Insight in Alzheimer's patients: results of a longitudinal study using three assessment methods

Cognitive Complaints in Memory Clinic Patients and in Depressive Patients: An Interpretative Phenomenological Analysis

BACKGROUND AND OBJECTIVES

Cognitive complaints are discussed as early signs of Alzheimer's disease (AD). However, they are also very common in cognitively normal older adults and in patients with depression. Qualitative, interview-based approaches might be useful to identify those features of cognitive complaints specific for the experiences of cognitive decline in preclinical or prodromal AD versus those complaints typically reported by depressed patients.

RESEARCH DESIGN AND METHODS

A semi-structured interview was administered to 21 cognitively normal older adults (HC), 18 nondemented memory clinic patients (MC), and 11 patients with a major depression (MD), all above 55 years. Interpretative phenomenological analysis (IPA) was applied to the interview transcripts to develop emerging complaint themes in each group. To identify thematic correspondence and possibly novel, hitherto unappreciated themes, the extracted complaint categories were compared with the neurocognitive domains in the DSM-5 and the content of the Everyday Cognition questionnaire (E-Cog).

RESULTS

IPA yielded 18 cognitive complaint categories in MC, 10 in depressive patients, and 10 categories in the HC group. Several themes were common across groups, but some were group-specific, for example, spatial disorientation was only reported in MC patients. Some of these MC-specific themes were neither represented by DSM-5 domains nor by the E-Cog.

DISCUSSION AND IMPLICATIONS

We report a comprehensive qualitative description of cognitive complaints in old age which could help to develop questionnaires or structured interviews to better assess AD-related subjective cognitive decline. This may help to increase specificity in selecting high-risk subjects in research settings and improve clinical judgment of diverse cognitive complaints types mentioned by their patients.

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

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

Investigating poor insight in Alzheimer’s disease

Persons with Alzheimer’s disease (AD) often seem to have a poor insight into the functional deficits brought about by the dementing process. There are many indications that preserved insight into deficits in dementia is of advantage to a person with AD. Various research approaches have been adopted to investigate poor insight related to AD. The purpose of this article was to present various research approaches for investigating poor insight into deficits in AD. The study is based on a literature survey. The findings show that concept of poor insight has been investigated in detail from different perspectives. Each one of the perspectives found, the neuropsychological, the psychological and the socio-psychological, has its merits, but none of them has yet led to study results that make us fully understand what poor insight implies and involves. We need integrated knowledge from the different perspectives, and in multidisciplinary research settings we believe that such knowledge could be developed.

Examining the Pathways Between Self-Awareness and Well-Being in Mild to Moderate Alzheimer Disease

OBJECTIVE

To investigate the relationship between awareness of memory loss and psychological well-being in a nonclinically depressed sample of participants with mild to moderate Alzheimer disease (AD).

METHODS

Study participants (N = 104) enrolled through Columbia University Medical Center and the University of Pennsylvania completed clinical and cognitive assessments. Participants were rated with regard to their degree of awareness of memory deficits and completed questionnaires relating to their psychological well-being, including mood and quality of life (QOL). Mediating models were used to establish the relationship between awareness, depression, and QOL and to examine potential mediators of awareness and depression, including psychological distress, objective memory deficits, and negative self-ratings.

RESULTS

There was a direct association between awareness of memory deficits and depressed mood but not awareness and QOL. However, there was an indirect association between awareness and QOL through depression. Neither psychological distress, memory deficits, nor negative self-ratings mediated the relationship between awareness and depression.

CONCLUSION

Awareness is associated with depressed mood in nonclinically depressed participants with mild to moderate AD. However, depressed mood does not appear to reflect the direct psychological reaction to awareness of memory loss. Moreover, awareness has only an indirect association with QOL via depressed mood. These results suggest that preserved awareness does not have a direct negative impact on overall psychological well-being in AD.

Anosognosia in people with cognitive impairment: association with cognitive deficits and behavioral disturbances

AIMS

To investigate, in a group of subjects at an early stage of cognitive impairment, the relationship between anosognosia and both cognitive and behavioral symptoms by exploring the various domains of insight.

METHODS

One hundred and eight subjects affected by cognitive impairment were consecutively enrolled. The level of awareness was evaluated by means of the Clinical Insight Rating Scale (CIRS). Psychiatric symptoms were evaluated using the Italian version of the Neuropsychiatric Inventory (NPI), whereas memory (memory index, MI) and executive (executive index, EI) functions were explored using a battery of neuropsychological tests and qualified by means of a single composite cognitive index score for each function.

RESULTS

A significant positive correlation between the total NPI score and global anosognosia score was found. Furthermore, both the MI and EI scores were lower in subjects with anosognosia than in those without anosognosia (p < 0.001 and p < 0.007, respectively). When the single domains of the CIRS were considered, anosognosia of reason of visit correlated with the EI score (r = -0.327, p = 0.01) and night-time behavioral disturbances (r = 0.225; p = 0.021); anosognosia of cognitive deficit correlated with depression (r = -0.193; p = 0.049) and the MI score (r = -0.201; p = 0.040); anosognosia of functional deficit correlated with the MI score (r = -0.257; p = 0.008), delusions (r = 0.232; p = 0.015) and aberrant motor behavior (r = 0.289; p = 0.003); anosognosia of disease progression correlated with the MI score (r = -0.236; p = 0.015), agitation (r = 0.247; p = 0.011), aberrant motor behavior (r = 0.351; p = 0.001) and night-time behavioral disturbances (r = 0.216; p = 0.027).

CONCLUSIONS

Our study suggests that, in the early stage of cognitive impairment, anosognosia is associated with both cognitive deficits and behavioral disorders according to the specific functional anatomy of the symptoms.

Abridged scale for the screening anosognosia in patients with dementia

The objective of this cross-sectional study was to validate an abridged version of the Anosognosia Questionnaire--Dementia (AQ-D) for screening anosognosia in daily practice. The authors reduce the AQ-D from 30 items to 9, with a large sample (n = 352) of patients with Alzheimer disease (AD). The Cronbach α was .793 and an area under the receiver-operating characteristic curve was 0.946. The κ index between new abridged AQ-D (AAQ) and original AQ-D was .800. The AAQ presents good validity and reliability indicators and kept concordance with the original scale. It is quick and easy to administer and it can simplify the clinical screening of anosognosia in patients with AD.

Insight in Alzheimer's disease and its relation to psychiatric and behavioral disturbances

OBJECTIVE

Individuals suffering from Alzheimer's disease (AD) often have impaired awareness or a lack of insight into their cognitive deficits and functional abilities, especially in the later stages of the disease. Previous research has documented a relationship between depression and insight in AD, such that greater awareness of one's disease has been associated with a higher degree of depression. However, little is known about the relationship between insight, cognitive decline, and other psychiatric or behavioral problems associated with AD.

METHODS

This study included 107 outpatients who met criteria for probable AD. Instruments included the Neurobehavioral Rating Scale, the Apathy Evaluation Scale, and the mini mental state exam. A series of hierarchical regression analyses were conducted to determine the relationship between insight and depressed mood, anxiety, psychosis, apathy, agitation, and behavioral retardation in AD patients after controlling for cognitive skills.

RESULTS

Insight was found to significantly predict depressed mood, anxiety, and apathy even after controlling for global cognition. Greater insight was found to be associated with depressed mood and anxiety. However, impaired insight was associated with higher levels of apathy.

CONCLUSION

Insight may be differentially related to mood symptoms and apathy within AD, such that patients with intact insight are more depressed, whereas patients with impaired insight are more apathetic. This suggests that assessment of insight in AD may complement the clinical evaluation of depression and apathy in AD and help guide the most appropriate interventions. Published 2013. This article is a U.S. Government work and is in the public domain in the USA.

Non-cognitive symptoms and related conditions in the Alzheimer's disease: a literature review

The Alzheimer's disease is considered a progressive cognitive disorder; however, several non-cognitive symptoms accompany all stages of the disease, appearing at times before the cognitive symptoms become manifest. This article reviews the literature on non-cognitive symptoms normally related to the Alzheimer's disease, including gait and balance dysfunction, olfactory dysfunction, diabetes, pain, and psychiatric symptoms.

Behavioral disturbances in dementia

Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety psychosis, agitation, aggression, disinhibition, and sleep disturbances. Approximately 30% to 90% of patients with dementia suffer from such behavioral disorders. There are complex interactions between cognitive deficits, psychological symptoms, and behavioral abnormalities. A large number of standardized, reliable, and well-validated instruments for assessing the behavioral and psychological symptoms of dementia have been developed in order to evaluate the efficacy of treatment. Neurodegenerative processes in various brain areas, particularly in the frontotemporal cortex and limbic regions, leading to cholinergic, serotonergic, and noradrenergic neurotransmitter dysfunctions constitute the biological matrix of behavioral symptoms, whereas psychological factors and personality traits play a modifying role. A large number of pharmacological, psychoeducational, psychotherapeutic, and social strategies have been developed to improve the quality of life of patients and their caregivers.

Patient self-report for evaluating mild cognitive impairment and prodromal Alzheimer's disease

Patient-reported outcome (PRO) measures are used to evaluate disease and treatments in many therapeutic areas, capturing relevant aspects of the disorder not obtainable through clinician or informant report, including those for which patients may have a greater level of awareness than those around them. Using PRO measures in mild cognitive impairment (MCI) and prodromal Alzheimer's disease (AD) presents challenges given the presence of cognitive impairment and loss of insight. This overview presents issues relevant to the value of patient report with emphasis on the role of insight. Complex activities of daily living functioning and executive functioning emerge as areas of particular promise for obtaining patient self-report. The full promise of patient self-report has yet to be realized in MCI and prodromal AD, however, in part because of lack of PRO measures developed specifically for mild disease, limited use of best practices in new measure development, and limited attention to psychometric evaluation. Resolving different diagnostic definitions and improving clinical understanding of MCI and prodromal AD will also be critical to the development and use of PRO measures.

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

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

Prevention of depression and sleep disturbances in elderly with memory-problems by activation of the biological clock with light--a randomized clinical trial

Background

Depression frequently occurs in the elderly and in patients suffering from dementia. Its cause is largely unknown, but several studies point to a possible contribution of circadian rhythm disturbances. Post-mortem studies on aging, dementia and depression show impaired functioning of the suprachiasmatic nucleus (SCN) which is thought to be involved in the increased prevalence of day-night rhythm perturbations in these conditions. Bright light enhances neuronal activity in the SCN. Bright light therapy has beneficial effects on rhythms and mood in institutionalized moderate to advanced demented elderly. In spite of the fact that this is a potentially safe and inexpensive treatment option, no previous clinical trial evaluated the use of long-term daily light therapy to prevent worsening of sleep-wake rhythms and depressive symptoms in early to moderately demented home-dwelling elderly.

Methods/Design

This study investigates whether long-term daily bright light prevents worsening of sleep-wake rhythms and depressive symptoms in elderly people with memory complaints. Patients with early Alzheimer's Disease (AD), Mild Cognitive Impairment (MCI) and Subjective Memory Complaints (SMC), between the ages of 50 and 75, are included in a randomized double-blind placebo-controlled trial. For the duration of two years, patients are exposed to ~10,000 lux in the active condition or ~300 lux in the placebo condition, daily, for two half-hour sessions at fixed times in the morning and evening. Neuropsychological, behavioral, physiological and endocrine measures are assessed at baseline and follow-up every five to six months.

Discussion

If bright light therapy attenuates the worsening of sleep-wake rhythms and depressive symptoms, it will provide a measure that is easy to implement in the homes of elderly people with memory complaints, to complement treatments with cholinesterase inhibitors, sleep medication or anti-depressants or as a stand-alone treatment.

Trial registration

ISRCTN29863753

Language-enriched exercise plus socialization slows cognitive decline in Alzheimer's disease

This article reports the effects of language-enriched physical fitness interventions provided by University of Arizona undergraduate students to 24 mild- to moderate-stage Alzheimer's disease patients (AD Rehab group). Socialization experiences consisted of supervised volunteer work and cultural/recreational activities. Changes in global functioning and neuropsychological test performance were tracked and compared to those of a similar group of untreated patients from the Consortium for the Establishment of a Registry for Alzheimer's Disease (CERAD). Cohorts completing 4 semesters or longer showed no significant between-year changes after their first year on the Clinical Dementia Rating, a measure of global functioning, and on 5 or 6 of the cognitive and language measures. Comparisons with the CERAD sample suggested a slower rate of decline for the AD Rehab group. The stabilization of global and cognitive performance was not apparent among participants who completed only 2 semesters. Significant physical fitness and mood outcomes were previously reported in this journal.

Late-life depression: a neuropsychiatric approach

Late-life depression refers to depressive syndromes defined in the American Psychiatric Association's Diagnostic and Statistical Manual and in the International Classification of Diseases that arise in adults older than 65 years of age. Late life depressive syndromes often arise in the context of medical and neurologic disorders. There is a high prevalence of depression in various neurodegenerative disorders such as Alzheimer's disease, Lewy body disease, Parkinson's disease, cerebrovascular disease and frontotemporal dementias. It has been well recognized that late life depression may itself be the presenting symptom of a latent neurodegenerative disorder. Therefore, an accurate diagnosis of late-onset depression may serve to identify a high-risk group that would benefit from initiation of therapies with the goal of delaying or possibly even preventing the onset of dementia.

Self-reported awareness of performance in dementia

The purpose of this study was to test the theory that patients with dementia do not update their self-perceptions based on actual performance. This experiment compared differences between post-task perceptions of performance and actual performance in persons with dementia and normal controls on seven cognitive tasks. Participants included 35 volunteers (12 with dementia and 23 without) from the Houston Veterans Affairs nursing home and geropsychiatric inpatient unit and outpatient clinics and from the Baylor College of Medicine's Alzheimer's Disease Center. Measurements included 7 subtests of the Alzheimer Disease Assessment Scale-Cognitive Subscale and standardized interview questions assessing perceived performance on each of these subtests. Participants with dementia had similar perceptions of performance to normal controls yet evidenced much worse performance on all seven cognitive screening tasks. Thirty-one percent of normal controls over-estimated their performance, compared to 64% of those with mild-moderate dementia and 93% with moderate-severe dementia. Our study supports the theory that demented individuals do not update their self-perceptions of performance. However, a large portion of normal controls was also inaccurate evaluating their own performances. Thus, post-diction measures provide useful insight into the mechanisms of self-awareness but may not be appropriate assessment tools to identify clinically significant impaired self-awareness.

Awareness in dementia: a review of clinical correlates

This article provides a review of the literature on clinical correlates of awareness in dementia. Most inconsistencies were found with regard to an association between depression and higher levels of awareness. Dysthymia, but not major depression, is probably related to higher levels of awareness. Anxiety also appears to be related to higher levels of awareness. Apathy and psychosis are frequently present in patients with less awareness, and may share common neuropathological substrates with awareness. Furthermore, unawareness seems to be related to difficulties in daily life functioning, increased caregiver burden, and deterioration in global dementia severity. Factors that may be of influence on the inconclusive data are discussed, as are future directions of research.

Effects of four years of exercise, language, and social interventions on Alzheimer discourse

This article describes a comprehensive cognitive-linguistic intervention program for mild to moderate Alzheimer's disease (AD) patients that provided communication skills practice in the context of health-enhancing and esteem-building community-based activities: physical fitness training and supervised volunteer work. The interventions were administered by undergraduate students who completed academic work, received faculty supervision, and earned three credits for one semester of participation. Effects of the interventions on the discourse of four participants who completed all 4 years of the program are reported in detail. The maintained or improved performance on multiple discourse outcome measures provides powerful rationale for making such interventions more widely available and preliminary support for their effectiveness in preserving communicative function. An additional role for speech-language pathologists (SLPs)--as trainers and supervisors of non-professional rehab partners for persons with dementia--is proposed.

LEARNING OUTCOMES

From this article, participants will be able to (1) list specific language tasks that can be used to assess discourse in individuals with AD; (2) identify several cognitive-linguistic interventions appropriate for use with AD patients; and (3) understand how long-term cognitive-linguistic interventions may affect the language performance of individuals with AD.

Depression in Alzheimer's disease: heterogeneity and related issues

Several studies have demonstrated that the great majority of Alzheimer's disease (AD) patients suffer "noncognitive" neuropsychiatric symptoms. Depression is one of the most frequent neuropsychiatric comorbidities of AD. Affecting up to 50% of AD patients, depression in AD is associated with serious negative consequences for patients and their caregivers. Yet available studies on the natural course, etiology, and treatment of depression in AD have been few and equivocal. Heterogeneity in research methodology and etiology of depression in AD might have contributed to inconsistent findings across studies. Recently, the National Institute of Mental Health (NIMH) convened the Depression of Alzheimer's Disease Workgroup, which proposed provisional diagnostic criteria for depression of Alzheimer's Disease (NIMH-dAD). These criteria may provide a framework for future studies to clarify the unresolved issues in nosology, etiology, and treatment of depression in AD. A longitudinal cohort study of depression in incident AD cases may provide further syndrome refinement that would facilitate investigation of the etiology and treatment of depression in AD.

The effect of a multisensory exercise program on engagement, behavior, and selected physiological indexes in persons with dementia

A multisensory exercise approach that evokes the stimulation and use of various senses, such as combining physical and cognitive stimuli, can assist in the management of persons with Alzheimer's disease (AD). The objective of this study was to evaluate the outcomes of a multisensory exercise program on cognitive function (engagement), behavior (mood), and physiological indices (blood pressure, resting heart rate, and weight) in 13 nursing home residents diagnosed with moderate to severe AD. A one-group pretest/post-test, quasi-experimental design was used. The program combined a variety of sensory stimulations, integrating storytelling and imaging strategies. Results showed an improvement in resting heart rate, overall mood, and in engagement of physical activity. The findings suggest that a multisensory exercise approach can be beneficial for individuals with AD.

Depression in Alzheimer's disease: overview and treatment

Psychiatric disturbances affect as many as 90% of patients with Alzheimer's disease (AD) and are a major focus of treatment. Depression is one of the most frequent psychiatric complications of AD, affecting as many as 50% of patients. In this context, depression is a significant public health problem that has a series of serious adverse consequences for patients and their caregivers. There has been little research into the course or treatment of depression associated with AD. This is in part due to the absence of validated operational criteria for defining depression in AD. Recently, the National Institute of Mental Health (NIMH) convened an expert consensus panel to develop draft criteria for depression of Alzheimer's disease (NIMH-dAD) and to establish research priorities in this area. This article provides an overview of recent knowledge with regard to depression in AD with a special emphasis on its treatment. We conclude with recommendations for further research in this area.