimaging Initiative (ADNI) replication cohort were included. They were divided into four clinical groups (Imagerie Multimodale de la maladie d'Alzheimer à un stade Précoce/Alzheimer's Disease Neuroimaging Initiative): controls (n = 67/147, age: 60-84/60-90, female: 54/55%), patients with subjective cognitive decline (n = 30/84, age: 54-84/65-80, female: 44/63%), mild cognitive impairment (n = 50/369, age: 58-86/55-88, female: 45/44%) or Alzheimer's-type dementia (n = 36/121, age: 51-86/61-90, female: 41/41%). Subjective and objective memory scores, and their difference (i.e. delta score reflecting memory awareness), were compared between groups. Then, voxelwise relationships between subjective memory decline and neuroimaging measures of neurodegeneration [atrophy (T1-MRI) and hypometabolism (¹⁸F-fluorodeoxyglucose-PET)] were assessed across clinical groups and the interactive effect of the level of cognitive impairment within the entire sample was assessed. Analyses were adjusted for age, sex and education, and repeated including only the amyloid-positive participants. In Imagerie Multimodale de la maladie d'Alzheimer à un stade Précoce, the level of subjective memory decline was higher in all patient groups (all P < 0.001) relative to controls, but similar between patient groups. In contrast, objective memory deficits progressively worsened from the subjective cognitive decline to the dementia group (all P < 0.001). Accordingly, the delta score showed a progressive decline in memory awareness across clinical groups (all P < 0.001). Voxelwise analyses revealed opposite relationships between the subjective memory decline score and neurodegeneration across the clinical continuum. In the earliest stages (i.e. patients with subjective cognitive decline or Mini Mental State Examination > 28), greater subjective memory decline was associated with increased neurodegeneration, while in later stages (i.e. patients with mild cognitive impairment, dementia or Mini Mental State Examination < 27) a lower score was related to more neurodegeneration. Similar findings were recovered in the Alzheimer's Disease Neuroimaging Initiative replication cohort, with slight differences according to the clinical group, and in the amyloid-positive subsamples. Altogether, our findings suggest that the subjective memory decline score should be interpreted differently from normal cognition to dementia. Higher scores might reflect greater neurodegeneration in earliest stages, while in more advanced stages lower scores might reflect decreased memory awareness, i.e. more anosognosia associated with advanced neurodegeneration.

Awareness dimensions and associated factors in Alzheimer's disease

OBJECTIVES

We recently reported the major role depression and apathy in awareness among Alzheimer patients, using the stage of the disease as an exposure factor and exploring different assessment methods. Using the same patient data, we aimed here to explore the different dimensions of awareness assessed by different sub-scales in awareness scales.

METHOD

Sixty-one Alzheimer patients were examined using four awareness scales relating to three assessment methods: (a) patient-caregiver discrepancy; (b) clinical rating; and (c) prediction of performance discrepancy. Global cognition, executive functioning, autonomy, depression and apathy were also assessed. Multivariate logistic models were performed using disease stage as an exposure factor for awareness scales and sub-scales. Correlations across the different factors and patient and caregiver awareness ratings were computed.

RESULTS

The patient-caregiver discrepancy and clinical rating methods (a, b) both identified the factors associated with awareness in the overall scales and the sub-scales as being depression and/or apathy. Depression correlated with patient self-ratings while apathy correlated with caregiver ratings. The prediction of performance discrepancy method (c) identified different factors in the overall scale, executive factors in three sub-scales involving executive domains and the memory factor in a sub-scale involving the mnesic domain.

DISCUSSION

The awareness scales using a referential based on a human rating (a, b) suggest that awareness is unidimensional, with depression impacting self-reports and apathy influencing caregiver/clinical reports. Scales based on a test rating (c) appear to be more closely associated with the dimensions assessed. This highlights the role of the reference system for awareness assessment in Alzheimer's disease.

Effects of Anosognosia on Static and Dynamic Amplitudes of Low-Frequency Fluctuation in Mild Cognitive Impairment

Background: Anosognosia is a significant symptom in patients with mild cognitive impairment (MCI) while the underlying neurological mechanism behind it is still unclear. Methods: A total of 121 subjects were included and classified into three groups, including 39 normal controls (NCs), 42 individuals with MCI without anosognosia (MCI-NA), and 40 individuals with MCI with anosognosia (MCI-A), based on their everyday cognition (ECog) questionnaire (discrepancy score). Resting-state functional MRIs were acquired from all the subjects, and the static amplitudes of low-frequency fluctuation (sALFF) and dynamic ALFF (dALFF) variance were investigated to evaluate the intrinsic functional network strength and stability, respectively, and both were corrected by age, sex, education, and gray matter volume. Eventually, correlation analyses were conducted to explore the relationship between brain activity changes and cognitive status in all the subjects. Results: No significant difference was found between MCI-A and MCI-NA (P > 0.05) in cognitive ability. Regarding intrinsic brain activity, MCI-A had increased sALFF and dALFF variance in the anterior cingulate cortex (ACC) relative to MCI-NA, as well as decreased sALFF and dALFF variance in the precuneus relative to MCI-NA and controls. Moreover, MCI-A had decreased sALFF in the inferior temporal gyrus (ITG) and paracentral lobule (PCL) compared to MCI-NA. Among all the subjects, correlation analyses showed that the sALFF and dALFF variance in the precuneus was related to the Ecog discrepancy score (r = 0.232 and 0.235, respectively), immediate story recall (r = 0.200 and 0.277, respectively), and delayed story recall (r = 0.255 and 0.298, respectively). Conclusion: Alterations of intrinsic brain activation in the ACC and precuneus seem to be associated with the anosognosia symptom in patients with MCI.

Anosognosia for memory in dementia with Lewy bodies compared with Alzheimer's disease

OBJECTIVES

Anosognosia is the inability to recognize one's own symptoms. Although dementia with Lewy bodies (DLB) is the second most common degenerative dementia, there is little evidence of memory deficit awareness in this condition. The objectives of this research were to compare anosognosia between individuals with DLB and dementia due to Alzheimer's disease (AD) and to evaluate whether medial temporal atrophy, a marker of AD pathology, could help to explain different rates of anosognosia in DLB and dementia due to AD.

METHODS/DESIGN

This is a cross-sectional study that took place at the Memory Clinic of D'Or Institute for Research and Education (IDOR). Twenty individuals with DLB and 20 with dementia due to AD were included in this study. We assessed anosognosia for memory using an index derived from subjective memory complaints (using the Memory Complaint Questionnaire) and from the performance in memory neuropsychological testing (Rey Auditory Verbal Learning Test). Thirty-one participants also underwent brain Magnetic Resonance Imaging to evaluate hippocampal atrophy with a visual scale (MTA-score [medial temporal atrophy score]).

RESULTS

There was no significant difference between groups regarding age, years of education, sex or time of disease. Individuals with DLB had a higher index of anosognosia than dementia due to AD (2.92 and 1.87; p = 0.024), meaning worse awareness of memory deficits. MTA-score was slightly higher in dementia due to AD than in DLB, albeit without statistical significance.

CONCLUSION

Our study was the first to demonstrate that anosognosia for memory is worse in DLB than in dementia due to AD. This finding supports the hypothesis that anosognosia in DLB is a heterogeneous phenomenon.

Structural Gray and White Matter Correlates of Awareness in Alzheimer's Disease

BACKGROUND

Unawareness of disease is a common feature of Alzheimer's disease (AD), but few studies explored its neural correlates. Additionally, neural correlates according to the object of awareness are unexplored.

OBJECTIVE

To investigate structural brain correlates in relation to different objects of awareness.

METHODS

27 people with AD underwent MRI scanning on a 3T Siemens Prisma. T1-MPRAGE was used to investigate cortical thickness and white matter microstructure was defined by DTI as fractional anisotropy, mean, axial, and radial diffusivity. Preprocessing used FreeSurfer6.0, ExploreDTI, and FSL-TBSS. Awareness of disease, cognitive deficits, emotional state, relationships, and functional capacity were assessed with the short version of the Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia. Voxel-wise correlations between brain structure and awareness were determined by FSL-PALM. Analyses were corrected for multiple comparisons using Threshold Free Cluster Enhancement and FWE.

RESULTS

Lower left hemisphere cortical thickness was related to poorer disease awareness uncorrected and corrected for age, sex, and MMSE. In the uncorrected model, mainly right-sided, but also left temporal lower cortical thickness was related to decreased awareness of cognitive deficits. Correcting for age, sex, and MMSE eliminated correlations for the right hemisphere, but extensive correlations in the left hemisphere remained. For white matter integrity, higher right hemisphere MD was related to lower cognitive awareness deficits, and lower FA was related to lower functional capacity awareness.

CONCLUSION

Findings suggest that extensive regions of the brain are linked to self-awareness, with particular frontal and temporal alterations leading to unawareness, in agreement with theoretical models indicating executive and mnemonic forms of anosognosia in AD.

Anosognosia in dementia with Lewy bodies: a systematic review

BACKGROUND

Anosognosia, i.e. lack of awareness of one's own symptoms, is a very common finding in patients with dementia and is related to neuropsychiatric symptoms and worse prognosis. Although dementia with Lewy bodies (DLB) is the second most common form of degenerative dementia, literature on anosognosia in this disease is scarce.

OBJECTIVES

This paper aimed to review the current evidence on anosognosia in patients with DLB, including its prevalence in comparison with other neurological conditions, its severity and anatomical correlations.

METHODS

Database searches were performed in PubMed, Web of Knowledge and PsycINFO for articles assessing anosognosia in DLB. A total of 243 studies were retrieved, but only six were included in the review.

RESULTS

Potential risk of selection, comparison or outcome biases were detected in relation to all the studies selected. Most of the studies used self-report memory questionnaires to assess cognitive complaints and compared their results to scores from informant-based instruments or to participants' cognitive performance in neuropsychological tasks. Subjects with DLB had worse awareness regarding memory than healthy older controls, but the results concerning differences in anosognosia between DLB and Alzheimer's disease (AD) patients were inconsistent across studies. Presence of AD pathology and neuroimaging biomarkers appeared to increase the prevalence of anosognosia in individuals with DLB.

CONCLUSION

Anosognosia is a common manifestation of DLB, but it is not clear how its prevalence and severity compare with AD. Co-existence of AD pathology seems to play a role in memory deficit awareness in DLB.

Awareness in severe Alzheimer's disease: a systematic review

Objective: There is limited understanding about how people in the severe stages of Alzheimer's disease (AD) experience and demonstrate awareness. We synthesised all available evidence with the aim of understanding how awareness is preserved or impaired in severe AD and what evidence there is for different levels of awareness according to the levels of awareness framework.Method: A systematic search of the following databases: Embase, PsycINFO, MEDLINE and Web of Science was carried out. A narrative synthesis and analysis was conducted of all included studies. All studies were assessed for quality using the AXIS and CASP tools.Results: Our findings suggest that lower level sensory awareness is relatively maintained in severe AD. Findings for higher level awareness are variable and this may be related to the diversity of methods that have been used to explore awareness in these circumstances.Conclusion: Awareness is complex, heterogeneous and varies significantly between individuals. Environmental and contextual factors have a significant impact on whether awareness is observed in people with severe AD. Adaptation of the environment has the potential to facilitate the expression of awareness while education of caregivers may increase understanding of people with severe AD and potentially improve the quality of care that is received.

Validation of the Korean Version of the Anosognosia Questionnaire for Dementia

OBJECTIVE

Anosognosia is a common phenomenon in individuals with dementia. Anosognosia Questionnaire for dementia (AQ-D) is a well-known scale for evaluating anosognosia. This study aimed to establish a Korean version of the AQ-D (AQ-D-K) and to evaluate the reliability and validity of the AQ-D-K in patients with Alzheimer's disease (AD) dementia.

METHODS

We translated the original English version of AQ-D into Korean (AQ-D-K). Eighty-four subjects with very mild or mild AD dementia and their caregivers participated. Reliability of AQ-D-K was assessed by internal consistency and one-month test-retest reliability. Construct validity and concurrent validity were also evaluated.

RESULTS

Internal consistencies of the AQ-D-K patient form and caregiver form were high (Cronbach alpha 0.95 and 0.93, respectively). The test-retest reliability of AQ-D-K measured by intra-class correlation coefficient was 0.84. Three factors were identified: 1) anosognosia of instrumental activity of daily living; 2) anosognosia basic activity of daily living; and 3) anosognosia of depression and disinhibition. AQ-D-K score was significantly correlated with the clinician-rated anosognosia rating scale (ARS), center for epidemiological studies-depression scale (CES-D) and state-trait anxiety inventory (STAI).

CONCLUSION

The findings suggest that the AQ-D-K is a reliable and valid scale for evaluating anosognosia for AD dementia patients using Korean language.

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.

Understanding Alzheimer's disease as a disorder of consciousness

People with Alzheimer's disease (AD) demonstrate a range of alterations in consciousness. Changes in awareness of cognitive deficit, self-awareness, and introspection are seen early in AD, and dysfunction of awareness and arousal progresses with increasing disease severity. However, heterogeneity of deficits between individuals and a lack of empirical studies in people with severe dementia highlight the importance of identifying and applying biomarkers of awareness in AD. Impairments of awareness in AD are associated with neuropathology in regions that overlap with proposed neural correlates of consciousness. Recent developments in consciousness science provide theoretical frameworks and experimental approaches to help further understand the conscious experience of people with AD. Recognition of AD as a disorder of consciousness is overdue, and important to both understand the lived experience of people with AD and to improve care.

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.

Spouse-Appraised Memory Functioning Predicts Memory Decline Better Than Subjective Memory Complaints in Community Dwelling Older Adults at Genetic Risk for Alzheimer's Disease

Objective: Alzheimer's disease (AD) begins with subtle memory decline, years before dementia onset. The presence of subjective memory complaints (SMC) has been proposed as a marker of preclinical AD. However, recent evidence has demonstrated early and progressive loss of awareness of memory difficulties in non-demented older adults harboring AD pathology. We investigated the respective contributions of SMC and spouse-appraised memory functioning (SAM) to predict memory decline in a large cohort of community dwelling older adults. Methods: The Wisconsin Longitudinal Study collected cognitive data from a community-based cohort of 3,583 participants in both 2005 and 2011. The participant and the participant's spouse were each asked to rate the participant's memory functioning using a Likert scale. We predicted change in objective episodic memory with models including baseline SMC, baseline SAM, or both SMC and SAM. We also evaluated an awareness index (SMC minus SAM). We then tested the interaction between Apolipoprotein E (APOE ε4) carrier status and SMC/SAM to evaluate whether the effects were driven by individuals at-risk for AD pathology. Results: In separate models, SMC (-0.081 ± 0.036, p = 0.025) and SAM (-0.084 ± 0.278, p = 0.003) were both associated with memory decline over ~6 years. However, the AI was not significantly associated with memory decline (0.031 ± 0.024, p = 0.19). When both predictors were included in the same model, SAM (-0.074 ± 0.03, p = 0.0092) was associated with memory decline, while SMC was not significant (-0.061 ± 0.04, p = 0.99). The association between SAM and memory decline was stronger in the APOE ε4 carriers than in the non-carriers (APOE-by-SAM interaction: F = 6.07; p = 0.002), and follow up analyses revealed that SAM was particularly predictive of decline only for APOE ε4 carriers. The association between SMC and memory decline was independent of APOE ε4 carrier status (APOE-by-SMC interaction: F = 2.29; p = 0.13). Conclusions: Spouse-appraised memory functioning was more predictive of memory decline than SMC or an awareness index, particularly in APOE ε4 carriers, who are at increased risk for AD pathology.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Awareness of Functional Status: People with Alzheimer's Disease Abilities to Self-Report Impairment in Activities of Daily Living

BACKGROUND

Awareness of functional status may underlie specific profiles and differences related to stage severity in individuals with Alzheimer's disease (AD).

OBJECTIVE

This study aimed to assess self-reported experiences of awareness of functional activity in people with mild and moderate AD.

METHODS

This is a mixed methods approach. The qualitative part was conducted through semi-structured interviews concerning the experiences and awareness of deficits in 38 older adults with mild or moderate AD. The quantitative approach included a comparison between groups with regard to concerns of awareness and clinic and demographic data.

RESULTS

Impairment on awareness of disease and awareness of functional deficits was observed even in the mild stages of AD. There was also a noticeable progression of impairments of both kinds of awareness from mild to moderate stage of disease. The majority of participants with mild and moderate AD were partially aware of their functional deficits. Both groups of participants reported some negative impact; however, they were not able to entirely describe their functional status. Also, deficits to recognize the need for help with hygiene and general tasks were observed. Significant differences were found in awareness of need for help with general tasks and awareness of need for help with hygiene tasks.

CONCLUSION

People with mild and moderate AD may describe their aware of the disease better than specific functional deficits, and most of them can provide some reports concerning to the impact of the disease.

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.

Modelling Awareness in Alzheimer's Disease

This study aimed to provide a model of awareness in Alzheimer's disease using the stage of the disease as a risk factor. Awareness was assessed using three methods (patient-caregiver discrepancy, prediction-performance discrepancy, clinical rating). Twenty-five healthy control subjects and sixty-one patients participated, with measures of cognition, apathy, depression, and awareness. These measures were introduced into a manual backward regression. Confounding factors impacting at least 15% of the exposure factor estimate were maintained in the model. Except for the prediction performance discrepancy, also presenting cognitive associations, the other awareness assessments suggested a major role of depression and apathy as impacting factors.

Awareness of Psychiatric Symptoms in a Mixed Clinical Sample of Older Adults

OBJECTIVE

This study examined the neuropsychological correlates and impact on caregiver distress of reduced awareness of mood symptoms in patients with suspected neurodegenerative disease.

METHOD

Records from a clinical sample of older adults were examined (N = 940).

RESULTS

More than one-third of patient and caregiver ratings of mood symptoms did not agree (comparing patient and caregiver self-report measures); 27.9% of patients were unaware of depression (UoD) and 16.6% of patients were unaware of anxiety (UoA). The UoD group exhibited poorer verbal memory and executive abilities and the UoA group exhibited poorer verbal memory than those with preserved awareness. Unawareness was not associated with caregiver distress.

CONCLUSIONS

These findings highlight the importance of capturing informant report in clinical practice with older adults suspected of cognitive impairment. Unawareness of mood symptoms was related to memory dysfunction and-to a lesser extent-to executive abilities and may have implications for addressing patient and caregiver needs for disorders affecting these cognitive systems.

Patterns of discrepancies in different objects of awareness in mild and moderate Alzheimer's disease

Objectives: Awareness is considered a heterogeneous and non-linear phenomenon in dementia. We aim to investigate patterns of change of different domains of awareness (awareness of cognitive functioning and health condition, activities of daily living, emotional state, social functioning, and relationships) in people with mild and moderate Alzheimer's disease (AD) and aspects related to each domain.Method: Cross-sectional assessment of dyads of people with AD (PwAD) and caregivers (n = 128; CDR1 = 74, CDR2 = 54). PwAD completed assessments about quality of life, cognition and their awareness of disease. Caregivers provided information about PwAD and received quality of life and burden of care assessments.Results: Mild AD group showed a mildly impaired awareness (n = 40; 54.05%), while moderate AD group, showed higher presence of moderately impaired awareness (n = 22; 40.74%). There was a significant difference between groups in awareness of cognitive functioning and health condition (p < 0.004), functional activity impairments (p < 0.001) and total score of awareness (p < 0.01). Conversely, awareness of emotional state (p = 0.22) and of social functioning and relationship (p = 0.44) presented no significant difference between groups. Unawareness of functional activity impairments showed higher discrepancy scores between PwAD and caregivers in both groups.Conclusions: Significant differences were found only in patterns of discrepancies in awareness of cognitive functioning and health condition, of ADL and socio-emotional functioning. Different factors are related to different domains in mild and moderate group, reinforcing the heterogeneity of awareness in dementia. ADL deficits have an important role in awareness phenomenon, independent of the severity of disease.

Anosognosia in patients with Alzheimer's disease: current perspectives

Alzheimer's disease (AD) is a neurodegenerative disease characterised by neurocognitive impairments, especially memory impairment, as core symptoms linked to reductions in activities of daily life. As marginal symptoms, neuropsychiatric symptoms (NPSs) appear during the progressive course of the disease. A lack of self-awareness (anosognosia) of cognitive and functional impairments is often seen in patients with AD, and associations between anosognosia and other NPSs have been previously reported. To account for anosognosia pathogenesis neurocognitively, the cognitive awareness model (CAM) has been helpful for explaining the stream of events from sensory input to behavioural/affective and metacognitive outputs. According to CAM, there are three types of anosognosia: (i) primary anosognosia, (ii) executive anosognosia, and (iii) mnemonic anosognosia. These types of anosognosia are generated from different neurocognitive modulations leading to metacognitive outputs or behavioural/affective regulations. Primary anosognosia is considered to be caused by deficits in the metacognitive awareness system (MAS). While preserved MAS function is associated with milder depression and anxiety in AD, a severer depressive mood in patients with mild AD can inversely cause self-underestimation. The modulation of executive anosognosia is thought to be associated with dangerous/disinhibition behaviours and apathy among NPS sub-symptoms, via impairments of comparator mechanism (Cm) within the central executive system. Other neurobehavioral reactions linked to self-awareness include 'denying' and 'confabulation', and each of these reactions is thought to be affected by the MAS and a Cm. Denial of one's own memory impairments appears as a defensive reaction to protect against dysphoric feelings, and the confabulatory comment is instantly reaction constructed by fabrications according to misinterpretations of memory information about oneself. Similarly, the innovative development of a theoretical model (CAM) has contributed to explaining the mechanism of anosognosia and some neurobehavioral outputs from a neurocognitive perspective.

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.

Comprehension of written texts for the assessment of clinical competence and decision making in people with mild to moderate Alzheimer disease

BACKGROUND

Clinical competence is the term used to describe an individual's capacity to express a choice regarding their participation in clinical procedures or experimental studies. Understanding the information provided is a prerequisite but consent forms are often lengthy and complicated. Alzheimer's disease patients may be vulnerable in written comprehension, due to cognitive deficits, but unfortunately to date, a specific evaluation of this ability is not included in periodical assessments.

METHODS

One hundred thirty Italian patients with Alzheimer's disease were compared with 130 controls in a comprehension task involving a simplified informed consent form. Their performance in this task was compared with their performance with two other types of reading material (a testament and a history text). In addition, the performance of a subgroup of very mild patients in this test was compared with their performance in a widely used interview for the assessment of clinical competence (MacArthur Competence Assessment Tool for Clinical Research).

RESULTS

Good sensitivity and specificity of the cut-offs identified consent form and the other texts as good instruments for evaluation of written comprehension. The comprehension of consent form may be compromised since the early stages of Alzheimer's disease. Nevertheless, a simplified, written text may help patients in comparison with interviews (MacCAT-CR). Better performance was correlated to the standard of education and better cognitive functions.

CONCLUSION

Deficits regarding the comprehension of written texts and the consent form may be early in Alzheimer's disease patients and need to be investigated during periodical neuropsychological assessment. Comprehension may be facilitated by means of specific simplification strategies.

"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.

Eye contact effects on social preference and face recognition in normal ageing and in Alzheimer's disease

Perceiving a direct gaze (i.e. another individual's gaze directed to the observer leading to eye contact) influences positively a wide range of cognitive processes. In particular, direct gaze perception is known to stimulate memory for other's faces and to increase their likeability. Alzheimer's disease (AD) results in social withdrawal and cognitive decline. However, patients show preserved eye contact behaviours until the middle stage of the disease. The eye contact effects could be preserved in AD and be used to compensate for cognitive and social deficits. Yet, it is unknown whether these effects are preserved in normal ageing. The aim of this study was to address whether the positive effects of eye contact on memory for faces and likeability of others are preserved in healthy older adults and in patients with early to mild AD. Nineteen AD patients, 20 older adults and 20 young adults participated in our study. Participants were first presented with faces displaying either direct or averted gaze and rated each face's degree of likeability. They were then asked to identify the faces they had previously seen during a surprise recognition test. Results showed that the effect of eye contact on other's likeability was preserved in normal ageing and in AD. By contrast, an effect of eye contact on memory for faces seems to emerge only in young participants, suggesting that this effect declines with ageing. Interestingly, however, AD patients show a positive correlation between ratings of likeability and recognition scores, suggesting that they implicitly allocated their encoding resources to most likeable faces. These results open a new way for a "compensating" therapy in AD.

Measuring awareness in people with dementia: protocol for a scoping review

BACKGROUND

People with dementia (PwD) vary in the degree of awareness they show about their situation, both generally concerning the diagnosis and more specifically around certain aspects or objects of awareness such as awareness of memory impairment, altered daily activities or social functioning. The extent of awareness or lack of awareness has consequences for well-being of PwD and carers, impacting on rates of hospital admission, institutionalization, mood, adjustment to diagnosis, outcomes from intervention and carer burden. An accurate estimation of a person's awareness could therefore be useful in a clinical setting to support PwD and their carers in making appropriate choices for health and care decisions, and could facilitate safe management by health care professionals, e.g. in an acute care setting. There is a range of different approaches to measuring awareness reported in the dementia research literature, with varying estimates of the frequency of lack of awareness, reflecting different methodologies and populations. The majority of the methods have been developed for research purposes and may not be suitable for clinical use. There are no recent scoping or systematic reviews of the available methods.

METHOD

We will conduct a scoping review of published studies that have assessed awareness in people with dementia of all types, and all degrees of severity. The systematic search will include the electronic databases PubMed, Embase, PsycInfo, CINAHL, Web of Science and Cochrane Library, using search terms for dementia ("dement*" or "Alzheimer*" or "Pick's disease") and "awareness", "unawareness", "anosognosia", "insight", "denial", "metacognit*" or "discrepanc*" identified from pilot searches. Findings will be mapped and described according to the method used, the setting and diagnosis and the object of awareness studied if specified. Validated measures will be identified.

DISCUSSION

This scoping review will provide an overview of the methods used to measure awareness in people with dementia, allowing comparison of the methods along with identification of validated measures. The methods or components will be appraised for potential clinical use, and gaps in research will be highlighted.

Poor awareness of IADL deficits is associated with reduced regional brain volume in older adults with cognitive impairment

Performance of instrumental activities of daily living (IADLs) can become compromised in older adults with mild cognitive impairment (MCI). Patients' level of insight into their everyday functioning varies both amongst individuals and across domains assessed, with some individuals exhibiting complete unawareness of deficits. The current cross-sectional study examined the neuroanatomical substrates of self-awareness in order to help explain the variability in this phenomenon in older adults across a continuum of cognitive impairment. Eighty-five participants (ages 54-88, mean age = 73 years, 57% female, 89% Caucasian) diagnosed with MCI or mild probable dementia underwent structural magnetic resonance imaging. Level of self-awareness was assessed by calculating the discrepancy between objective and subjective performance across six IADLs (Financial Management, Driving, Grocery Shopping, Nutrition Evaluation, Medication Management, and Telephone Use). Over-estimation of current abilities occurred in 13-31% of the sample depending on which IADL was evaluated. Poor awareness was significantly related to reduced volume in the bilateral medial prefrontal cortex, middle and posterior cingulate cortex, right insular cortex, and cerebellum. No associations were found with total white matter lesion load. These findings were broadly consistent across all functional domains assessed, supporting the theory that cortical midline and cerebellar structures are involved in self-referential processing across a variety of different cognitive and behavioral skills. Longitudinal studies are needed to confirm this association.

Awareness in Dementia: Development and Evaluation of a Short Version of the Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia (ASPIDD-s) in Brazil

Awareness of disease is defined as the recognition of changes caused by the deficits related to the disease process. We aimed to examine the psychometric properties of the short versions of the Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia (ASPIDD-s), a multidimensional awareness scale. Using a cross-sectional design, we included 201 people with dementia and their family caregivers. The creation of the short versions was based on items with higher loadings on each factor, the correlations between the short versions and demographic or clinical variables and the relevance of the item to the respondent population. Three short versions were created: version 1 and 3, with 12 items and version 2, with 16 items. The short versions correlated very strongly with the full scale and with the 4 factors of the original scale, maintaining the multidimensional nature of the ASPIDD. Loss of awareness was associated with worse quality of life, decreased functionality and cognitive level, and higher caregiver burden across the short versions. Considering the appropriateness of the items and their clinical relevance, we recommend version 3 for use. With only 12 items, the time required for the completion of the scale is short, while maintaining robust psychometric properties.

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

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

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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