Neuropsychological Correlates of Anosognosia for Objective Functional Difficulties in Older Adults on the Mild Cognitive Impairment Spectrum

Abstract

Objective To examine the neuropsychological correlates of anosognosia for instrumental activities of daily living (IADLs) in older adults with mild cognitive impairment (MCI) and mild dementia. Method Participants (n = 103; age range = 54–88, 52% female) with MCI and mild dementia were recruited from neurology and geriatrics clinics for cross-sectional analysis. They completed neuropsychological tests along with subjective and performance-based assessments of six IADLs: financial management, driving, grocery shopping, nutrition evaluation, telephone use, and medication management. For each IADL, participants were classified as having anosognosia when there was objective difficulty but no subjective complaints. Results Depending on functional domain, 13–39% of the sample had objective IADL difficulty, and of those, 65–93% lacked insight into these deficits. Binomial logistic regression models controlling for demographic variables revealed that measures of global cognition, executive function, visual attention, and verbal memory predicted classification of anosognosia, and these relationships varied across IADLs. In contrast, basic auditory attention, working memory, depressive symptoms, nor cognitive reserve were significantly related to anosognosia for any IADL. Conclusion Results support the Conscious Awareness Model, which theorizes that accurate metacognitive output is reliant on attentional, memory, and executive functioning systems. Findings from this study suggest that anosognosia for different IADLs may arise from breakdowns at varying points in this model, explaining both inter- and intra-patient variability in self-awareness of functional deficits.

Awareness of Performance on a Functional Cognitive Performance-Based Assessment Across the Adult Lifespan

“…Our normative data on performance, awareness, and strategy use across the adult lifespan, on the WCPA-10, add to the utility of this brief functional cognitive tool for identifying possible C-IADL and awareness deficits that might otherwise go unnoticed. Older adults with decreased self-awareness are likely to under-report functional difficulties to others and subtle decline may not be noticed by friends or relatives (Steward et al, 2020). Therefore, a brief performance-based assessment such as the WCPA might be useful in triggering referrals for further assessment and intervention.…”

Altered metamemory precedes cognitive impairment in subjective cognitive decline with positive amyloid-beta

“…A self-experienced decline in cognitive capacity, especially in the memory domain, is an important clinical feature in Alzheimer’s disease (AD), amnestic mild cognitive impairment (aMCI), and subjective cognitive decline (SCD) ( Albert et al, 2011 ; Jessen’s et al, 2014 ). The capacity to accurately assess one’s cognitive states or memory state (metacognition or metamemory) can be impaired in AD and those deficits may become more pronounced as the disease progresses ( Starkstein, 2014 ; Castrillo et al, 2016 ; Steward et al, 2020 ; Huntley et al, 2021 ). Impaired metamemory capacity may portend a preclinical stage of progressive disease and reflect the first effects of AD pathology ( Jessen’s et al, 2014 ; Hanseeuw et al, 2020 ), such as amyloid-beta (Aβ) burden ( Vannini et al, 2017 ; Hanseeuw et al, 2020 ) and tauopathy ( Vannini et al, 2019 ).…”

“…About 71–93% of patients with AD dementia were observed with metacognition impairment ( Starkstein, 2014 ; Castrillo et al, 2016 ; Steward et al, 2020 ; Huntley et al, 2021 ). Metamemory is described as lacking insight or awareness of their own cognitive and functional impairments in the memory domain ( Souchay, 2007 ).…”

Difficulty Taking Medications: a Corollary to Dementia Risk

“…When asking about problems in tasks such as medication or financial management, it is important to recognize that anosognosia, or the loss of insight to one's functional decline, is correlated with cognitive decline in those progressing along the MCI to dementia spectrum. 8 Over time, it is necessary to corroborate the patient's self-reported history and functional abilities with those of family members or caregivers to understand the extent of the functional changes.…”