Differences in self-awareness of functional deficits between amnestic single- and multidomain mild cognitive impairment

Abstract

Introduction: Prior research examining self-awareness of deficits in those with Mild Cognitive Impairment (MCI) has been inconsistent, suggesting that preservation of insight at this disease stage may be conditional on the domain(s) examined as well as individual characteristics. The current study is the first to examine differences in objective performance and self-awareness of difficulties between older adults with amnestic single-(MCI-ASD) and multi-domain MCI (MCI-AMD) across six instrumental activities of daily living (IADLs). Methods: Seventy-five individuals (mean age=73.9 years, range 55-88 years; 56% female) with MCI-ASD (n=30) and MCI-AMD (n=45) were recruited primarily from a hospital-based memory disorders clinic. Participants were administered self-report and objective measures assessing six functional domains: Financial Management, Driving, Telephone Use, Nutrition Evaluation, Grocery Shopping, and Medication Management. Self-awareness discrepancy scores were calculated for each of these IADLs and participants were classified as either 'overestimating ability' or 'accurately/under-estimating ability.' Results: Individuals with MCI-AMD performed significantly worse on objective measures of Financial Management, Driving, and Nutrition Evaluation in comparison to those with MCI-ASD. Across MCI subtypes, participants were most likely to lack awareness of their difficulties in Nutrition Evaluation (31%), Financial Management (25%), and Driving (23%) domains. Individuals with MCI-AMD were significantly more likely than those with MCI-ASD to overestimate performance on Driving and Telephone Use domains. A similar trend was found for Financial Management and Nutrition Evaluation domains. Conclusion: In comparison to those with MCI-ASD, individuals with MCI-AMD are more likely to have impairment in their everyday function and to lack awareness into their IADL difficulties. When possible, clinicians should obtain objective measures in combination with detailed informant reports of functional abilities in order to evaluate capacity to independently engage in various daily activities. Finally, level of self-awareness varies across IADL domains, providing further evidence that insight is not a unitary construct.

Poor awareness of IADL deficits is associated with reduced regional brain volume in older adults with cognitive impairment

“…Thus, a discrepancy score of +1 indicates overestimation of their ability, a 0 indicates accurate estimation, and a −1 indicates underestimation of performance. Similar dichotomization methods and calculation of discrepancy scores have been previously published as a data reduction step for ease of interpretation and to minimize experiment-wise error rate Okonkwo, et al, 2008;Steward, et al, 2019).…”

“…Unawareness of deficits occurs in 50-80% of individuals with Alzheimer's disease (AD) (Reed, et al, 1993;Starkstein, et al, 2006;Vogel, et al, 2005) and 10-60% of those with mild cognitive impairment (MCI) Okonkwo, et al, 2010;Starkstein, et al, 2006;Steward, et al, 2019;Tabert, et al, 2002). Patients' level of insight can range from a mild underreporting of symptoms to a complete lack of awareness of their disease process (Okonkwo, et al, 2010;Reed, et al, 1993) and may vary according to the specific domain that patients are asked to self-evaluate (Clare, et al, 2011;Steward, et al, 2019). Poor self-awareness predicts conversion to dementia (Spalletta, et al, 2014;Tabert, et al, 2002) and thus has become an important clinical symptom to understand in those with MCI.…”

“…However, only one previous study specifically examined the neural basis of self-awareness of IADLs, and the sample in this study consisted solely of subjects with frontotemporal dementia (Amanzio, et al, 2016). There is evidence that level of insight in individuals with neurodegenerative disease may vary across cognitive, emotional, behavioral, and functional domains (Banks & Weintraub, 2008;Clare, et al, 2011;Steward, et al, 2019). Therefore, it is possible that selfawareness of memory or other cognitive domains may not necessarily share the same neural correlates as self-awareness of everyday functional abilities (e.g., financial management, driving, meal preparation, medication management, technology use).…”

Behavioral and emotional quality of life of patients undergoing inpatient geriatric rehabilitation.

“…Although the study included patients with a neurological disease, the MMSE-screening results were satisfactory with reference to the cognitive abilities of these very old and multimorbid patients after an acute event ( M = 26.3 ( SD = 3.3), range = 16–30 4 ), and all study participants performed well in the face-to-face interviews at admission and discharge. Therefore, it can be assumed that the participants in the study sample were sufficiently capable of self-report and self-perception, although some reported self-perceptions may be inaccurate or skewed as it cannot be completely ruled out that some of those patients with a low MMSE score had reduced self-awareness due to cognitive impairments (compare Steward, Bull, & Wadley, 2019).…”

“…Third, in this study a MMSE score of at least 17 was set as an inclusion criterion (compare Wahl et al, 2001) to ensure that participating patients were not too severely cognitively impaired and, thus, were capable of self-report and self-perception. However, previous studies indicate that even early stages of cognitive impairment may be related to reduced self-awareness, leading, for example, to a lack of insight into functional deficits (for example, Albert et al, 1999; Steward et al, 2019). Thus, it is possible that participants with a rather low MMSE score accompanied by a lack of insight into their functional deficits could have overestimated their health status.…”