Standardised measurement of self-awareness deficits in FTD and AD

Validation of the Japanese version of the Social Functioning in Dementia scale and COVID-19 pandemic's impact on social function in mild cognitive impairment and mild dementia

OBJECTIVES

We aimed to psychometrically evaluate and validate a Japanese version of the Social Functioning in Dementia scale (SF-DEM-J) and investigate changes in social function in people with dementia during the coronavirus disease-19 (COVID-19) pandemic.

DESIGN

We interviewed people with mild cognitive impairment (MCI) and mild dementia and their caregivers during June 2020-March 2021 to validate patient- and caregiver-rated SF-DEM-J and compared their scores at baseline (April 2020 to May 2020) and at 6-8 months (January 2021 to March 2021) during a time of tighter COVID-19 restrictions.

SETTING

The neuropsychology clinic in the Department of Psychiatry at Osaka University Hospital and outpatient clinic in the Department of Psychiatry and Neurology at Daini Osaka Police Hospital, Japan.

PARTICIPANTS

103 dyads of patients and caregivers.

MEASUREMENTS

SF-DEM-J, Mini-Mental State Examination, Neuropsychiatric Inventory, UCLA Loneliness Scale, and Apathy Evaluation Scale.

RESULTS

The scale's interrater reliability was excellent and test-retest reliability was substantial. Content validity was confirmed for the caregiver-rated SF-DEM-J, and convergent validity was moderate. Caregiver-rated SF-DEM-J was associated with apathy, irritability, loneliness, and cognitive impairment. The total score of caregiver-rated SF-DEM-J and the score of Section 2, "communication with others," significantly improved at 6-8 months of follow-up.

CONCLUSIONS

The SF-DEM-J is acceptable as a measure of social function in MCI and mild dementia. Our results show that the social functioning of people with dementia, especially communicating with others, improved during the COVID-19 pandemic, probably as a result of adaptation to the restrictive life.

Incongruences Between Facial Expression and Self-Reported Emotional Reactivity in Frontotemporal Dementia and Related Disorders

OBJECTIVE

Emotional reactivity normally involves a synchronized coordination of subjective experience and facial expression. These aspects of emotional reactivity can be uncoupled by neurological illness and produce adverse consequences for patient and caregiver quality of life because of misunderstandings regarding the patient's presumed internal state. Frontotemporal dementia (FTD) is often associated with altered social and emotional functioning. FTD is a heterogeneous disease, and socioemotional changes in patients could result from altered internal experience, altered facial expressive ability, altered language skills, or other factors. The authors investigated how individuals with FTD subtypes differ from a healthy control group regarding the extent to which their facial expressivity aligns with their self-reported emotional experience.

METHODS

Using a compound measure of emotional reactivity to assess reactions to three emotionally provocative videos, the authors explored potential explanations for differences in alignment of facial expressivity with emotional experience, including parkinsonism, physiological reactivity, and nontarget verbal responses.

RESULTS

Participants with the three main subtypes of FTD all tended to express less emotion on their faces than they did through self-report.

CONCLUSIONS

Exploratory analyses suggest that reasons for this incongruence likely differ not only between but also within diagnostic subgroups.

Anosognosia in Dementia: Evaluation of Perfusion Correlates Using 99mTc-HMPAO SPECT and Automated Brodmann Areas Analysis

(1) Background: Considerable inconsistency exists regarding the neural substrates of anosognosia in dementia in previous neuroimaging studies. The purpose of this study was the evaluation of anosognosia perfusion correlates across various types of dementia using automated Brodmann areas (BAs) analysis and comparison with a database of normal subjects. (2) Methods: We studied 72 patients: 32 with Alzheimer’s disease, 26 with frontotemporal dementia—FTD (12 behavioral FTD, 9 semantic FTD, 5 Progressive Non-Fluent Aphasia), 11 with corticobasal syndrome, and 3 with progressive supranuclear palsy. Addenbrook’s Cognitive Examination—Revised (ACE-R) mean(±SD) was 55.6(±22.8). For anosognosia measurement, the Anosognosia Questionnaire—Dementia was used. Total anosognosia score mean(±SD) was 22.1(±17.9), cognitive anosognosia score mean(±SD) was 18.1(±15.1) and behavioral–mood anosognosia score mean(±SD) was 3.3(±4.7). (3) Results: Higher anosognosia total score was associated with hypoperfusion in the inferior temporal, anterior cingulate, and inferior frontal cortices of the right hemisphere (BAs 20R, 24R, 32R, 45R). Higher anosognosia cognitive score was correlated with hypoperfusion in the left middle and anterior temporal cortices, and right dorsal anterior cingulate cortex (BAs 21L, 22L, 32R). No association was found with behavioral–mood anosognosia. (4) Conclusions: Automated analysis of brain perfusion Single Photon Emission Computed Tomography could be useful for the investigation of anosognosia neural correlates in dementia.

Psychometric Evaluation of the German Version of the Social Functioning in Dementia Scale

BACKGROUND

Dementia is one of the most common and most severe disorder in old age. In addition to cognitive decline and functional impairment, changes in social functioning occur in the course of dementia. Currently, there is no valid instrument in German language to assess social functioning in individuals with dementia.

OBJECTIVE

We aim to adapt and psychometrically evaluate a German version of the Social Functioning in Dementia Scale (SF-DEM).

METHODS

First, a multi-step and team-based translation process based on the TRAPD model was performed. Second, we interviewed dyads of individuals with mild dementia and caregivers to test the internal consistency, test-retest reliability, interrater reliability, construct validity, and acceptance of the German version of the SF-DEM.

RESULTS

The internal consistency of the patient-rated (α= 0.72) and the caregiver-rated (α= 0.76) SF-DEM is at an acceptable level. The interrater reliability was excellent for both versions (patients: ICC = 0.98, CI [0.95-0.99]; caregiver: ICC = 0.95, CI [0.89-0.98]) and the test-retest reliability was moderate (patients: ICC = 0.57, CI [0.26-0.77]; caregiver: ICC = 0.58, CI [0.27-0.78]). Caregiver-rated SF-DEM correlated strong with LSNS-6 (rs = 0.60, p < 0.01), QoL-AD (marriage: rs = 0.61, p < 0.01; friends: rs = 0.51, p = 0.01). In addition, the SF-DEM was accepted by the participants.

CONCLUSION

The German SF-DEM is a valid, reliable, and acceptable instrument to assess social functioning in individuals with dementia. Further research should address the psychometric properties in individuals with more severe dementia.

Use of Telephone- and Internet-Based Support to Elicit and Address Financial Abuse and Mismanagement in Dementia: Experiences from the Care Ecosystem Study

BACKGROUND

Financial mismanagement and abuse in dementia have serious consequences for patients and their families. Vulnerability to these outcomes reflects both patient and contextual factors.

OBJECTIVE

Our study aimed to assess how multidisciplinary care coordination programs assist families in addressing psychosocial vulnerabilities and accessing needed resources.

METHODS

Our study was embedded in a clinical trial of the Care Ecosystem, a telephone- and internet-based supportive care intervention for patients with dementia and caregivers. This program is built around the role of the Care Team Navigator (CTN), an unlicensed dementia care guide who serves as the patient and caregiver's primary point of contact, screening for common problems and providing support. We conducted a qualitative analysis of case summaries from a subset of 19 patient/caregiver dyads identified as having increased risk for financial mismanagement and abuse, to examine how Care Ecosystem staff identified vulnerabilities and provided support to patients and families.

RESULTS

CTNs elicited patient and caregiver needs using templated conversations to address common financial and legal planning issues in dementia. Sources of financial vulnerability included changes in patients' behavior, caregiver burden, intrafamily tension, and confusion about resources to facilitate end-of-life planning. The Care Ecosystem staff's rapport with their dyads helped them address these issues by providing emotional support, information on how to access financial, medical, and legal resources, and improving intra-familial communication.

CONCLUSION

The Care Ecosystem offers a scalable way to address vulnerabilities to financial mismanagement and abuse in patients and caregivers through coordinated care by unlicensed care guides supported by a multidisciplinary team.

Psychometric utility of the international HIV dementia scale and Montreal Cognitive Assessment in HIV-associated asymptomatic neurocognitive impairment

There is a growing need for brief screening measures for HIV Associated Neurocognitive Disorders (HAND). We compared two commonly used measures (the Montreal Cognitive Assessment [MoCA] and the International HIV Dementia Scale [IHDS]) in their ability to identify asymptomatic HAND (i.e., asymptomatic neurocognitive impairment [ANI]). Participants included 74 Thai PLWH: 38 met Frascati criteria for ANI and 36 were cognitively normal (CN). Participants completed Thai language versions of the MoCA (MoCA-T) and IHDS, and a validated neurocognitive battery. We examined between-group differences for MoCA-T and IHDS total scores, and scale subcomponents. We also conducted receiver operating characteristic (ROC) analyses to determine the ability of the MoCA-T and IHDS to discriminate between CN and ANI groups, and compared their area under the curve (AUC) values. Results revealed lower MoCA-T total score, as well as the Visuospatial/Executive and Delayed Recall subtask scores, in the ANI relative to CN group. Groups did not differ on the IHDS. For ROC analyses, the MoCA-T, but not the IHDS, significantly differentiated the ANI from CN group, and there was a significant difference in AUC values between the MoCA-T (AUC = .71) and IHDS (AUC = .56). Sensitivity and specificity statistics were poor for both screening measures. These data indicate while the MoCA-T functions better than the IHDS in detecting Thai PLWH with ANI, the mildest form of HAND, neither cognitive screener, showed strong utility. Our findings reflect the limited efficacy of common screening measures in detecting subtler cognitive deficits among Thai PLWH, and highlight the need for better screening tools.

Metacognition, psychopathology and daily functioning in adult ADHD

OBJECTIVE

Previous research indicated that adults with ADHD may have deficits in metacognition, yet the evidence base is scarce. This study aims to explore the existence and nature of metacognitive deficits in adults with ADHD, how psychopathology (such as inattention and depression) may affect metacognition and whether metacognition may impact daily functioning in adults with ADHD.

METHOD

Forty-six adult patients with ADHD and 46 controls completed questionnaires for metacognition, psychopathology and daily functioning (subjective assessment; self- and informant report). Participants performed two attention tests in a neuropsychological assessment. After test completion, participants were asked to evaluate their performance with the help of a visual aid and this self-evaluation of test performance was compared with their actual test performance (objective assessment).

RESULTS

Patients with ADHD reported large deficits in knowledge of cognition and medium deficits in regulation of cognition compared to controls. Self-evaluation of cognitive test performance revealed no significant deficits. Regression analyses revealed that psychopathology may explain a part of the variation in metacognition. Further regressions indicated that metacognition may account for a significant and meaningful proportion of variance in daily functioning, both self-rated and informant-rated.

CONCLUSIONS

Current findings of compromised metacognitive functioning of adults with ADHD suggest that clinicians may not want to rely on patients' self-reports in the clinical assessment. Inattention predicted impairments in metacognition, pointing toward the importance of attention for awareness and metacognition. Finally, we recommend that metacognition is addressed in the treatment trajectory of patients with ADHD, given that aspects of metacognition were directly linked to impairments in daily functioning as rated by participants and their relatives.

Metacognition in adult ADHD: subjective and objective perspectives on self-awareness of cognitive functioning

Although attention deficit hyperactivity disorder (ADHD) in adulthood is associated with marked cognitive impairment, research on metacognition in adult ADHD is scarce. Deficits in metacognition may have a negative impact on treatment adherence, functional outcomes, and everyday life. This study explores metacognition, specifically self-awareness of cognitive performance, in adults with ADHD by combining objective and subjective assessments. Forty-seven patients with ADHD and 47 control individuals completed a neuropsychological assessment battery including tests for attention, executive functions and memory (objective assessment), as well as questionnaires for cognitive functioning and symptom severity (subjective assessment; self- and informant-report). Participants evaluated their test performance of the objective assessment after test completion by selecting a percentile rank which was subtracted from their normed test result, yielding a discrepancy score. Compared to controls, adults with ADHD showed impairments in attention (medium effects) and memory (small and medium effects), but not in executive functions. The discrepancy scores between self-evaluation and cognitive performance revealed deficits in self-awareness of attentional functions (small effects), but not in executive functions and memory in patients with ADHD compared to controls. Discrepancy scores between self- and informant-reports of cognitive functioning revealed no significant differences. Adults with ADHD show impairments in metacognition in attentional functions, but may have intact metacognitive abilities in other domains. Patients with ADHD tend to overestimate their abilities, especially in attentional functions. Subjective and objective measures of metacognition may not correspond, highlighting the need for clinicians to not solely rely on patients' self-report in their assessment.

Frontotemporal dementia as underlying cause of newly altered mental status in a 59-year-old female: a case presentation and literature review

59 y.o. female is evaluated for chronic behavioral abnormalities. We describe the diagnostic approach to cases of altered mental status.

Before considering the different possible etiologies including, for example, metabolic, infectious, toxic, hypoxemic, endocrine, or iatrogenic ones, we underline the importance of assessing patient’s baseline functional status. Often, in particular in older patients’ population, dementia is the underlying culprit of mentation abnormalities.

Through extensive history and with the help of neuroimaging studies, our patient was diagnosed with frontotemporal dementia.

Comparing Self to Peers in Percentile Equivalents during Cognitive Testing: More Accurate Self-Appraisal Estimates are Associated with Greater Ability and Less Reliance on the Representativeness Heuristic

OBJECTIVE

For individuals with neurologic disorders, self-awareness of cognitive impairment is associated with indicators of better treatment course and clinical outcomes. Lower self-appraisal accuracy has been found to be associated with impairments in neuropsychological test performance, but individuals who perform unusually well may be equally vulnerable to inaccurate self-ratings. The mixed pattern of cognitive strengths and deficits in individuals with neurologic disorders complicates development of formal metrics for assessment of self-awareness. It remains unclear to what extent distortions in self-appraisal represent a deficit associated with impaired cognitive functioning, or a normal reliance on the "representativeness-heuristic" that results in greater bias in self-ratings in both strong and poor performers.

METHOD

The present study investigated these hypotheses using a common-metric approach (Rothlind, Dukarm, and Kraybill, 2016). Participants included 199 adults, recruited from community sources, including healthy adult volunteers and individuals at-risk for neuropsychological impairment secondary to human immunodeficiency virus (HIV) positive status or active heavy alcohol consumption or both. Immediately following completion of standardized neuropsychological tests, participants estimated their own performance percentile ranking.

RESULTS

Both high and low-scoring examinees displayed a conservative bias in ranking their own neuropsychological performance. However, lower scores were associated with least accurate self-appraisals overall.

CONCLUSION

Findings suggest that cognitive impairments are associated with lower accuracy in self-rating of cognitive ability, but also that normal biases complicate interpretation of self-appraisal ratings across the spectrum of neuropsychological functioning. The importance of recognizing these biases in clinical research and practice is emphasized, and directions for future research are discussed.

Vicarious Embarrassment or "Fremdscham": Overendorsement in Frontotemporal Dementia

OBJECTIVE

The experience of embarrassment signals violations in social norms, and impairment in this social emotion may underlie much of the social dysfunction in behavioral variant frontotemporal dementia (bvFTD). The authors investigated whether impaired self-awareness of embarrassment may distinguish patients with bvFTD early in the course of disease from healthy control subjects (HCs).

METHODS

Self-reported embarrassment was examined among 18 patients with early bvFTD and 23 HCs by using the 36-item Embarrassability Scale, which includes items of situations eliciting embarrassment for oneself ("self-embarrassment") and embarrassment for others ("vicarious embarrassment"). The two study groups were also compared with the Social Norms Questionnaire (SNQ). The analyses included correlations of SNQ results (total score, violations or "break" errors, and overendorsement of social rules or "overadhere" errors) with Embarrassability Scale scores.

RESULTS

Patients with bvFTD did not differ from HCs on total or self-embarrassment scores but did have significantly higher vicarious embarrassment scores. Unlike in the HC group, reports of vicarious embarrassment did not differ from reports of self-embarrassment among patients in the bvFTD group. The Embarrassability Score further correlated with overadherence to norms on the SNQ.

CONCLUSIONS

In the presence of social dysfunction and emotional blunting, these findings suggest that patients with bvFTD rely on their own perspective for a rule-based application of social norms in reporting vicarious embarrassment. The assessment of reports of embarrassment for others may indicate an early and previously unrecognized clinical measure for detecting bvFTD.

Evaluation of a performance-rating method to assess awareness of cognitive functioning in Huntington's disease

Objective: Anosognosia, or lack of awareness of symptoms, is commonly observed in Huntington's disease (HD) using patient/informant-report discrepancy methods. The purpose of this study was to examine the utility of a performance-rating method for assessing awareness of cognitive performance in HD.Method: Persons with manifest HD (n = 54) rated their performance on the daily living tests from the Neuropsychological Assessment Battery (NAB) using a bell curve. We also examined patient/informant-report discrepancies of executive functioning (FrSBe) in a subset (n = 47) of patients and their informants.Results: Patients were able to reliably use our method of categorizing their performance as evidenced by significant correlations between verbal descriptions of their performance and the percentile ratings they indicated on the bell curve. Patients across the range of observed Unified HD Rating Scale motor scale scores rated their performance on the NAB tasks significantly higher than actual performance for both pretest prediction and posttest evaluation ratings. Only patients with more severe motor impairment underestimated their problems relative to informant report on the FrSBe.Conclusions: This is the first study to use a performance-rating method for examining awareness in HD. Patients could reliably use this performance-based bell curve method to provide accurate estimations of their performance and as a group they tended to overestimate performance as has been demonstrated in previous studies. Unlike previous studies using self-report methodology, we also demonstrated decreased awareness in the persons with HD with less severe motor impairment using the performance-rating method, suggesting the two methods may measure different constructs of awareness.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cognitive and Affective Perspective-Taking: Evidence for Shared and Dissociable Anatomical Substrates

Perspective-taking refers to the ability to recognize another person's point of view. Crucial to the development of interpersonal relationships and prosocial behavior, perspective-taking is closely linked to human empathy, and like empathy, perspective-taking is commonly subdivided into cognitive and affective components. While the two components of empathy have been frequently compared, the differences between cognitive and affective perspective-taking have been under-investigated in the cognitive neuroscience literature to date. Here, we define cognitive perspective-taking as the ability to infer an agent's thoughts or beliefs, and affective perspective-taking as the ability to infer an agent's feelings or emotions. In this paper, we review data from functional imaging studies in healthy adults as well as behavioral and structural imaging studies in patients with behavioral variant frontotemporal dementia in order to determine if there are distinct neural correlates for cognitive and affective perspective-taking. Data suggest that there are both shared and non-shared cognitive and anatomic substrates. For example, while both types of perspective-taking engage regions such as the temporoparietal junction, precuneus, and temporal poles, only affective perspective-taking engages regions within the limbic system and basal ganglia. Differences are also observed in prefrontal cortex: while affective perspective-taking engages ventromedial prefrontal cortex, cognitive perspective-taking engages dorsomedial prefrontal cortex and dorsolateral prefrontal cortex (DLPFC). To corroborate these findings, we also examine if cognitive and affective perspective-taking share the same relationship with executive functions. While it is clear that affective perspective-taking requires emotional substrates that are less prominent in cognitive perspective-taking, it remains unknown to what extent executive functions (including working memory, mental set switching, and inhibitory control) may contribute to each process. Overall results indicate that cognitive perspective-taking is dependent on executive functioning (particularly mental set switching), while affective perspective-taking is less so. We conclude with a critique of the current literature, with a focus on the different outcome measures used across studies and misconceptions due to imprecise terminology, as well as recommendations for future research.

Assessment of Self-Awareness of Cognitive Function: Correlations of Self-Ratings with Actual Performance Ranks for Tests of Processing Speed, Memory and Executive Function in Non-Clinical Samples

Objective

For individuals with neurologic disorders, self-awareness of cognitive impairment is associated with improved treatment course and clinical outcome. However, methods for assessment of levels of self-awareness are limited, and most require collateral information, which may not be readily available. Although distortions in self-awareness are most often associated with low cognitive ability, the frequently mixed pattern of cognitive strengths and deficits in individuals with neurologic disorders complicates assessment. The present study explores relationships between actual test performance and self-ratings, utilizing a brief probe administered during testing. The "common-metric" approach solicits self-appraisal ratings in percentile equivalents and capitalizes on available normative data for specific standardized neuropsychological tests to allow direct comparisons.

Method

A convenience sample of 199 adults recruited from community sources participated in this study, including healthy adults and neuropsychologically "at-risk" volunteers who were HIV positive and/or endorsing heavy current alcohol consumption. Immediately following completion of standardized neuropsychological tests, participants estimated their own percentile ranking.

Results

Across study groups, participant's estimates of their own percentile rank were modestly correlated with actual performance ranking. Highest correlations were obtained for tests of learning, memory and conceptual reasoning, and executive function, with smaller correlations for simple tests of motor and psychomotor speed.

Conclusions

The study reveals normal biases affecting the self-appraisal during standardized testing, and suggests that a common-metric approach for assessing self-appraisal may play a role in establishing clinical thresholds and identifying and quantifying reductions in insight in persons with neuropsychological deficits.

Cognitive and Affective Perspective-Taking: Evidence for Shared and Dissociable Anatomical Substrates

Perspective-taking refers to the ability to recognize another person's point of view. Crucial to the development of interpersonal relationships and prosocial behavior, perspective-taking is closely linked to human empathy, and like empathy, perspective-taking is commonly subdivided into cognitive and affective components. While the two components of empathy have been frequently compared, the differences between cognitive and affective perspective-taking have been under-investigated in the cognitive neuroscience literature to date. Here, we define cognitive perspective-taking as the ability to infer an agent's thoughts or beliefs, and affective perspective-taking as the ability to infer an agent's feelings or emotions. In this paper, we review data from functional imaging studies in healthy adults as well as behavioral and structural imaging studies in patients with behavioral variant frontotemporal dementia in order to determine if there are distinct neural correlates for cognitive and affective perspective-taking. Data suggest that there are both shared and non-shared cognitive and anatomic substrates. For example, while both types of perspective-taking engage regions such as the temporoparietal junction, precuneus, and temporal poles, only affective perspective-taking engages regions within the limbic system and basal ganglia. Differences are also observed in prefrontal cortex: while affective perspective-taking engages ventromedial prefrontal cortex, cognitive perspective-taking engages dorsomedial prefrontal cortex and dorsolateral prefrontal cortex (DLPFC). To corroborate these findings, we also examine if cognitive and affective perspective-taking share the same relationship with executive functions. While it is clear that affective perspective-taking requires emotional substrates that are less prominent in cognitive perspective-taking, it remains unknown to what extent executive functions (including working memory, mental set switching, and inhibitory control) may contribute to each process. Overall results indicate that cognitive perspective-taking is dependent on executive functioning (particularly mental set switching), while affective perspective-taking is less so. We conclude with a critique of the current literature, with a focus on the different outcome measures used across studies and misconceptions due to imprecise terminology, as well as recommendations for future research.

Metabolic correlate of memory-deficit awareness in dementia with Lewy bodies: Implication in cortical midline structure

The neural substrate of memory-deficit awareness has been studied in mild cognitive impairment and Alzheimer's disease (AD). However, little is known about that in dementia with Lewy bodies (DLB). To determine the neural substrates of memory-deficit awareness in DLB, we investigated the relationship between awareness of memory-deficit and glucose metabolism in DLB. Thirty-four patients with DLB were assessed by ¹⁸F-FDG-PET and dopamine transporter (DAT)-SPECT. The awareness was evaluated using an awareness index that represents the discrepancy between objective and subjective memory scores. The association between awareness index and FDG uptake was analyzed using SPM12. Awareness index was significantly lower in DLB than in individuals with normal cognition and was associated with glucose metabolism in the bilateral posterior cingulate cortex and right orbitofrontal cortex. Moreover, the awareness index positively correlated with the cingulate island sign ratio but not with striatal DAT density. The findings suggested that the awareness of memory-deficit in DLB was to some extent impaired and its neural substrate was located in cortical midline structure. The concomitant AD-type pathology might have influenced memory-deficit awareness in DLB.

Mistakes, Too Few to Mention? Impaired Self-conscious Emotional Processing of Errors in the Behavioral Variant of Frontotemporal Dementia

Anosognosia, or lack of awareness of one's deficits, is a core feature of the behavioral variant of frontotemporal dementia (bvFTD). We hypothesized that this deficit has its origins in failed emotional processing of errors. We studied autonomic and facial emotional reactivity to errors in patients with bvFTD (n = 17), Alzheimer's disease (AD, n = 20), and healthy controls (HC, n = 35) during performance of a timed two-alternative-choice button press task. Performance-related behavioral responses to errors were quantified using rates of error correction and post-error slowing of reaction times. Facial emotional responses were measured by monitoring facial reactivity via video and subsequently coding the type, duration and intensity of all emotional reactions. Skin conductance response (SCR) was measured via noninvasive sensors. SCR and total score for each facial emotion expression were quantified for each trial. Facial emotions were grouped into self-conscious (amusement, embarrassment) and negative (fear, sadness, anger, disgust, contempt) emotions. HCs corrected 99.4% of their errors. BvFTD patients corrected 94% (not statistically different compared with HC) and AD corrected 74.8% of their errors (p < 0.05 compared with HC and bvFTD). All groups showed similar post-error slowing. Errors in HCs were associated with greater facial reactivity and SCRs compared with non-error trials, including both negative and self-conscious emotions. BvFTD patients failed to produce self-conscious emotions or an increase in SCR for errors, although they did produce negative emotional responses to a similar degree as HCs. AD showed no deficit in facial reactivity to errors. Although, SCR was generally reduced in AD during error trials, they showed a preserved increase in SCR for errors relative to correct trials. These results demonstrate a specific deficit in emotional responses to errors in bvFTD, encompassing both physiological response and a specific deficit in self-conscious emotions, despite intact awareness and correction of errors. The findings provide a potential mechanism for anosognosia and possibly other behavioral abnormalities in bvFTD and highlight the importance of studying multiple channels of reactivity to errors, including performance related responses and emotional responses, in order to understand how impaired error processing could influence behavior.

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

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

Development of an instrument to assess social functioning in dementia: The Social Functioning in Dementia scale (SF-DEM)

Introduction

Social functioning is a core domain in the life of people with dementia, but there is no accepted instrument to measure it. We aimed to develop the Social Functioning in Dementia (SF-DEM) scale and test its psychometric properties for assessing social function in people with dementia.

Methods

We interviewed people with mild dementia and family caregivers to develop patient and caregiver-rated SF-DEM versions and refined them through interviews with health care professionals. We tested its psychometric properties in 30 dyads of people with dementia and family caregivers.

Results

Both SF-DEM versions had content validity and demonstrated concurrent validity against a single item rating overall social functioning (patient rated r = 0.42, 95% CI [0.07–0.68]; caregiver rated r = 0.59, 95% CI [0.29–0.78]). All participants found it acceptable. Analyses showed reliability (test–retest, inter-rater, internal consistency) and indications of responsiveness to change.

Discussion

SF-DEM shows promise as a valid, reliable, acceptable measure of social functioning in dementia.

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Social function is key to dementia diagnosis and important to patients and families.

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SF-DEM is the first assessment tool for measuring social functioning in dementia.

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In SF-DEM, core social functioning domains are assessed by self- or proxy-report.

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These measures are acceptable to clinicians and respondents, and are reliable.

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SF-DEM has content and concurrent validity in mild dementia.

A Clinical Guide to Frontotemporal Dementias

The term frontotemporal dementia (FTD) describes a diverse group of clinical syndromes, including behavioral-variant FTD (bvFTD), nonfluent/agrammatic-variant primary progressive aphasia (nfvPPA), semantic-variant primary progressive aphasia (svPPA), FTD motor neuron disease (FTD-MND), progressive supranuclear palsy syndrome (PSP-S), and corticobasal syndrome (CBS). Although each of these syndromes may be distinguished by their respective disturbances in behavior, language, or motor function and characteristic imaging findings, they may present a diagnostic dilemma when encountered clinically. In this article, we review the clinical features, diagnostic criteria, pathology, genetics, and therapeutic interventions for FTD spectrum disorders.

A Systematic Review of Metacognitive Differences Between Alzheimer's Disease and Frontotemporal Dementia

Clinicians often have difficulty distinguishing between various forms of dementia to achieve a correct diagnosis. Little research has been done to examine whether awareness of one's cognitive deficits, or metacognitive monitoring, might differ between dementia diagnoses, thereby providing an additional means of differentiating between dementia subtypes. We review articles examining metacognitive comparisons between two of the most common dementia subtypes: Alzheimer's disease and frontotemporal dementia. Greater monitoring deficits were apparent in frontotemporal dementia than in Alzheimer's disease, and participants with frontotemporal dementia were less likely to utilize task experience to update and improve the accuracy of subsequent monitoring judgments. Results provide evidence for the utility of metacognitive measures as a means of distinguishing between Alzheimer's disease and frontotemporal dementia.

Decreased Self-Appraisal Accuracy on Cognitive Tests of Executive Functioning Is a Predictor of Decline in Mild Cognitive Impairment

OBJECTIVE

Mild cognitive impairment (MCI) in older individuals is associated with increased risk of progression to dementia. The factors predicting progression are not yet well established, yet cognitive performance, particularly for memory, is known to be important. Anosognosia, meaning lack of awareness of one's impaired function, is commonly reported in dementia and is often also a feature of MCI, but its association with risk of progression is not well understood. In particular, self-appraisal measures provide an autonomous measure of insight abilities, without the need of an informant.

METHODS

The present study examined the utility of self-appraisal accuracy at baseline for predicting cognitive decline in 51 patients using an informant-free assessment method. Baseline task performance scores were compared to self-assessments of performance to yield a discrimination score (DS) for tasks tapping into memory and executive functions.

RESULTS

Linear regression revealed that a larger DS for executive function tasks in MCI predicted functional decline, independent of age, education, and baseline memory and executive task scores.

CONCLUSION

These findings indicate that objective estimates of self-appraisal can be used to quantify anosognosia and increase predictive accuracy for decline in MCI.

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.

Self-Consciousness in Patients with Behavioral Variant Frontotemporal Dementia

Self-consciousness (SC) is multifaceted and considered to be the consciousness of one's own mental states. The medial prefrontal cortex may play a critical role in SC. The main aim of this paper was to examine SC in patients with behavioral variant frontotemporal dementia, who are characterized more by changes in personal, social, and emotional conduct and loss of insight than by cognitive disturbances. Control and patient groups of 21 subjects each, matched by age, educational level, gender, and nationality were assessed using a SC questionnaire. It measures several aspects: Personal identity, Anosognosia, Affective state, Body representation, Prospective memory, Introspection, and Moral judgments. The most disturbed ones in patients were Anosognosia, Affective state, and Moral judgments, and the least disturbed aspects were awareness of identity and of body representation. No significant correlations were found between the SC score and any clinical or demographical characteristics. The core deficiency of SC in patients was related to behavioral SC aspects, which are more dependent on orbito-frontal functioning.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Self-awareness in neurodegenerative disease relies on neural structures mediating reward-driven attention

Accurate self-awareness is essential for adapting one's tasks and goals to one's actual abilities. Patients with neurodegenerative diseases, particularly those with right frontal involvement, often present with poor self-awareness of their functional limitations that may exacerbate their already jeopardized decision-making and behaviour. We studied the structural neuroanatomical basis for impaired self-awareness among patients with neurodegenerative disease and healthy older adults. One hundred and twenty-four participants (78 patients with neurodegenerative diseases including Alzheimer's disease, behavioural variant frontotemporal dementia, right-temporal frontotemporal dementia, semantic variant and non-fluent variant primary progressive aphasia, and 46 healthy controls) described themselves on the Patient Competency Rating Scale, rating observable functioning across four domains (daily living activities, cognitive, emotional control, interpersonal). All participants underwent structural magnetic resonance imaging. Informants also described subjects' functioning on the same scale. Self-awareness was measured by comparing self and informant ratings. Group differences in discrepancy scores were analysed using general linear models, controlling for age, sex and disease severity. Compared with controls, patients with behavioural variant frontotemporal dementia overestimated their functioning in all domains, patients with Alzheimer's disease overestimated cognitive and emotional functioning, patients with right-temporal frontotemporal dementia overestimated interpersonal functioning, and patients with non-fluent aphasia overestimated emotional and interpersonal functioning. Patients with semantic variant aphasia did not overestimate functioning on any domain. To examine the neuroanatomic correlates of impaired self-awareness, discrepancy scores were correlated with brain volume using voxel-based morphometry. To identify the unique neural correlates of overlooking versus exaggerating deficits, overestimation and underestimation scores were analysed separately, controlling for age, sex, total intracranial volume and extent of actual functional decline. Atrophy related to overestimating one's functioning included bilateral, right greater than left frontal and subcortical regions, including dorsal superior and middle frontal gyri, lateral and medial orbitofrontal gyri, right anterior insula, putamen, thalamus, and caudate, and midbrain and pons. Thus, our patients' tendency to under-represent their functional decline was related to degeneration of domain-general dorsal frontal regions involved in attention, as well as orbitofrontal and subcortical regions likely involved in assigning a reward value to self-related processing and maintaining accurate self-knowledge. The anatomic correlates of underestimation (right rostral anterior cingulate cortex, uncorrected significance level) were distinct from overestimation and had a substantially smaller effect size. This suggests that underestimation or 'tarnishing' may be influenced by non-structural neurobiological and sociocultural factors, and should not be considered to be on a continuum with overestimation or 'polishing' of functional capacity, which appears to be more directly mediated by neural circuit dysfunction.

C9ORF72 hexanucleotide repeats in behavioral and motor neuron disease: clinical heterogeneity and pathological diversity

Hexanucleotide repeat expansion in C9ORF72 is the most common genetic cause of frontotemporal dementia (FTD), a predominantly behavioral disease, and amyotrophic lateral sclerosis (ALS), a disease of motor neurons. The primary objectives of this review are to highlight the clinical heterogeneity associated with C9ORF72 pathogenic expansion and identify potential molecular mechanisms underlying selective vulnerability of distinct neural populations. The proposed mechanisms by which C9ORF72 expansion causes behavioral and motor neuron disease highlight the emerging role of impaired RNA and protein homeostasis in a spectrum of neurodegeneration and strengthen the biological connection between FTD and ALS.

Neural substrates of socioemotional self-awareness in neurodegenerative disease

BACKGROUND

Neuroimaging studies examining neural substrates of impaired self-awareness in patients with neurodegenerative diseases have shown divergent results depending on the modality (cognitive, emotional, behavioral) of awareness. Evidence is accumulating to suggest that self-awareness arises from a combination of modality-specific and large-scale supramodal neural networks.

METHODS

We investigated the structural substrates of patients' tendency to overestimate or underestimate their own capacity to demonstrate empathic concern for others. Subjects' level of empathic concern was measured using the Interpersonal Reactivity Index, and subject-informant discrepancy scores were used to predict regional atrophy pattern, using voxel-based morphometry analysis. Of the 102 subjects, 83 were patients with neurodegenerative diseases such as behavioral variant frontotemporal dementia (bvFTD) or semantic variant primary progressive aphasia (svPPA); the other 19 were healthy older adults.

RESULTS

bvFTD and svPPA patients typically overestimated their level of empathic concern compared to controls, and overestimating one's empathic concern predicted damage to predominantly right-hemispheric anterior infero-lateral temporal regions, whereas underestimating one's empathic concern showed no neuroanatomical basis.

CONCLUSIONS

These findings suggest that overestimation and underestimation of one's capacity for empathic concern cannot be interpreted as varying degrees of the same phenomenon, but may arise from different pathophysiological processes. Damage to anterior infero-lateral temporal regions has been associated with semantic self-knowledge, emotion processing, and social perspective taking; neuropsychological functions partly associated with empathic concern itself. These findings support the hypothesis that-at least in the socioemotional domain-neural substrates of self-awareness are partly modality-specific.

Metacognition in the behavioral variant of frontotemporal dementia and Alzheimer's disease

OBJECTIVE

Impaired self-awareness is characteristic of nearly all dementias, including Alzheimer's disease (AD), but the deficit is most severe in the behavioral variant of frontotemporal dementia (bvFTD). The prominence of frontal pathology in bvFTD suggests that failure of online monitoring, the process by which individuals monitor their own cognitive processing in real time, is an important contributor. Metacognitive research offers several approaches to measure self-assessment, some more and others less sensitive to online monitoring. The goal of this study was to assess metacognition in bvFTD using several approaches, and to compare the results with those in AD.

METHOD

We examined metacognition in 12 patients with bvFTD, 14 with AD, and 35 healthy controls using feeling of knowing (FOK), ease of learning (EOL), judgment of learning (JOL), and retrospective confidence rating (CR) tasks, as well as response to feedback about performance.

RESULTS

BvFTD and AD were both impaired at FOK compared with controls, although AD showed some sparing. Both groups were similarly impaired at CR and neither group was impaired at JOL after accounting for memory performance. Most striking, bvFTD patients failed to appropriately adjust their predictions about future memory performance even after receiving explicit feedback that they had performed worse than they expected.

CONCLUSIONS

Both bvFTD and AD show deficits in online monitoring, although the deficit appears more severe in bvFTD. The insensitivity of bvFTD patients to overt feedback may point to unique mechanisms, possibly frontally mediated, that add to their severe lack of self-awareness.

Deficits in self-awareness impact the diagnosis of asymptomatic neurocognitive impairment in HIV

A recent national survey of HIV(+) adults noted that nearly three-quarters of cognitively impaired individuals are categorized as having asymptomatic neurocognitive impairment (ANI), lacking documented compromise of everyday function. The clinical impact and long-term consequences of ANI are unknown and the importance of this asymptomatic diagnosis has raised concerns in clinical care settings where competing priorities often exist. In this study, we conducted structured tests of everyday functioning in a sample of HIV(+) subjects over 60 years of age and asked subjects to rate their performance relative to peers. We demonstrate that individuals with neuropsychological testing impairment often lack self-awareness of functional performance deficits. Specifically, ANI subjects rated functional performance similar to that of HIV-negative control subjects, despite noted deficits in objective measures of function. These findings have important implications for use of self-report of function in the diagnosis of HIV-associated neurocognitive disorders (HAND), likely underestimating symptomatic impairment.

Cognitive insight in Alzheimer's disease

BACKGROUND/RATIONALE

We investigated the cognitive insight profile of patients with Alzheimer's disease (AD) using the Beck Cognitive Insight Scale (BCIS).

METHODS

This study involved 30 patients with probable AD and 15 healthy participants (ie, the controls). All individuals completed the BCIS, the Hamilton Rating Scale for Depression (HAMD), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Mean scores of the HADS-depression subscale, HAMD, BCIS-self-reflectiveness (BCIS-R), and BCIS-self-certainty (BCIS-C) subscales were significantly different between the patients and the controls. However, there was no significant difference in BCIS reflectiveness-certainty index scores between the patients and the control groups. Regression analyses showed a moderately positive correlation between hallucinations and BCIS-C scores.

CONCLUSION

This study is the first to investigate cognitive insight in patients with probable AD. The BCIS-R and BCIS-C scores were significantly lower in patients than in control group.

Dementia Risk and Financial Decision Making by Older Households: The Impact of Information

The knowledge and reasoning ability needed to manage one's finances is a form of human capital. Alzheimer's disease and other dementias cause progressive declines in cognition that lead to a complete loss of functional capacities. In this paper we analyze the impact of information about cognitive decline on the choice of household financial decision-maker. Using longitudinal data on older married couples in a novel application of survival analysis, we find that as the financial decision maker's cognition declines, the management of finances is eventually turned over to his cognitively intact spouse, often well after difficulties handling money have already emerged. However, a memory disease diagnosis increases the hazard of switching the financial respondent by over 200 percent for couples who control their retirement accounts, like 401(k) accounts, relative to those who passively receive retirement income. This finding is consistent with a model of the value of information: households with the most to gain financially from preparation are most responsive to information about cognitive decline.

Trail Making Test A improves performance characteristics of the International HIV Dementia Scale to identify symptomatic HAND

Although HIV-associated dementia (HAD) occurs in less than 5 % of individuals with access to combination antiretroviral therapy, rates of milder forms of HIV-associated neurocognitive disorder (HAND) are much higher. We sought to define an optimal cut point for the International HIV Dementia Scale (IHDS) in Thailand for the identification of symptomatic HAND, defined as both HAD and mild neurocognitive disorder. We then sought to determine if adding a simple test from a larger neuropsychological battery could improve the performance characteristics for identifying symptomatic HAND. In this study, subjects comprising 75 seropositive adults in Bangkok, Thailand, completed neuropsychological tests and underwent a full neurological assessment. HAND diagnoses were determined by consensus conference using the 2007 Frascati criteria, blinded to the IHDS results. The optimal IHDS cut point was determined by receiver operating characteristic analysis with cross-validation. Individual neuropsychological tests were then evaluated and combined with the IHDS to test performance characteristics. The IHDS was poor at detecting symptomatic HAND at the optimized cut point of ≤ 10 (sensitivity, 53.3 %; specificity, 89.8 %). Trail Making Test A was most effective in improving performance characteristics when combined with the IHDS, with net sensitivity of 86 % and specificity of 79 %. In this setting, the IHDS performed poorly in identifying symptomatic HAND, but was substantially improved by the addition of Trail Making Test A, which typically requires less than 2 min to complete. This combination should be validated in a larger setting since it may address the critical need for HAND screening instruments in international settings.

Self-appraisal in behavioural variant frontotemporal degeneration

OBJECTIVE

Previous work investigating deficits in self-appraisal in behavioural-variant frontotemporal degeneration (bvFTD) has focused on a single domain: social/behavioural processes. We examined whether a domain-specific versus multi-domain model best explains degraded self-appraisal in bvFTD.

METHODS

49 patients with bvFTD and 73 patients with Alzheimer's disease (AD) were administered quantitative assessments of episodic memory, naming and grammatical comprehension. Self-appraisal of cognitive test performance was assessed by asking patients to rate their performance immediately after completing each neuropsychological test. A discrepancy score was created to reflect the difference between patient performance on neuropsychological tests and self-appraisal of their test performance. Self-appraisal for each neuropsychological measure was related to grey matter (GM) density in each group using voxel-based morphometry.

RESULTS

bvFTD patients were poor at evaluating their own performance on all cognitive tests, with no significant correlations between self-appraisal and actual performance. By contrast, poor self-appraisal in AD was restricted to episodic memory performance. Poor self-appraisal on each task in bvFTD and AD was related to reduced GM density in several ventral and rostral medial prefrontal regions. Crucially, poor self-appraisal for all domains in bvFTD was related to a specific area of reduced GM density in the subgenual cingulate (BA 25).

CONCLUSION

Poor self-appraisal in bvFTD affects multiple domains, and this multi-domain impairment pattern is associated with frontal disease in the subgenual cingulate.

Ventromedial-frontopolar prefrontal cortex atrophy correlates with insight loss in frontotemporal dementia and Alzheimer's disease

Loss in insight is a major feature of frontotemporal dementia (FTD) but has been investigated relatively little. More importantly, the neural basis of insight loss is still poorly understood. The current study investigated insight deficit profiles across a large cohort of neurodegenerative patients (n = 81), including FTD and Alzheimer's disease (AD) patients. We employed a novel insight questionnaire, which tapped into changes across different domains: social interaction, emotion, diagnosis/treatment, language, and motivation. FTD subtypes varied considerably for insight loss, with the behavioral variant worst and the progressive non-fluent variant least affected. All other subtypes and AD showed milder but consistent insight loss. Voxel-based morphometry analysis revealed that overall insight loss correlated with ventromedial and frontopolar prefrontal atrophy, with exception of social interaction and emotion insight loss, which additionally correlated with lateral temporal and amygdala atrophy, respectively. Our results show that patients with neurodegenerative conditions show variable loss of insight, with ventromedial and frontopolar cortex regions appearing to be particularly important for insight.

Failures of metacognition and lack of insight in neuropsychiatric disorders

Lack of insight or unawareness of illness are the hallmarks of many psychiatric disorders, especially schizophrenia (SCZ) and other psychoses and could be conceived of as a failure in metacognition. Research in this area in the mental health field h as burgeoned with the development and widespread use of standard assessment instruments and the mapping out of the clinical and neuropsychological correlates of insight and its loss. There has been a growing appreciation of the multi-faceted nature of the concept and of the different 'objects' of insight, such as the general awareness that one is ill, to more specific metacognitive awareness of individual symptoms, impairments and performance. This in turn has led to the notion that insight may show modularity and may fractionate across different domains and disorders, supported by work that directly compares metacognition of memory deficits and illness awareness in patients with SCZ, Alzheimer's disease and brain injury. The focus of this paper will be on the varieties of metacognitive failure in psychiatry, particularly the psychoses. We explore cognitive models based on self-reflectiveness and their possible social and neurological bases, including data from structural and functional MRI. The medial frontal cortex appears to play an important role in self-appraisal in health and disease.

Self- and informant ratings of personality in mild cognitive impairment, reviewed

AIMS

To examine the degree of agreement between self- and informant ratings of personality in relation to cognitive function in patients with mild cognitive impairment (MCI), subjective cognitive impairment (SCI) and healthy controls (HC).

METHODS

Thirty-two patients and informants with MCI, 23 with SCI and 22 HC completed the Swedish universities Scales of Personality (SSP). Correlations and incongruence between self- and informant ratings were calculated. The Mini Mental State Examination (MMSE) was used to assess cognitive function.

RESULTS

The correlations between self- and informant ratings were fair-to-moderate on a majority of SSP scales and significant in 44%. The incongruence between patients and informants was significantly larger in MCI than in HC across SSP scales. There was a significant negative correlation between the incongruence index and the MMSE for all subjects.

CONCLUSIONS

Self-informant agreement on ratings of patients' personality was reasonable. Incongruence between patients and their informants was associated with MCI but not SCI or HC. Disagreement between patients and informants indicates cognitive impairment.

Longitudinal stability of subsyndromal symptoms of depression in individuals with mild cognitive impairment: relationship to conversion to dementia after 3 years

OBJECTIVE

To evaluate the degree to which longitudinal stability of subsyndromal symptoms of depression (SSD) is associated with conversion to dementia in patients with mild cognitive impairment (MCI).

METHODS

Data from 405 MCI participants from the Alzheimer's Disease Neuroimaging Initiative (ADNI) study were analyzed. Participants were evaluated at baseline and 12-month intervals over 3 years. Participants were designated as MCI converters if dementia was diagnosed within 3 years or as cognitively stable MCI if dementia was not diagnosed during this interval. SSD were evaluated utilizing the 15-item Geriatric Depression Scale (GDS). Endorsement of specific SSD at baseline and the stability of SSD over 36 months were compared between the two MCI groups.

RESULTS

Baseline symptom endorsement and stability of total GDS scores did not differentiate MCI groups. Worsening of four individual items from the GDS over time (memory problems, feelings of helplessness, loss of interest, and preference for staying at home) differentiated MCI converters from cognitively stable MCI (p < 0.05 for all). However, only increased endorsement of memory symptoms over time was associated with progression to dementia after controlling for other clinical variables (p = 0.05).

CONCLUSIONS

SSD in MCI participants largely consist of cognitive symptoms and activity limitations, and the stability of SSD over time differentiated the MCI groups better than baseline endorsement of symptoms. However, the only significant predictor of conversion to dementia was increased endorsement of memory problems, which likely represents insight into cognitive problems more than depressive symptomatology in MCI individuals.

Self-projection and the default network in frontotemporal dementia

Converging evidence suggests that when individuals are left to think to themselves, a so-called default network of the brain is engaged, allowing the individual to daydream, reflect on their past, imagine possible future scenarios, and consider the viewpoints of others. These flexible self-relevant mental explorations enable the anticipation and evaluation of events before they occur, and are essential for successful social interactions. Such self-projective efforts are particularly vulnerable to disruption in frontotemporal dementia (FTD), a neurodegenerative disorder involving damage to the frontal and temporal lobes of the brain. In this Review, we explore how the progressive degeneration of the neural networks in two subtypes of FTD-the behavioral variant and semantic dementia-affects key structures of the default network and putative self-projective functions. We examine the available evidence from studies of autobiographical memory, episodic future thinking, theory of mind, moral reasoning, and economic decision-making in these neurodegenerative diseases. Finally, we propose that the mapping of default-network functions onto discrete subsystems of the default network may need revision in light of neuropsychological and clinical evidence from studies in patients with FTD.

Loss of emotional insight in behavioral variant frontotemporal dementia or "frontal anosodiaphoria"

Loss of insight is a prominent clinical manifestation of behavioral variant frontotemporal dementia (bvFTD), but its characteristics are poorly understood. Twelve bvFTD patients were compared with 12 Alzheimer's disease (AD) patients on a structured insight interview of cognitive insight (awareness of having a disorder) and emotional insight (concern over having a disorder). Compared to the AD patients, the bvFTD patients were less aware and less concerned about their disorder, and they had less appreciation of its effects on themselves and on others. After corrective feedback ("updating"), the bvFTD patients were just as aware of their disorder as the AD patients but remained unconcerned and unappreciative of its effects. These findings suggest that lack of insight in bvFTD is not due to "anosognosia," or impaired cognitive and executive awareness of disease, but to "frontal anosodiaphoria," or lack of emotional concern over having bvFTD and its impact on themselves and others.

Everyday episodic memory in amnestic mild cognitive impairment: a preliminary investigation

BACKGROUND

Decline in episodic memory is one of the hallmark features of Alzheimer's disease (AD) and is also a defining feature of amnestic Mild Cognitive Impairment (MCI), which is posited as a potential prodrome of AD. While deficits in episodic memory are well documented in MCI, the nature of this impairment remains relatively under-researched, particularly for those domains with direct relevance and meaning for the patient's daily life. In order to fully explore the impact of disruption to the episodic memory system on everyday memory in MCI, we examined participants' episodic memory capacity using a battery of experimental tasks with real-world relevance. We investigated episodic acquisition and delayed recall (story-memory), associative memory (face-name pairings), spatial memory (route learning and recall), and memory for everyday mundane events in 16 amnestic MCI and 18 control participants. Furthermore, we followed MCI participants longitudinally to gain preliminary evidence regarding the possible predictive efficacy of these real-world episodic memory tasks for subsequent conversion to AD.

RESULTS

The most discriminating tests at baseline were measures of acquisition, delayed recall, and associative memory, followed by everyday memory, and spatial memory tasks, with MCI patients scoring significantly lower than controls. At follow-up (mean time elapsed: 22.4 months), 6 MCI cases had progressed to clinically probable AD. Exploratory logistic regression analyses revealed that delayed associative memory performance at baseline was a potential predictor of subsequent conversion to AD.

CONCLUSIONS

As a preliminary study, our findings suggest that simple associative memory paradigms with real-world relevance represent an important line of enquiry in future longitudinal studies charting MCI progression over time.

Anosognosia for memory deficit in amnestic mild cognitive impairment and Alzheimer's disease

OBJECTIVE

to investigate patterns of anosognosia for memory deficit in subjects with amnestic mild cognitive impairment (MCI) and Alzheimer's disease (AD).

METHODS

the study involved twenty-five subjects with MCI, 15 with mild AD and 21 normal controls (NC). Subjective rating of memory functioning was assessed with a six-items questionnaire that was administered before and after memory testing; an informant version from caregivers gave a discrepancy score (SRD). In the Objective Judgement (OJ) task, aiming to evaluate memory-monitoring abilities, subjects were requested three times to predict their memory performance in recalling words from a list of ten. Then they had to recall the words. Prediction accuracy was computed by subtracting the predicted performance from the actual performance.

RESULTS

MCI and AD showed reduced awareness of memory difficulties at the SRD and did not change their rating of these difficulties after memory testing. At the OJ task, MCI and AD consistently overestimated their memory performances as compared with NC. The SRD and OJ measures were not correlated with some patients being impaired on only one measure. Only the OJ measure was significantly related to executive functioning.

CONCLUSIONS

AD and MCI subjects show unawareness for memory deficit and significant memory-monitoring disorder. This confirms that anosognosia is an important symptom of MCI. Similarities of patterns of impaired awareness between AD and MCI supports the view of a continuum of the anosognosia phenomenon in MCI and AD.

Know thyself: real-world behavioral correlates of self-appraisal accuracy

Accurate appraisal of one's own abilities is one metacognitive skill considered to be an important factor affecting learning and behavior in childhood. The present study measured self-appraisal accuracy in children using tasks of executive function, and investigated relations between self-appraisal and informant ratings of real-world behaviors measured by the BRIEF. We examined self-appraisal accuracy on fluency tasks in 91 children ages 10-17. More accurate self-appraisal was correlated with fewer informant ratings of real-world behavior problems in inhibition and shifting, independent of actual performance. Findings suggest that self-appraisal represents cognitive processes that are at least partially independent of other functions putatively dependent on the frontal lobes, and these self-appraisal-specific processes have unique implications for optimal daily function.