Cognitive anosognosia and behavioral changes in probable Alzheimer's disease patients

Satler, Corina; Tomaz, Carlos

doi:10.1590/S1980-57642013DN70200010

ABSTRACT

Anosognosia, impairment insight and unawareness of deficits are used as equivalent terms in this study. Objective: To investigate the relationship between the presence of anosognosia symptoms and cognitive domains, functional abilities, and neuropsychiatric symptoms in patients with probable Alzheimer's disease (pAD) and elderly controls (EC). Methods: Twenty-one pAD (14 women) and twenty-two EC (16 women) were submitted to a neuropsychological battery of tests assessing global cognitive status, and specific cognitive functions: memory, executive and attention functions, verbal fluency and visuoconstructive abilities. Additionally, functional abilities (FAQ) and neuropsychiatric symptoms (NPI) were measured. Results: The linear regression statistical test found general anosognosia to be associated with subjective memory complaints, age and Arithmetic-DRS in the EC group. On the other hand, cognitive and functional abilities scores (Arithmetic- DRS, IQCODE and FAQ) were the best predictors in pAD patients, particularly for behavioral awareness. Conclusion: These results indicated that different variables are associated with self-awareness for pAD patients and EC, but for both groups executive functions appear to play an important role, contributing particularly to awareness of behavioral changes.

Key words:
awareness; anosognosia; insight; aging; Alzheimer's disease; dementia

RESUMO

Anosognosia, comprometimento do insight e ausência de reconhecimento de déficits são usados como termos equivalentes neste estudo. Objetivo: Investigar a relação entre a presença de sintomas de anosognosia e domínios cognitivos, habilidades funcionais, e sintomas neuropsiquiátricos em pacientes com provável doença de Alzheimer (pAD) e idosos controles. Métodos: vinte e um pDA (14 mulheres) e vinte e dois EC (16 mulheres) foram submetidos a uma bateria neuropsicológica de testes avaliando o estado cognitivo global, e funções cognitivas específicas: memória, funções executivas e atencionais, fluência verbal e habilidades visoconstrutivas. Adicionalmente, habilidades funcionais (FAQ) e sintomas neuropsiquiátricos (NPI) foram avaliados. Resultados: Teste estatístico de regressão linear indicou uma associação entre anosognosia e queixas subjetivas de memória, idade e aritmética-DRS no grupo controle. Por outro lado, aritmetica-DRS, IQCODE e FAQ (habilidades cognitivas e funcionais) foram melhores predictores nos pacientes com pDA, especificamente para consciência das alterações comportamentais. Conclusão: Os resultados indicaram que diferentes variáveis estão associadas com auto-percepção nos pacientes com pDA e controles, porém para ambos os grupos parece que o funcionamento executivo tem um papel importante contribuindo principalmente na percepção das alterações comportamentais.

Palavras-chave:
percepção; anosognosia; consciência; envelhecimento; doença de Alzheimer; demência

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REFERENCES

McGlynn S, Schacter D. Unawareness of deficits in neuropsychological syndromes. J Clin Exp Neuropsychol 1989;11:143-205.
Derouesné C, Thibault S, Lagha-Pierucci S, Baudouin-Madec V, Ancri D, Lacomblez L. Decreased awareness of cognitive deficits in patients with mild dementia of the Alzheimer type. Int J Geriatr Psychiatry 1999;14:1019-1039.
Leicht H, Berwig M, Gertz H. Anosognosia in Alzheimer's disease: the role of impairment levels in assessment of insight across domains. J Int Neuropsychol Soc 2010;16:463-473.
Reed B, Jagust W, Coulter L Anosognosia in Alzheimer's disease: Relationships to depression, cognitive function, and cerebral perfusion. J Clin Exp Neuropsychol1993;15:231-244.
Lamar M, Lasarev M, Libon D. Determining levels of unawareness in dementia research. J Neuropsychitry Clin Neurosci 2002;14:430-436.
Berwig M, Leicht H, Gertz H. Critical evaluation of self-rated quality of life in mild cognitive impairment and Alzheimer's disease-further evidence for the impact of anosognosia and global cognitive impairment. J Nutr health Aging 2009;13:226-230.
Harwood D, Sultzer D, Wheatley M. Impaired insight in Alzheimer disease: Association with cognitive deficits, psychiatric symptoms and behavioral disturbances. Neuropsychiatry, Neuropsychol Behav Neurol 2000;13:83-88.
Seltzer B, Vasterling J. Awareness of deficit in Alzheimer's disease: Association with psychiatric symptoms and other disease variables. J Clin Geropsychol 1995;1:79-87.
Starkstein S, Sabe L, Chemerinski E, Jason L, Leiguarda R. Two domains of anosognosia in Alzheimer's disease. J Neurol Neurosurg Psychiatry 1996;61:485-490.
Ponds R, Commissaris K, Jolles J. Prevalence and covariates of subjective forgetfulness in a normal population in the Netherlands. Int J Aging Hum Dev 1997;45:207-221.
Ginó S, Mendes T, Maroco J, et al. Memory complaints are frequent but qualitatively different in young and elderly healthy people. Gerontology 2010;56:272-277.
Jorm A, Butterfield B, Anstey K, al e. Memory complaints in a community sample aged 60-64 years: associations with cognitive functioning, psychiatric symptoms, medical conditions, APOE genotype, hippocampus and amygdala volumes, and whiter-matter hyperintensities. Psychol Med 2004;34:1495-1506.
McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan E. Clinical diagnosis of Alzheimer's disease. Report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer's disease. Neurology 1984; 34:939-944.
Hughes C, Berg L, Danziger W, Coben L, Martin R. A new clinical scale for the staging of dementia. Br J Psychiatry 1982;140:566-572.
Jorm A. A short-form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and cross-validation. Psychol Med1994;24:145-153.
Cummings J, Mega M, Gray K, Rosenberg-Thompson S, Carusi D, Gornbein J. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-2314.
Bertolucci P, Brucki S, Campacci S, Juliano Y. O Mini-exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.
Porto C, CharchatFichman H, Caramelli P, Bahia V, Nitrini R. Brazilian version of the Mattis Dementia Rating Scale. Arq Neuropsiquiatr2003;61:339-345.
Wechsler D. WMS-III Administration and Scoring Manual. San Antonio, Tx: The Psychological Corporation; 1997.
Spreen O, Strauss E. A compendium of neuropsychological tests. New York: Oxford University Press; 1998.
Rey A. L´Examen psychologique dans le cas d´encephalo-pathic traumatique. Arch Psychol 1942;28:286-340.
Morris J, Heyman A, Mohs R, et al. The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer's disease. Neurology 1989;39:1159-1165.
Royall D, Cordes J, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry1998;64:588-594.
Zubicaray G, Smith G, Ghalk J, Semple J. The modified Card Sorting Test: test-retest stability and relationships with demographic variables in a healthy older adult sample. Br J Psychiatry1998;37:457-466.
Pfeffer R, Kurosaki T, CH H, Chance J, Filos S. Measurement of functional activities in older adults in the community. J Gerontology 1982;37:323-329.
Mattos P, Lino V, Rizo L, Alfano A, Araujo C, Raggio R. Memory complains and test performance in health elderly persons. Arq Neuropsiquiatr2003;61:920-924.
Alexopoulos G, Abrams R, Young R, Shamoian C. Cornell Scale for Depression in dementia. Biol Psychiatry 1988;23:271-284.
Almeida O, Crocco E. Percepção dos déficits cognitivos e alterações do comportamento em pacientes com Doença de Alzheimer. Arq Neuropsiquiatr2000;58:292-299.
Sato J, Nakaaki S, Murata Y, et al. Two dimensions of anosognosia in patients with Alzheimer's disease: reliability and validity of the Japanese version of the Anosognosia Questionnaire for Dementia (AQ-D). Psychiatry Clin Neurosci 2007;61:672-677.
Lopez O, Becker J, Somsak D, Dew M, DeKosky S. Awareness of cognitive deficits and anosognosia in probable Alzheimer's disease. Eur Neurol 1994;34:277-282.
Starkstein S, Sabe L, GarciaCuerva A, Kuzis G, Leiguarda R. Anosognosia and procedural learning in Alzheimer's disease. Neuropsychiatry, Neuropsychol Behav Neurol1997;10:96-101.
Ecklund-Johnson E, Torres I. Unawereness of deficits in Alzheimer's disease and other dementias: Operational definitions and empirical findings. Neuropsychol Rev 2005;15:147-166.
Starkestein S, Jorge R, Mizrahi R, Robinson R. A diagnostic formulation for anosognosia in Alzheimer's disease. J Neurol, Neurosurgy Psychiatry 2006;77:719-725.
Stout J, Wyman M, Johnson S, Peavy G, Salmon D. Frontal behavioral syndromes and functional status in probable Alzheimer disease. Ame J Geriatr Psychiatry 2003;11:683-686.
Dodge H, Shen C, Pandav R, DeKosky S, Ganguli M. Functional transitions and active life expectancy associated with Alzheimer disease. Arch Neurol 2003;60:253-259.
Monaci L, Morris R. Neuropsychological screening performance and the association with activities of daily living and instrumental activities of daily living in dementia: baseline and 18- to 24- month follow-up. Int J Geriatr Psychiatry2011;27:197-204.
Barberger-Gateau P, Fabriogule C, Rouch I, Letenneur L, Dartigues J. Neuropsychological correlates of self-reported performance in instrumental activities of daily living and prediction of dementia. J Gerontology1999;54B:293-303.
Geary D. Mathematical disabilities: Cognitive, neuropsychological, and genetic components. Psychol Bull 1993;114:345-362.
Rickard T. A revised identical elements model of arithmetic fact representation. J Exp Psychol: Learn Mem Cogn 2005;31:250-257.
Zago L, Pesenti M, Mellet E, Crivello F, Mazoyer B, Tzourio-Mazoyer N. Neural correlates of simple and complex mental calculation. Neuroimage 2001;13:314-327.
Cirino P, Morris M, Morris R. Neuropsychological concomitants of calculation skills in college students referred for learning difficulties. Dev Neuropsychol 2002;21:201-218.
Bull R, Scerif G. Executive functioning as a predictor od children's mathematics ability: Inhibition, switching, and working memory. Dev Neuropsychol2001;19:273-293.
Spieler D, Balota D, Faust M. Stroop Performance in Healthy Younger and Older Adults and in Individuals With Dementia of the Alzheimer's Type. J Exp Psychol Hum Percept Perform 1996;22:461-479.
Bach L, David A. Self-Awareness after acquired and traumatic brain injury. Neuropsychol Rehabil 2006;16:397-414.
Small B, Fratiglioni L, Viitanen M, Winblad B, Bäckman L. The course of cognitive impairment in preclinical Alzheimer disease: three- and 6-year follow-up of a population-based sample. Arch Neurol2000;57:839-844.
Braak H, Braak E. Neuropathological staging of Alzheimer-related changes. Acta Neuropathol 1991;82:239-259.
Nyberg L, McIntosh A, Houle S, Nilsson L, Tulving E. Activation of medial temporal structures during episodic memory retrieval. Nature 1996;380:715-717.
Becker J, Overman A. The memory deficit in Alzheimer' Disease. In: Baddeley A, Kopelman M, Wilson B, eds. The handbook of memory disorders: John Wiley & Sons Ltd, 2002: 569-589.
Jonker C, Geerlings M, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population- based studies. Int J Geriatric Psychiatr 2000;15:983-991.
Zanetti O, Vallotti B, Frisoni G, et al. Insight in dementia: When does it occur? Evidence for a non-linear relationship between insight and cognitive status. J Gerontology1999;54:100-107.

Publication Dates

Publication in this collection
Apr-Jun 2013

History

Received
18 Feb 2012
Accepted
18 Apr 2013

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] McGlynn S, Schacter D. Unawareness of deficits in neuropsychological syndromes. J Clin Exp Neuropsychol 1989;11:143-205.

[2] Derouesné C, Thibault S, Lagha-Pierucci S, Baudouin-Madec V, Ancri D, Lacomblez L. Decreased awareness of cognitive deficits in patients with mild dementia of the Alzheimer type. Int J Geriatr Psychiatry 1999;14:1019-1039.

[3] Leicht H, Berwig M, Gertz H. Anosognosia in Alzheimer's disease: the role of impairment levels in assessment of insight across domains. J Int Neuropsychol Soc 2010;16:463-473.

[4] Reed B, Jagust W, Coulter L Anosognosia in Alzheimer's disease: Relationships to depression, cognitive function, and cerebral perfusion. J Clin Exp Neuropsychol1993;15:231-244.

[5] Lamar M, Lasarev M, Libon D. Determining levels of unawareness in dementia research. J Neuropsychitry Clin Neurosci 2002;14:430-436.

[6] Berwig M, Leicht H, Gertz H. Critical evaluation of self-rated quality of life in mild cognitive impairment and Alzheimer's disease-further evidence for the impact of anosognosia and global cognitive impairment. J Nutr health Aging 2009;13:226-230.

[7] Harwood D, Sultzer D, Wheatley M. Impaired insight in Alzheimer disease: Association with cognitive deficits, psychiatric symptoms and behavioral disturbances. Neuropsychiatry, Neuropsychol Behav Neurol 2000;13:83-88.

[8] Seltzer B, Vasterling J. Awareness of deficit in Alzheimer's disease: Association with psychiatric symptoms and other disease variables. J Clin Geropsychol 1995;1:79-87.

[9] Starkstein S, Sabe L, Chemerinski E, Jason L, Leiguarda R. Two domains of anosognosia in Alzheimer's disease. J Neurol Neurosurg Psychiatry 1996;61:485-490.

[10] Ponds R, Commissaris K, Jolles J. Prevalence and covariates of subjective forgetfulness in a normal population in the Netherlands. Int J Aging Hum Dev 1997;45:207-221.

[11] Ginó S, Mendes T, Maroco J, et al. Memory complaints are frequent but qualitatively different in young and elderly healthy people. Gerontology 2010;56:272-277.

[12] Jorm A, Butterfield B, Anstey K, al e. Memory complaints in a community sample aged 60-64 years: associations with cognitive functioning, psychiatric symptoms, medical conditions, APOE genotype, hippocampus and amygdala volumes, and whiter-matter hyperintensities. Psychol Med 2004;34:1495-1506.

[13] McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan E. Clinical diagnosis of Alzheimer's disease. Report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer's disease. Neurology 1984; 34:939-944.

[14] Hughes C, Berg L, Danziger W, Coben L, Martin R. A new clinical scale for the staging of dementia. Br J Psychiatry 1982;140:566-572.

[15] Jorm A. A short-form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and cross-validation. Psychol Med1994;24:145-153.

[16] Cummings J, Mega M, Gray K, Rosenberg-Thompson S, Carusi D, Gornbein J. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-2314.

[17] Bertolucci P, Brucki S, Campacci S, Juliano Y. O Mini-exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.

[18] Porto C, CharchatFichman H, Caramelli P, Bahia V, Nitrini R. Brazilian version of the Mattis Dementia Rating Scale. Arq Neuropsiquiatr2003;61:339-345.

[19] Wechsler D. WMS-III Administration and Scoring Manual. San Antonio, Tx: The Psychological Corporation; 1997.

[20] Spreen O, Strauss E. A compendium of neuropsychological tests. New York: Oxford University Press; 1998.

[21] Rey A. L´Examen psychologique dans le cas d´encephalo-pathic traumatique. Arch Psychol 1942;28:286-340.

[22] Morris J, Heyman A, Mohs R, et al. The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer's disease. Neurology 1989;39:1159-1165.

[23] Royall D, Cordes J, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry1998;64:588-594.

[24] Zubicaray G, Smith G, Ghalk J, Semple J. The modified Card Sorting Test: test-retest stability and relationships with demographic variables in a healthy older adult sample. Br J Psychiatry1998;37:457-466.

[25] Pfeffer R, Kurosaki T, CH H, Chance J, Filos S. Measurement of functional activities in older adults in the community. J Gerontology 1982;37:323-329.

[26] Mattos P, Lino V, Rizo L, Alfano A, Araujo C, Raggio R. Memory complains and test performance in health elderly persons. Arq Neuropsiquiatr2003;61:920-924.

[27] Alexopoulos G, Abrams R, Young R, Shamoian C. Cornell Scale for Depression in dementia. Biol Psychiatry 1988;23:271-284.

[28] Almeida O, Crocco E. Percepção dos déficits cognitivos e alterações do comportamento em pacientes com Doença de Alzheimer. Arq Neuropsiquiatr2000;58:292-299.

[29] Sato J, Nakaaki S, Murata Y, et al. Two dimensions of anosognosia in patients with Alzheimer's disease: reliability and validity of the Japanese version of the Anosognosia Questionnaire for Dementia (AQ-D). Psychiatry Clin Neurosci 2007;61:672-677.

[30] Lopez O, Becker J, Somsak D, Dew M, DeKosky S. Awareness of cognitive deficits and anosognosia in probable Alzheimer's disease. Eur Neurol 1994;34:277-282.

[31] Starkstein S, Sabe L, GarciaCuerva A, Kuzis G, Leiguarda R. Anosognosia and procedural learning in Alzheimer's disease. Neuropsychiatry, Neuropsychol Behav Neurol1997;10:96-101.

[32] Ecklund-Johnson E, Torres I. Unawereness of deficits in Alzheimer's disease and other dementias: Operational definitions and empirical findings. Neuropsychol Rev 2005;15:147-166.

[33] Starkestein S, Jorge R, Mizrahi R, Robinson R. A diagnostic formulation for anosognosia in Alzheimer's disease. J Neurol, Neurosurgy Psychiatry 2006;77:719-725.

[34] Stout J, Wyman M, Johnson S, Peavy G, Salmon D. Frontal behavioral syndromes and functional status in probable Alzheimer disease. Ame J Geriatr Psychiatry 2003;11:683-686.

[35] Dodge H, Shen C, Pandav R, DeKosky S, Ganguli M. Functional transitions and active life expectancy associated with Alzheimer disease. Arch Neurol 2003;60:253-259.

[36] Monaci L, Morris R. Neuropsychological screening performance and the association with activities of daily living and instrumental activities of daily living in dementia: baseline and 18- to 24- month follow-up. Int J Geriatr Psychiatry2011;27:197-204.

[37] Barberger-Gateau P, Fabriogule C, Rouch I, Letenneur L, Dartigues J. Neuropsychological correlates of self-reported performance in instrumental activities of daily living and prediction of dementia. J Gerontology1999;54B:293-303.

[38] Geary D. Mathematical disabilities: Cognitive, neuropsychological, and genetic components. Psychol Bull 1993;114:345-362.

[39] Rickard T. A revised identical elements model of arithmetic fact representation. J Exp Psychol: Learn Mem Cogn 2005;31:250-257.

[40] Zago L, Pesenti M, Mellet E, Crivello F, Mazoyer B, Tzourio-Mazoyer N. Neural correlates of simple and complex mental calculation. Neuroimage 2001;13:314-327.

[41] Cirino P, Morris M, Morris R. Neuropsychological concomitants of calculation skills in college students referred for learning difficulties. Dev Neuropsychol 2002;21:201-218.

[42] Bull R, Scerif G. Executive functioning as a predictor od children's mathematics ability: Inhibition, switching, and working memory. Dev Neuropsychol2001;19:273-293.

[43] Spieler D, Balota D, Faust M. Stroop Performance in Healthy Younger and Older Adults and in Individuals With Dementia of the Alzheimer's Type. J Exp Psychol Hum Percept Perform 1996;22:461-479.

[44] Bach L, David A. Self-Awareness after acquired and traumatic brain injury. Neuropsychol Rehabil 2006;16:397-414.

[45] Small B, Fratiglioni L, Viitanen M, Winblad B, Bäckman L. The course of cognitive impairment in preclinical Alzheimer disease: three- and 6-year follow-up of a population-based sample. Arch Neurol2000;57:839-844.

[46] Braak H, Braak E. Neuropathological staging of Alzheimer-related changes. Acta Neuropathol 1991;82:239-259.

[47] Nyberg L, McIntosh A, Houle S, Nilsson L, Tulving E. Activation of medial temporal structures during episodic memory retrieval. Nature 1996;380:715-717.

[48] Becker J, Overman A. The memory deficit in Alzheimer' Disease. In: Baddeley A, Kopelman M, Wilson B, eds. The handbook of memory disorders: John Wiley & Sons Ltd, 2002: 569-589.

[49] Jonker C, Geerlings M, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population- based studies. Int J Geriatric Psychiatr 2000;15:983-991.

[50] Zanetti O, Vallotti B, Frisoni G, et al. Insight in dementia: When does it occur? Evidence for a non-linear relationship between insight and cognitive status. J Gerontology1999;54:100-107.

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