Awareness in dementia is increasingly recognized not only as multifactorial, but also as domain specific. We demonstrate differential clinical correlates for awareness of daily function, awareness of memory, and the novel exploration of awareness of balance. Awareness of function was higher for participants with mild cognitive impairment (aMCI and non-aMCI) than for those with dementia (due to Alzheimer disease; AD and non-AD), whereas awareness of memory was higher for both non-aMCI and non-AD dementia patients than for those with aMCI or AD. Balance awareness did not differ based on diagnostic subgroup. Awareness of function was associated with instrumental activities of daily living and caregiver burden. In contrast, awareness of balance was associated with fall history, balance confidence, and instrumental activities of daily living. Clinical correlates of awareness of memory depended on diagnostic group: associations held with neuropsychological variables for non-AD dementia, but for patients with AD dementia, depression and instrumental activities of daily living were clinical correlates of memory awareness. Together, these data provide support for the hypothesis that awareness and dementia are not unitary and are, instead, modality specific. 1. Introduction Unawareness, lack of insight, or anosognosia refers to impaired awareness in persons with dementia [1–7]. Awareness is multifactorial and likely modular [4, 8–10], with each domain separable and potentially unique. Most of the literature on awareness in persons with dementia describes the clinical correlates of one awareness domain (reviews by [1, 4, 11]), but the few studies that have contrasted awareness for different domains have found differential patterns of clinical correlates [12–15]. This paper provides further support for the modality specific nature of awareness in dementia by contrasting the clinical correlates for awareness of balance in addition to more commonly measured awareness of day-to-day function and memory. Awareness quantification remains elusive, and there is no consensus method for measuring awareness (e.g., [4, 9]). Awareness has been measured with clinician ratings [16, 17]; or based on discrepancy between self-report versus clinicians’ impression [10] or versus informant report assessed with interview [10, 18] or questionnaires [7, 12, 14, 19–21]; or discrepancy between self-report and objective performance [21, 22], which, depending on the task, measures self-monitoring or metacognitive abilities [3]. Each assessment method has limitations: Clare et al. [21] detail
References
[1]
P. Aalten, E. van Valen, L. Clare, G. Kenny, and F. Verhey, “Awareness in dementia: a review of clinical correlates,” Aging and Mental Health, vol. 9, no. 5, pp. 414–422, 2005.
[2]
E. Ecklund-Johnson and I. Torres, “Unawareness of deficits in Alzheimer's disease and other dementias: operational definitions and empirical findings,” Neuropsychology Review, vol. 15, no. 3, pp. 147–166, 2005.
[3]
S. Cosentiono and Y. Stern, “Metacognitive theory and assessment in dementia: do we recognize our areas of weakness?” Journal of the International Neuropsychological Society, vol. 11, no. 7, pp. 910–919, 2005.
[4]
I. S. Marková and G. E. Berrios, “Insight in clinical psychiatry. A new model,” The Journal of nervous and mental disease, vol. 183, no. 12, pp. 743–751, 1995.
[5]
D. C. Mograbi, R. G. Brown, and R. G. Morris, “Anosognosia in Alzheimer's disease—the petrified self,” Consciousness and Cognition, vol. 18, no. 4, pp. 989–1003, 2009.
[6]
K. P. Rankin, E. Baldwin, C. Pace-Savitsky, J. H. Kramer, and B. L. Miller, “Self awareness and personality change in dementia,” Journal of Neurology, Neurosurgery and Psychiatry, vol. 76, no. 5, pp. 632–639, 2005.
[7]
S. E. Starkstein, R. Jorge, R. Mizrahi, and R. G. Robinson, “A diagnostic formulation for anosognosia in Alzheimer's disease,” Journal of Neurology, Neurosurgery and Psychiatry, vol. 77, no. 6, pp. 719–725, 2006.
[8]
L. Clare, I. Marková, F. Verhey, and G. Kenny, “Awareness in dementia: a review of assessment methods and measures,” Aging and Mental Health, vol. 9, no. 5, pp. 394–413, 2005.
[9]
P. Howorth and J. Saper, “The dimensions of insight in people with dementia,” Aging and Mental Health, vol. 7, no. 2, pp. 113–122, 2003.
[10]
A. L. Snow, M. P. Norris, R. Doody, V. A. Molinari, C. A. Orengo, and M. E. Kunik, “Dementia deficits scale: rating self-awareness of deficits,” Alzheimer Disease and Associated Disorders, vol. 18, no. 1, pp. 22–31, 2004.
[11]
A. L. Snow, D. P. Graham, V. A. Molinari et al., “Factors affecting deficit awareness in persons with dementia,” Dementia and Geriatric Cognitive Disorders, vol. 20, no. 2-3, pp. 133–139, 2005.
[12]
B. R. Ott, G. Lafleche, W. M. Whelihan, G. W. Buongiorno, M. S. Albert, and B. S. Fogel, “Impaired awareness of deficits in Alzheimer disease,” Alzheimer Disease and Associated Disorders, vol. 10, no. 2, pp. 68–76, 1996.
[13]
R. Migliorelli, A. Teson, L. Sabe et al., “Anosognosia in Alzheimer's disease: a study of associated factors,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 7, no. 3, pp. 338–344, 1995.
[14]
B. Seltzer, J. J. Vasterling, J. Yoder, and K. A. Thompson, “Awareness of deficit in Alzheimer's disease: relation to caregiver burden,” Gerontologist, vol. 37, no. 1, pp. 20–24, 1997.
[15]
S. E. Starkstein, L. Sabe, E. Chemerinski, L. Jason, and R. Leiguarda, “Two domains of anosognosia in Alzheimer's disease,” Journal of Neurology Neurosurgery and Psychiatry, vol. 61, no. 5, pp. 485–490, 1996.
[16]
K. D. McDaniel, S. D. Edland, A. Heyman et al., “Relationship between level of insight and severity of dementia in Alzheimer disease,” Alzheimer Disease and Associated Disorders, vol. 9, no. 2, pp. 101–104, 1995.
[17]
B. R. Ott and B. S. Fogel, “Measurement of depression in dementia: self vs clinician rating,” International Journal of Geriatric Psychiatry, vol. 7, no. 12, pp. 899–904, 1992.
[18]
P. Aalten, E. van Valen, M. E. de Vugt, R. Lousberg, J. Jolles, and F. R. J. Verhey, “Awareness and behavioral problems in dementia patients: a prospective study,” International Psychogeriatrics, vol. 18, no. 1, pp. 3–17, 2006.
[19]
Y. Kashiwa, Y. Kitabayashi, J. Narumoto, K. Nakamura, H. Ueda, and K. Fukui, “Anosognosia in Alzheimer's disease: association with patient characteristics, psychiatric symptoms and cognitive deficits,” Psychiatry and Clinical Neurosciences, vol. 59, no. 6, pp. 697–704, 2005.
[20]
C. A. Mangone, D. B. Hier, P. B. Gorelick et al., “Impaired insight in Alzheimer's disease,” Journal of Geriatric Psychiatry and Neurology, vol. 4, no. 4, pp. 189–193, 1991.
[21]
L. Clare, B. A. Wilson, G. Carter, I. Roth, and J. R. Hodges, “Assessing awareness in early-stage Alzheimer's disease: development and piloting of the memory awareness rating scale,” Neuropsychological Rehabilitation, vol. 12, no. 4, pp. 341–362, 2002.
[22]
C. H. Y. Wong, L. C. W. Lam, V. W. C. Lui, H. F. K. Chiu, S. S. M. Chan, and C. W. C. Tam, “Subjective complaints and self-evaluation of memory test performancen in questionable dementia,” International Journal of Geriatric Psychiatry, vol. 21, no. 10, pp. 937–944, 2006.
[23]
L. Clare and B. A. Wilson, “Longitudinal assessment of awareness in early-stage Alzheimer's disease using comparable questionnaire-based and performance-based measures: a prospective one-year follow-up study,” Aging and Mental Health, vol. 10, no. 2, pp. 156–165, 2006.
[24]
M. B. Spitznagel, G. Tremont, L. B. Brown, and J. Gunstad, “Cognitive reserve and the relationship between depressive symptoms and awareness of deficits in dementia,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 18, no. 2, pp. 186–190, 2006.
[25]
D. G. Harwood, D. L. Sultzer, and M. V. Wheatley, “Impaired insight in Alzheimer disease: association with cognitive deficits, psychiatric symptoms, and behavioral disturbances,” Neuropsychiatry, Neuropsychology and Behavioral Neurology, vol. 13, no. 2, pp. 83–88, 2000.
[26]
A. Vogel, F. B. Waldorff, and G. Waldemar, “Impaired awareness of deficits and neuropsychiatric symptoms in early Alzheimer's disease: the Danish Alzheimer Intervention Study (DAISY),” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 22, no. 1, pp. 93–99, 2010.
[27]
A. Michon, B. Deweer, B. Pillon, Y. Agid, and B. Dubois, “Relation of anosognosia to frontal lobe dysfunction in Alzheimer's disease,” Journal of Neurology Neurosurgery and Psychiatry, vol. 57, no. 7, pp. 805–809, 1994.
[28]
E. Salmon, D. Perani, F. Collette et al., “A comparison of unawareness in frontotemporal dementia and Alzheimer's disease,” Journal of Neurology, Neurosurgery and Psychiatry, vol. 79, no. 2, pp. 176–179, 2008.
[29]
A. Vogel, S. G. Hasselbalch, A. Gade, M. Ziebell, and G. Waldemar, “Cognitive and functional neuroimaging correlates for anosognosia in mild cognitive impairment and Alzheimer's disease,” International Journal of Geriatric Psychiatry, vol. 20, no. 3, pp. 238–246, 2005.
[30]
D. G. Harwood, D. L. Sultzer, D. Feil, L. Monserratt, E. Freedman, and M. A. Mandelkern, “Frontal lobe hypometabolism and impaired insight in Alzheimer disease,” American Journal of Geriatric Psychiatry, vol. 13, no. 11, pp. 934–941, 2005.
[31]
M. F. Mendez and J. S. Shapira, “Loss of insight and functional neuroimaging in frontotemporal dementia,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 17, no. 3, pp. 413–416, 2005.
[32]
S. E. Starkstein, S. Brockman, D. Bruce, and G. Petracca, “Anosognosia is a significant predictor of apathy in Alzheimer's disease,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 22, no. 4, pp. 378–383, 2010.
[33]
K. Shibata, J. Narumoto, Y. Kitabayashi, Y. Ushijima, and K. Fukui, “Correlation between anosognosia and regional cerebral blood flow in Alzheimer's disease,” Neuroscience Letters, vol. 435, no. 1, pp. 7–10, 2008.
[34]
M. Mimura, “Memory impairment and awareness of memory deficits in early-stage Alzheimer's disease,” Tohoku Journal of Experimental Medicine, vol. 215, no. 2, pp. 133–140, 2008.
[35]
M. L. Ries, B. M. Jabbar, T. W. Schmitz et al., “Anosognosia in mild cognitive impairment: relationship to activation of cortical midline structures involved in self-appraisal,” Journal of the International Neuropsychological Society, vol. 13, no. 3, pp. 450–461, 2007.
[36]
H. Hanyu, T. Sato, T. Akai et al., “Neuroanatomical correlates of unawareness of memory deficits in early Alzheimer's disease,” Dementia and Geriatric Cognitive Disorders, vol. 25, no. 4, pp. 347–353, 2008.
[37]
D. T. Stuss and B. Levine, “Adult clinical neuropsychology: lessons from studies of the frontal lobes,” Annual Review of Psychology, vol. 53, pp. 401–433, 2002.
[38]
N. Kamata, Y. Matsuo, T. Yoneda, H. Shinohara, S. Inoue, and K. Abe, “Overestimation of stability limits leads to a high frequency of falls in patients with Parkinson's disease,” Clinical Rehabilitation, vol. 21, no. 4, pp. 357–361, 2007.
[39]
I. S. Markova, L. Clare, M. Wang, B. Romero, and G. Kenny, “Awareness in dementia: conceptual issues,” Aging and Mental Health, vol. 9, no. 5, pp. 386–393, 2005.
[40]
A. Vogel, J. Stokholm, A. Gade, B. B. Andersen, A.-M. Hejl, and G. Waldemar, “Awareness of deficits in mild cognitive impairment and Alzheimer's disease: do MCI patients have impaired insight?” Dementia and Geriatric Cognitive Disorders, vol. 17, no. 3, pp. 181–187, 2004.
[41]
D. G. Morgan, M. Crossley, A. Kirk et al., “Improving access to dementia care: development and evaluation of a rural and remote memory clinic,” Aging and Mental Health, vol. 13, no. 1, pp. 17–30, 2009.
[42]
A. Robillard, “Clinical diagnosis of dementia,” Alzheimer's and Dementia, vol. 3, no. 4, pp. 292–298, 2007.
[43]
K. Rockwood, “Vascular cognitive impairment and vascular dementia,” Journal of the Neurological Sciences, vol. 203-204, pp. 23–27, 2002.
[44]
J. C. Morris, “The clinical dementia rating (CDR): current version and scoring rules,” Neurology, vol. 43, no. 11, pp. 2412–2414, 1993.
[45]
S. E. O'Bryant, S. C. Waring, C. M. Cullum et al., “Staging dementia using clinical dementia rating scale sum of boxes scores: a Texas Alzheimer's Research Consortium Study,” Archives of Neurology, vol. 65, no. 8, pp. 1091–1095, 2008.
[46]
M. P. Lawton, M. Moss, M. Fulcomer, and M. H. Kleban, “A research and service oriented multilevel assessment instrument,” Journals of Gerontology, vol. 37, no. 1, pp. 91–99, 1982.
[47]
R. I. Pfeffer, T. T. Kurosaki, C. H. Harrah, J. Chance, and S. Filos, “Measurement of functional activities in older adults in the community,” Journals of Gerontology, vol. 37, no. 3, pp. 323–329, 1982.
[48]
R. S. Bucks, D. L. Ashworth, G. K. Wilcock, and K. Siegfried, “Assessment of activities of daily living in dementia: development of the Bristol activities of Daily Living Scale,” Age and Ageing, vol. 25, no. 2, pp. 113–120, 1996.
[49]
J. L. Cummings, M. Mega, K. Gray, S. Rosenberg-Thompson, D. A. Carusi, and J. Gornbein, “The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia,” Neurology, vol. 44, no. 12, pp. 2308–2314, 1994.
[50]
P. M. Lewinsohn, J. R. Seeley, R. E. Roberts, and N. B. Allen, “Center for epidemiologic studies depression scale (CES-D) as a screening instrument for depression among community-residing older adults,” Psychology and Aging, vol. 12, no. 2, pp. 277–287, 1997.
[51]
N. O'Rourke and H. A. Tuokko, “Psychometric properties of an abridged version of the Zarit Burden Interview within a representative Canadian caregiver sample,” Gerontologist, vol. 43, no. 1, pp. 121–127, 2003.
[52]
L. Derogatis, Brief Symptom Inventory, Clinical Psychometric Research, Baltimore, Md, USA, 1975.
[53]
K. Berg, S. Wood-Dauphinee, J. I. Williams, and D. Gayton, “Measuring balance in the elderly: preliminary development of an instrument,” Physiotherapy Canada, vol. 41, no. 6, pp. 304–311, 1989.
[54]
M. E. Tinetti, “Performance-orientated assessment of mobility problems in elderly patients,” Journal of the American Geriatrics Society, vol. 34, no. 2, pp. 119–126, 1986.
[55]
A. Shumway-Cook, M. Baldwin, N. L. Polissar, and W. Gruber, “Predicting the probability for falls in community-dwelling older adults,” Physical Therapy, vol. 77, no. 8, pp. 812–819, 1997.
[56]
L. E. Powell and A. M. Myers, “The Activities-specific Balance Confidence (ABC) Scale,” Journals of Gerontology A, vol. 50, no. 1, pp. M28–M34, 1995.
[57]
E. Strauss, E. M. S. Sherman, and O. Spreen, A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary, Oxford University Press, New York, NY, USA.
[58]
R. M. Reitan and D. Wolfson, The Halstead-Reitan Neuropsycholgical Test Battery: Therapy and Clinical Interpretation, Neuropsychological Press, Tucson, AZriz, USA, 1985.
[59]
M. R. Trennery, B. Crosson, J. DeBoe, and W. R. Leber, Stroop Neuropsychological Screening Test, Psychological Assessment Resources, Fla, USA, 1989.
[60]
H. Goodglass and E. Kaplan, The Assessment of Aphasia and Related Disorders, Lea & Febiger, Philadelphia, PA, 2nd edition, 1983.
[61]
H. Tuokko and M. E. O'Connell, “A review of quantified approaches to the qualitative assessment of clock drawing,” in The Quantified Process Approach to Neuropsychological Assessment, A. M. Poreh, Ed., pp. 173–206, Taylor & Francis, New York, NY, USA, 2006.
[62]
D. Wechsler, Wechsler Adult Intelligence Scale, Psychological Corporation, San Antonio, Tex, USA, 3rd edition, 1997.
[63]
C. Randolph, Repeatable Battery for the Assessment of Neuropsychological Status Manual, Psychological Corporation, San Antonio, Tex, USA, 1998.
[64]
L. R. Squire and J. A. Zouzounis, “Self-ratings of memory dysfunction: different findings in depression and amnesia,” Journal of Clinical and Experimental Neuropsychology, vol. 10, no. 6, pp. 727–738, 1988.
[65]
S. N. Robinovitch and T. Cronin, “Perception of postural limits in elderly nursing home and day care participants,” Journals of Gerontology A, vol. 54, no. 3, pp. B124–B131, 1999.
[66]
J. Cohen, Statistical Power Analysis for the Behavioral Sciences, Lawrence Erlbaum Associates, Mahwah, NJ, USA, 2nd edition, 1988.
[67]
M. S. Albert, S. T. DeKosky, D. Dickson et al., “The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging and Alzheimer's Association workgroup,” Alzheimer's and Dementia, 2011.
[68]
T. Herman, A. Mirelman, N. Giladi, A. Schweiger, and J. M. Hausdorff, “Executive control deficits as a prodrome to falls in healthy older adults: a prospective study linking thinking, walking, and falling,” Journals of Gerontology A, vol. 65, no. 10, pp. 1086–1092, 2010.
[69]
J. Michell, “Quantitative science and the defination of measurement in psychology,” British Journal of Psychology, vol. 88, no. 3, pp. 355–383, 1997.
[70]
C. Helmer, K. Pérès, A. Pariente et al., “Primary and secondary care consultations in elderly demented individuals in France: results from the three-city study,” Dementia and Geriatric Cognitive Disorders, vol. 26, no. 5, pp. 407–415, 2008.
