Neural correlates of impaired cognitive processes underlying self-unawareness in Alzheimer's disease

Self-unawareness concerning current symptoms remains a clinical challenge in Alzheimer's disease. Reduced self-awareness likely depends on complex biopsychosocial mechanisms that comprise multiple cognitive processes, regulated by personal goals and values. We specifically reviewed the cognitive processes impaired in unaware participants with AD by emphasizing the related impaired brain activity observed during task-based fMRI. Unawareness can be explained by a failure in functioning of or in connection between brain regions that intervene in access, retrieval and updating of (present or extended) self-information (posterior midline, medial temporal, inferior parietal cortices), or in its monitoring, evaluation, or control (medial and lateral prefrontal cortices). Although one must be cautious when relating function to brain regions, impaired processes were tentatively related to the Cognitive Awareness Model. Although brain function depends on neural networks, impaired brain activity during cognitive processes was discussed according to previous studies reporting correlations between brain regions and scores of anosognosia. The review provides a framework to help clinicians considering processes that can explain unawareness in dementia. In patients at early stages of AD, different levels of awareness of cognitive or social clinical changes might be described as impairment in the interaction between specific cognitive processes and contents.

Neural Correlates of Impaired Self-awareness of Deficits after Acquired Brain Injury: A Systematic Review

Self-awareness is essential for the process and outcome of rehabilitation but is often affected by acquired brain injury (ABI). While many studies investigated the psychological aspects of self-awareness deficits, the biological underpinnings are not well understood. The aim of this systematic review was to identify the neural correlates of self-awareness after ABI. Results indicate that anticipation of future problems is associated with lesions and decreased neural functioning in the right frontal lobe, as well as increased diffusivity throughout the white matter of the brain. Poor behavioral adjustment on implicit awareness tasks is associated with less functional connectivity of anterior cingulate cortex and right or middle inferior frontal gyri to the fronto-parietal control network, as well as more activation in the left insula and left parietal operculum during error processing. Recognition of mistakes is associated with internetwork connectivity of anterior or posterior default mode network to salience network. In conclusion, after ABI, different results in brain activation and connectivity are found depending on level of awareness measured. Future studies are necessary to confirm these findings.

Trends in chronic kidney disease awareness and related clinical and demographic characteristics from 1998 to 2018 in Koreans

PURPOSE

Chronic kidney disease (CKD) is a common and growing problem in Korea. Although CKD awareness is the first step in CKD management, evidence indicates that the rate of CKD awareness is unsatisfactory worldwide. Thus, we investigated the trend of CKD awareness for CKD patients in Korea.

METHODS

Through analyzing data from the Korea National Health and Nutrition Examination Survey (KNHAES) in 1998, 2001, 2007-2008, 2011-2013, and 2016-2018, we evaluated the rate of CKD awareness according to CKD stage in each phase of KNHANES. Clinical and sociodemographic characteristics were compared between CKD awareness and unawareness groups. Multivariate regression analysis was used to calculate the adjusted odds ratio (OR) and 95% confidence interval (CI) for CKD awareness [adjusted OR (95% CI)] in given socioeconomic and clinical factors.

RESULTS

The overall awareness rate of CKD stage 3 remained at low levels of less than 6.0% through all phases of KNHAES except that of V-VI. In particular, CKD awareness was remarkably low in stage 3 CKD. Compared to CKD unawareness group, CKD awareness group was of young age, higher income, higher education, more medical aid, higher prevalence of comorbidities, and more advanced CKD. In multivariate analysis, CKD awareness was significantly associated with age [0.94 (0.91-0.96)], medical aid [3.23 (1.44-7.28)], proteinuria [0.27 (0.11-0.69)], and renal function [0.90 (0.88-0.93)].

CONCLUSION

CKD awareness has been consistently low in Korea. This trend warrants the special endeavor to promote CKD awareness in Korea.

The Role of Unawareness, Volition, and Neural Hyperconnectivity in Alcohol Use Disorder: A Functional Magnetic Resonance Imaging Study

BACKGROUND

Automated alcohol craving and habitual alcohol consumption characterize the later stages of alcohol use disorder (AUD). This study reanalyzed previously collected functional neuroimaging data in combination with the Craving Automated Scale for Alcohol (CAS-A) questionnaire to investigate the neural correlates and brain networks underlying automated drinking characterized by unawareness and nonvolition.

METHODS

We assessed 49 abstinent male patients with AUD and 36 male healthy control participants during a functional magnetic resonance imaging-based alcohol cue-reactivity task. We performed whole-brain analyses examining the associations between CAS-A scores and other clinical instruments and neural activation patterns in the alcohol versus neutral contrast. Furthermore, we performed psychophysiological interaction analyses to assess the functional connectivity between predefined seed regions and other brain areas.

RESULTS

In patients with AUD, higher CAS-A scores correlated with greater activation in dorsal striatal, pallidal, and prefrontal regions, including frontal white matter, and with lower activation in visual and motor processing regions. Between-group psychophysiological interaction analyses showed extensive connectivity between the seed regions inferior frontal gyrus and angular gyrus and several frontal, parietal, and temporal brain regions in AUD versus healthy control participants.

CONCLUSIONS

The present study applied a new lens to previously acquired alcohol cue-reactivity functional magnetic resonance imaging data by correlating neural activation patterns with clinical CAS-A scores to elucidate potential neural correlates of automated alcohol craving and habitual alcohol consumption. Our results support previous findings showing that alcohol addiction is associated with hyperactivation in habit-processing regions, with hypoactivation in areas mediating motor and attention processing, and with general hyperconnectivity.

A Pilot Study of Self-Rated and Psychophysical Olfactory Dysfunction in Men Living with HIV

Background

Olfactory loss is associated with poor quality of life, malnutrition, and increased risk of depression, yet few studies have examined unawareness of olfactory dysfunction in men living with HIV (MLWH).

Method

MLWH (n = 51) completed olfaction self-ratings, psychophysical odor identification testing, cognitive measures, and questionnaires assessing smell habits, mood, cognitive failures, and quality of life. The sensitivity and specificity of olfactory self-ratings was calculated, and t-tests were used to examine factors contributing to discordance between self-rated and psychophysical olfaction dysfunction.

Results

We found that 33.3% (17 of 51 MLWH) of our sample demonstrated discordance between self-reported and psychophysical olfactory scores. Those unaware of olfaction dysfunction reported using less scented products in daily life but showed no other differences across demographic, clinical, or cognitive indices.

Conclusions

Our results cohere with prior studies of cognitively normal older adults, traumatic brain injury, and Parkinson's disease, which found that olfactory self-ratings may inadequately capture the full range of a person's olfactory status. Our work extends these findings to MLWH, with discordance rates ranging from 35 to 61% for self-rated and psychophysical olfactory dysfunction.

Implications

Given the differing rates of self-rated and psychophysical olfaction in our sample, psychophysical olfactory measures may be useful to consider in the neuropsychological assessment and clinical care of PLWH.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12078-022-09305-x.

Human Papillomavirus (HPV): unawareness of the causal role of HPV infection in cervical cancer, HPV vaccine availability, and HPV vaccine uptake among female schoolteachers in a Middle Eastern country

BACKGROUND

Human papillomavirus (HPV) is the most common viral infection of the reproductive tract. This cross-sectional study among female schoolteachers assessed the prevalence of i) unawareness of HPV infection's causal role in cervical cancer; ii) unawareness of HPV vaccine availability and iii) examined the sociodemographic variables associated both the outcome variables.

METHODS

This cross-sectional study was conducted among female schoolteachers employed in public and private sectors schools in Kuwait using a structured questionnaire for data collection. Prevalence of each of the outcome variables was computed. Multivariable logistic regression analyses were used to evaluate independent predictors of two dependent variables.

RESULTS

A total 1341 female schoolteachers were enrolled. Of the participants, 60% were unaware of HPV causal role in cervical cancer and 88% were unaware of HPV vaccine availability. Among those who were aware of HPV vaccine availability, 83.8% were unvaccinated. Multivariable logistic regression (MLR) model showed that 20-29 years old participants or those with low family income (< 500 KD/month) were significantly (p < 0.05) more likely to be unaware of HPV causal role in cervical cancer. Moreover, participants with family/ personal history of cervical cancer were significantly (p < 0.05) less likely to be unaware of HPV role in causation of cervical cancer. A separate MLR model revealed that the participants were significantly more likely to be unaware of HPV vaccine availability if they were Kuwaiti nationals or non-Kuwaiti Arabs (p < 0.05), employed in public schools (p = 0.003) or less likely to be unaware if they had personal or family history of cervical cancer (p < 0.001).

CONCLUSION

High prevalences of unawareness of causal role of HPV in cervical cancer and unawareness of HPV vaccine availability were recorded. Targeted education among identified sociodemographic groups with high levels of unawareness is warranted. If undertaken, future studies may evaluate the impact of recommended efforts.

Consciousness recovery after various periods in vegetative state

BACKGROUND

Recent studies suggest that late recovery from vegetative state (VS) is more prevalent today than previously thought. This study examined the decline in the rate of recovery from VS with time after admission to rehabilitation, and established a new time frame, in which the odds of recovery from VS remain substantial.

METHODS

Data of 206 patients with VS after traumatic and non-traumatic brain injuries (TBI and NTBI), who were treated at the Loewenstein Rehabilitation Hospital (LRH), in Raanana, Israel, between 2003 and 2015, and described in a previous publication, were further analysed. Rate of recovery from VS was monitored at several time points after admission to intensive care and consciousness rehabilitation (ICCR).

RESULTS

The odds of consciousness recovery were at least 54% at admission to ICCR, and 48%, 33%, 19%, and 7% at 3, 6, 9, and 12 months after admission, respectively.

CONCLUSIONS

The rate of recovery from VS decreases significantly with time, but contrary to previous consensus, 6-12 months after admission to ICCR, the odds of recovery from VS after TBI and NTBI remain substantial.

Unawareness of health insurance expiration status among women of reproductive age in Northern Ghana: implications for achieving universal health coverage

BACKGROUND

Ghana implemented a national health insurance scheme in 2005 to promote the provision of accessible, affordable, and equitable healthcare by eliminating service user fees. Termed the National Health Insurance Scheme (NHIS), its active enrollment has remained low despite a decade of program implementation. This study assesses factors explaining this problem by examining the correlates of insurance status unawareness among women of reproductive age.

METHODS

In 2015, a random probability cross-sectional survey of 5914 reproductive-aged women was compiled in the Upper East Region, an impoverished and remote region in Northern Ghana. During the survey, two questions related to the NHIS were asked: "Have you ever registered with the NHIS?" and "Do you currently have a valid NHIS card?" If the answer to the second question was yes, the respondents were requested to show their insurance card, thereby enabling interviewers to determine if the NHIS requirement of annual renewal had been met. Results are based on the tabulation of the prevalence of unawareness status, tests of bivariate associations, and multivariate estimation of regression adjusted effects.

RESULTS

Of the 5914 respondents, 3614 (61.1%) who reported that they were actively enrolled in the NHIS could produce their insurance cards upon request. Of these respondents, 1243 (34.4%) had expired cards. Factors that significantly predicted unawareness of card expiration were occupation, district of residence, and socio-economic status. Relative to other occupational categories, farmers were the most likely to be unaware of their card invalidity. Respondents residing in three of the study districts were less aware of their insurance card validity than the other four study districts. Unawareness was observed to increase monotonically with relative poverty.

CONCLUSION

Unawareness of insurance care validity status contributes to low active enrollment in Ghana's NHIS. Educational messages aimed at improving health insurance coverage should include the promotion of annual renewal and also should focus on the information needs of farmers and low socio-economic groups.

Utility of a one-step screening and diagnosis strategy for viremic HCV infection among people who inject drugs in Catalonia

BACKGROUND

In Catalonia (Spain), people who inject drugs (PWID) face numerous barriers to access to mainstream healthcare services for hepatitis C confirmatory diagnosis and treatment, so simplified testing strategies for viremic infection are urgently needed. Among PWID attending harm-reduction services in Catalonia, we aimed (i) to assess the utility of an in-house HCV-RNA detection assay on dried blood spots (DBS) as a one-step screening and confirmatory diagnosis strategy for hepatitis C, (ii) to estimate the prevalence of viremic HCV infection, and (iii) to identify factors associated with unawareness of viremic infection.

METHODS

A cross-sectional study of current PWID (N  = 410) was performed in four harm-reduction services. All participants underwent HCV antibody point-of-care testing and parallel DBS collection for centralized RNA testing. An epidemiological questionnaire was administered. Paired EDTA-plasma samples were additionally collected for HCV viral load testing in 300 participants.

RESULTS

HCV-RNA testing from DBS was feasible and showed 97.2% sensitivity and 100% specificity for viral loads >3000 IU/mL in real-life conditions. No significant differences in the performance when detecting viremic infections were observed between this one-step testing strategy vs. the conventional two-step algorithm involving venepuncture. Overall HCV seroprevalence was 79.8%, and prevalence of viremic infection was 58.5%. Importantly, 35.8% of viremic HCV participants were unaware of their status, and no specific socio-demographic or bio-behavioral factors independently associated with unawareness of viremic infection were identified. Among participants reporting a past or current HCV infection, 29.0% stated having received HCV antiviral treatment.

CONCLUSION

The high viremic HCV infection burden among PWID attending HRS, estimated for the first time in Catalonia, together with the low levels of awareness of viremic status and access to treatment, suggest that scaling up this one-step screening and diagnosis strategy to the network of harm-reduction services would help to achieve HCV elimination targets set by the World Health Organization.

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

BACKGROUND

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

METHOD

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

DISCUSSION

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

Richer, wiser and in better health? The socioeconomic gradient in hypertension prevalence, unawareness and control in South Africa

The socioeconomic gradient in chronic conditions is clear in the poorest and wealthiest of countries, but extant evidence on this relationship in low- and middle-income countries is inconclusive. We use data gathered between 2008 and 2012 from a nationally representative sample of over 10,000 South African adults, and objective health measures to analyse the differential effects of education, income and other factors on the prevalence of hypertension, individuals' awareness and control of hypertensive status. Prevalence of hypertension is high at 38% among women and 34% among men. 59% of hypertensive individuals are unaware of their status. We find prevalence and unawareness of hypertension are a public health concern across all income groups in South Africa. Higher income is however associated with effective control amongst men. Completing secondary education is associated with 7 mmHg lower blood pressure only in a small sub-group of women but is associated with 22 percentage point higher likelihood of effective hypertension control amongst women. We conclude that poorer and less educated individuals are particularly at high risk of cardiovascular disease in South Africa.

Unawareness for Motor Impairment and Distorted Perception of Task Difficulty

OBJECTIVES

Anosognosia for motor impairment is a complex syndrome that can manifest itself under different forms, guiding patients' behavior and task decisions. However, current diagnostic tools tend to evaluate only more explicit aspects of anosognosia (asking the patients about their motor abilities) and fail to address more subtle features of awareness. We have developed a new assessment measure, the ECT (Errand Choice Test), where patients are asked to judge task difficulty rather than estimate their own impairment.

METHODS

We assessed awareness in a group of 73 unilateral left- and right-brain damaged (30 LBD and 43 RBD, respectively) patients by means of the VATAm, which explicitly requires them to evaluate their own motor abilities, and the ECT. A control group of 65 healthy volunteers was asked to perform the ECT under two conditions: Current condition (i.e., using both hands) and Simulated conditions (i.e., simulating hemiplegia).

RESULTS

A total of 27% of the patients showed different performance on the VATAm and ECT, 21% of the patients showing lack of awareness only on VATAm and 6% only on ECT. Moreover, despite the ECT identified a higher frequency of anosognosia after RBD (33.3%) than LBD (27.6%), this hemispheric asymmetry was not significant. Remarkably, anosognosic patients performed very similarly to controls in the "current condition", suggesting that anosognosic patients' ability to perceive the complexity of each task per se is not altered.

CONCLUSION

Different methods may be able to tackle different aspects of awareness and the ECT proved to be able to detect less evident forms of awareness. (JINS, 2018, 24, 45-56).

Vegetative state outcomes improved over the last two decades

OBJECTIVE

To describe late outcomes in patients with prolonged unawareness, and factors affecting them.

DESIGN

A retrospective study of 154 patients with traumatic brain injury (TBI) and 52 with non-traumatic brain injury (NTBI), admitted for intensive care and consciousness rehabilitation (ICCR), in a vegetative state (VS) lasting over 1 month.

RESULTS

Survival rate (67% total) was higher than in past studies carried out at the same facility (p < 0.01). Consciousness recovery rate (54% total) was higher in NTBI VS patients (p < 0.01) than in earlier cohorts, and similar in TBI VS patients, despite their older age than that of earlier cohorts. No meaningful differences were found in characteristics or in outcomes between the TBI and NTBI groups. Age, length of stay in ICCR, and hydrocephalus were found to affect survival (p < 0.001). Younger age, absence of hydrocephalus, and anti-Parkinsonian medication contributed to consciousness recovery after VS (p < 0.05).

CONCLUSIONS

The present study demonstrated an improvement in survival and recovery of consciousness in VS patients over the last two decades, and similar outcomes for both TBI and NTBI VS. Outcomes suggest that acute medical care and ICCR have contributed to advances in VS care.

Supravaginal hysterectomy in Curaçao prevalence and impact on screening for cervical cancer

In Curaçao, hysterectomies are frequently performed. A common reason for this procedure is the high incidence of leiomyomatosis. However in some cases the cervix is conserved. Following supravaginal hysterectomy most women discontinue cervical cancer screening because they think the cervix is not conserved. We aimed to get insight in the proportion of supravaginal hysterectomies and the level of awareness on the necessity to continue with cervical cancer screening in case of retained cervix. In 2014, data from all hysterectomies performed between 2003 and 2013 on Curaçao were collected. Information about: type of hysterectomy (supravaginal or not), age of the patient, reason for a hysterectomy and incidence of cervical cancer post-hysterectomy were obtained from the nationwide pathology database. In addition, 600 hysterectomised volunteers answered a questionnaire in which the awareness of their type of hysterectomy and continuation of screening for cervical cancer after surgery were investigated. In the at-risk population (≥ 15 years old), 6.0 per1000 women (95% CI 5.9-6.2) had a hysterectomy between 2003 and 2013 (n = 692,304). From the performed hysterectomies, 2.9% were supravaginal and no cases of cervical cancer post-hysterectomy were reported. The majority (55.3%) of women were unaware of their cervical status post-hysterectomy. About one-third (34.3%) of these women had their last Pap-smear pre-hysterectomy. Information campaigns are needed to raise awareness in women, to continue cervical-screening after supravaginal hysterectomy.

Metacognitive knowledge and experience in recently diagnosed patients with bipolar disorder

INTRODUCTION

Metacognition, which refers to an individual's ability to assess their own cognitive ability or performance, is poorly understood in bipolar disorder. This study was conducted to evaluate two aspects of metacognitive ability in recently diagnosed patients with bipolar disorder: (a) metacognitive knowledge, pertaining to awareness of one's own general cognitive functioning; and (b) metacognitive experience, referring to awareness of one's cognitive performance on a specific, online cognitive task.

METHOD

Participants consisted of 50 clinically euthymic patients recently diagnosed with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) bipolar I disorder who were within three months of resolution of their first manic episode, and a comparison group of 38 demographically similar healthy volunteers. To assess metacognitive knowledge, participants provided a general rating of their estimated cognitive ability prior to completing a neuropsychological battery, and self-ratings were compared to actual ability based on a composite score of overall cognitive functioning. To assess metacognitive experience, subjects provided a postdiction rating of their perceived memory performance after completing a list learning verbal memory test, and self-ratings were compared to actual memory performance. Measures of both relative and absolute accuracy of ratings were obtained.

RESULTS

Results indicated that patients showed diminished accuracy in rating their general cognitive ability, implying deficits in metacognitive knowledge. In contrast, patients were accurate in rating their online memory performance, suggesting intact metacognitive experience.

CONCLUSIONS

Findings suggest that in patients with bipolar disorder, intact task-specific cognitive self-appraisals may fail to generalize to or to modify inaccurate global cognitive self-appraisals. Further research using more comprehensive metacognitive tasks is warranted in bipolar disorder.

The construction of anosognosia: history and implications

The construction of anosognosia as a clinical 'disorder' resulted from the convergence (in the work of various writers and culminating in Babinski) of a name, a concept, and a clinical phenomenon. During the early stages of this convergence, unawareness of neurological dysfunction was not considered as an independent clinical phenomenon. Started in the work of Anton, the process of separating it as a differentiable clinical state is completed by Babinski who reaffirmed the semiological independence of 'unawareness'. The history of the construction of 'anosognosia' parallels the late 19th century debate on the nature and brain inscription of the concept of 'consciousness'.

Effect of unawareness on rehabilitation outcome in a randomised controlled trial of multicomponent intervention for patients with mild Alzheimer's disease

Unawareness of deficit has been shown to affect the outcome of targeted cognitive intervention programmes applied to patients with Alzheimer' disease (AD), but the effects on multimodal therapeutic approaches have not yet been explored. This research investigated the efficacy of the Multi-Intervention Programme (MIP) approach on improving cognitive, functional, affective, and behavioural symptoms in people with mild AD. In addition, we examined whether the presence of unawareness influences the MIP outcomes. Sixty-one mild stage AD patients were randomly assigned to either an experimental group which carried out an MIP individually (48 sessions, 16 weeks duration), combining diverse cognitive tasks, training in daily life and recreational activities, or a waiting list group which did not receive any treatment for the same time period. The efficacy of MIP (vs. waiting list) was tested using various standardised neuropsychological, functional, and behavioural outcome measures. Planned analyses were carried out to determine the effect of unawareness versus awareness on such outcomes. The results showed that patients overall benefited from the MIP in terms of both cognitive and non-cognitive symptoms. AD patients with awareness of deficits showed positive effects on all outcome measures in comparison with the waiting list group, while AD patients with unawareness showed improvements in non-cognitive symptoms only. In conclusion, the presence of unawareness reduces the cognitive and functional effects of MIP in patients with mild AD.

The nature and evolution of insight in schizophrenia: a multi-informant longitudinal study of first-episode versus chronic patients

BACKGROUND AND AIMS

This study investigated a novel distinction between two possible sources of poor insight in schizophrenia: primary unawareness, in which the ill person is not aware that other people think one has a problem, and secondary unawareness (or disagreement), in which a person does appreciate that other people think one has a problem. A secondary goal was to compare the evolution of insight in first-episode and chronic schizophrenia.

METHODS

Sixty-eight first-episode and 51 chronic patients were administered two versions of the Scale of Unawareness of Mental Disorder (SUMD) at three time points: hospital admission, discharge, and 6-month post-discharge. In the first standard SUMD version, they were asked about their own opinions, whereas in the second modified version, they were asked about their best guess of their doctor's opinion.

RESULTS

While overall level of unawareness remained stable within each single episode, there were significant Type of Unawareness (primary versus secondary) by Clinical Status (admission versus discharge versus 6-month post-discharge) and Type of Unawareness by Phase of Illness (first-episode versus chronic) interaction effects. More specifically, in the first-episode group, primary unawareness steadily decreased over time. In contrast, in the chronic group, primary unawareness decreased markedly during hospitalization and returned to baseline after discharge.

CONCLUSIONS

These results provide preliminary support for the notion that impaired insight is an additive outcome of primary unawareness and disagreement, and that change in insight over time occurs mostly at the level of their relative proportion as opposed to their overall sum. Implications for studying and treating poor insight in schizophrenia are discussed.

Anosognosia and depression in patients with Alzheimer's dementia

Anosognosia refers to impaired awareness of patients to realize deficits related to a disorder and is a common symptom of dementia. Anosognosia has far-reaching consequences for diagnosis and treatment and is probably associated with unfavorable prognosis. This study examined the relationship between anosognosia and depression in patients with Alzheimer's dementia (AD). Assessment included interviews of patients and their caregivers. Depressive symptoms were evaluated with observer and self-rating instruments: the Geriatric Depression Scale (GDS), and the "mood" subscale of the Nurses Observation Scale for geriatric patients (NOSGER). Anosognosia was evaluated with the Anosognosia Questionnaire for Dementia (AQ-D). For the evaluation of behavioral and neuropsychological symptoms in dementia and the caregiver burden, the neuropsychiatric inventory (NPI) and the Cares of older People in Europe (COPE) Index were administered. A total of 47 patients were enrolled in the study at the department's geriatric psychiatry outpatient clinic. A considerable discrepancy was found between observer- and self-ratings of depressive symptoms. In 74.5% of the participants, caregiver ratings indicated secondary symptoms of depression as opposed to patient ratings. Thus, in AD, anosognosia may affect not only deficits in cognition and everyday functioning but also affective symptoms ("affective anosognosia"). Caregiver rating therefore is particularly important when assessing mood changes in AD patients.