Awareness of cognitive deficits and clinical competence in mild to moderate Alzheimer’s disease: their relevance in clinical practice

Abstract

Awareness of cognitive deficits and clinical competence were investigated in 79 mild to moderate Alzheimer's disease patients. Awareness was assessed by the anosognosia questionnaire for dementia, and clinical competence by specific neuropsychological tests such as trail making test-A, Babcock story recall test, semantic and phonemic verbal fluency. The findings show that 66 % of the patients were aware of memory deficits, while the 34 % were unaware. Deficit in awareness correlated with lower scores on the Mini Mental State Examination test that, in the score range from 24.51 to 30 and from 19.50 to 24.50, appeared to be a significant predictor of level of awareness. None of the AD patients had fully preserved clinical competence, only 7 patients (9 %) had partially preserved clinical competence and 72 patients (91 %) had completely lost clinical competence. All the patients with partially preserved clinical competence (9 %) were aware of their memory deficit. The study indicates that neuropsychological tests used for the assessment of executive functions are not suitable for investigating clinical competence. Therefore, additional and specific tools for the evaluation of clinical competence are necessary. Indeed, these might allow clinicians to identify AD patients who, despite their deficits in selected functions, retain their autonomy of choice as well as recognize those patients who should proceed to the nomination of a legal representative.

The interaction between implicit and explicit awareness in anosognosia: Emergent awareness

“…Moreover, it induces the use of strategies aimed at correcting their behavior, which are not employed in subjects who do not show any signs of emergent awareness (but have, for example, spared implicit awareness; Moro et al, 2011). Finally, emergent awareness might guide decision-making processes in complex contexts, for example, during procedures requesting a subject's consensus to medical treatment (Clinical Competence; Gambina et al, 2013).…”

Concepts and objects of awareness in Alzheimer’s disease: an updated systematic review

“…Among them, 13 evaluated only this domain 20,23,27,38,39,41,44,47,[50][51][52][53]55 . Ten studies evaluated awareness of cognitive and functional deficits domains 1,18,20,[33][34][35]40,45,46,54 , nine assessed cognitive and social-emotional functioning domains 12,13,17,24,28,30,36,37,49 , and three focused on cognitive and behavioral impairment domains 14,16,42 .…”

“…Different concepts were used to define the construct of awareness [12][13][14][15][16][17][18][19][20] , anosognosia [21][22][23][24][25][26][27][28][29][30][31][32] , self-awareness 33,34 , self -appraisal 35 , insight 36,37 , cognitive insight 38 , metacognition [39][40][41] , unawareness of deficits 42 , awareness of deficit 43,44 , awareness of disease 1,45 , awareness of functioning 46 , awareness of cognitive deficits 47 , awareness of disabilities 48 , awareness of performance 49 , unawareness of memory 42,[50][51][52] , anosognosia of memory 53 , awareness of memory deficits 54,55 , awareness of memory function and functional abilities 56 , unawareness of psychosis or behavioral problems …”

“…Even people with very mild dementia and great awareness showed substantial deficits in CC. We can assume that deficits in executive function, memory and language may refer to the association between capacity and awareness, suggesting that these two constructs may be differently impaired in PwD 47 . On self-evaluating their predictions, people with AD were generally less accurate in evaluating the level of their cognitive abilities than healthy older adults, significantly overestimating their performance on the pretest 19,53,55 .…”

“…It is important to note that unawareness for memory deficit may be easily identified in standard clinical setting and used to evaluate the role of unawareness in predicting conversion from MCI to AD 51 . A study 47 investigated the eventual existence of relationship between awareness and Clinical Competence (CC) in mild to moderate AD. A great proportion of PwD were unaware of cognitive, functional and behavioral deficits, with an increase of severity and prevalence of awareness along the progression of disease.…”