Elsevier

Archives of Gerontology and Geriatrics

Volume 57, Issue 3, November–December 2013, Pages 282-287
Archives of Gerontology and Geriatrics

Anosognosia and depression in patients with Alzheimer's dementia

https://doi.org/10.1016/j.archger.2013.03.012Get rights and content

Abstract

Anosognosia refers to impaired awareness of patients to realize deficits related to a disorder and is a common symptom of dementia. Anosognosia has far-reaching consequences for diagnosis and treatment and is probably associated with unfavorable prognosis. This study examined the relationship between anosognosia and depression in patients with Alzheimer's dementia (AD). Assessment included interviews of patients and their caregivers. Depressive symptoms were evaluated with observer and self-rating instruments: the Geriatric Depression Scale (GDS), and the “mood” subscale of the Nurses Observation Scale for geriatric patients (NOSGER). Anosognosia was evaluated with the Anosognosia Questionnaire for Dementia (AQ-D). For the evaluation of behavioral and neuropsychological symptoms in dementia and the caregiver burden, the neuropsychiatric inventory (NPI) and the Cares of older People in Europe (COPE) Index were administered. A total of 47 patients were enrolled in the study at the department's geriatric psychiatry outpatient clinic. A considerable discrepancy was found between observer- and self-ratings of depressive symptoms. In 74.5% of the participants, caregiver ratings indicated secondary symptoms of depression as opposed to patient ratings. Thus, in AD, anosognosia may affect not only deficits in cognition and everyday functioning but also affective symptoms (“affective anosognosia”). Caregiver rating therefore is particularly important when assessing mood changes in AD patients.

Introduction

The expanding field of Alzheimer's dementia (AD) research is increasingly focusing on how patients experience the disorder and, in particular, on their awareness of disorder-related deficits. Partial or complete absence of illness awareness is referred to as anosognosia. The terms “unawareness” or “denial” also are frequently found in the literature, although the latter refers rather to conscious denial of deficits despite intact awareness. This paper uses the term anosognosia throughout.

The phenomenon of anosognosia is considered to be an independent symptom complex (Leicht, Berwig, & Gertz, 2010) and is widespread, even though little information on prevalence exists. According to a more recent study of 111 outpatients by Orfei et al. (2010), 42% of patients with mild cognitive impairment (MCI) or early AD showed symptoms of anosognosia.

The vast majority of studies performed on this topic supports the assumption that anosognosia increases as the disorder progresses (Clare, 2004) and correlates negatively with cognitive performance (assessed by the Mini-Mental Status Examination, MMSE) (Aalten et al., 2006, Harwood et al., 2000, Kashiwa et al., 2005, Vasterling et al., 1995). However, some older studies do not support this correlation (e.g. Auchus et al., 1994, Michon et al., 1994).

There is great interindividual variability in the manifestation of anosognosia. Thus, deficits in awareness can affect either distinct cognitive domains or components relevant for daily living or can be global in nature.

Anosognosia is relevant because it likely has unfavorable effects on compliance with treatment, e.g. consent to receive drug treatment (Karlawish et al., 2005, Rosen, 2011). It may even cause danger to the patient or others, for example, if the patient does not stop driving despite of cognitive deficits (Cotrell & Wild, 1999).

There is some methodological difficulty in assessing the phenomenon of anosognosia, mainly due to the lack of uniform diagnostic instruments (Leicht et al., 2010, Rosen, 2011). Altogether, three possible evaluation approaches exist: clinical evaluation, performance discrepancy, and discrepancy between caregiver and self-ratings (Leicht et al., 2010). However, these methods have in common that results are primarily based on subjective assessments and therefore have a high risk of error and that there is no “gold standard” for measuring them (Vogel, Hasselbalch, Gade, Ziebell, & Waldemar, 2005).

The relationship between anosognosia and other neuropsychiatric symptoms such as depression requires clarification. This relationship is discussed controversially in the literature: One position states that unawareness is associated with more depressive symptoms (Harwood et al., 2000, Kashiwa et al., 2005, Smith et al., 2000). Other studies refuted this relationship, implying that anosognosia and depression occur independently (Michon et al., 1994, Verhey et al., 1993, Zanetti et al., 1999) and yet others (Aalten et al., 2006) found that even increased awareness may be associated with depression and dysthymia. Most of the studies performed to date assessed depressive symptoms using either caregiver rating or self-rating. Furthermore, the study samples and designs differed greatly, limiting the comparability and generalizability of their results.

The present study focused primarily on the relationship between depression and anosognosia. Besides prevalence, a possible discrepancy between self- and caregiver assessments was also of interest. In this context, another question was to what extent the failure to recognize dementia-related deficits may be accompanied by non-recognition of possible affective symptoms. We hypothesized that anosognosia subjects with dementia are not aware of their affective status. Unawareness of cognitive deficits and the non-recognition of depressive symptoms might have a synergistic impact on the patients care and treatment.

Section snippets

Sample

Forty-nine patients of the department's geriatric psychiatry outpatient clinic initially agreed to participate. However, 2 patients showed no signs of anosognosia in the AQ-D and therefore were excluded from further evaluations. The final sample size was N = 47.

Inclusion and exclusion criteria

Patients diagnosed with AD according to ICD-10 (F00.0–F00.2) (Dilling, Mombour, & Schmidt, 1993) and NINCDS-ADRDA criteria (McKhann et al., 1984) were included in the study. Only individuals with a relative or close friend as their

Results

Patient characteristics are presented in Table 1. The cognitive status as assessed by MMSE ranged widely from 8 to 28 points. A large number of subjects were in early stages of the disease (score 24–28: n = 18). Mild (score: 18–23), moderate (score: 10–17), and severe dementia (MMSE 0–9) occurred in 12, 16, and one cases (with n = 47 altogether), respectively.

The anosognosia score ranged from 4 to 64 points, indicating a considerable variation in the level of insight among the patients. The mean

Discussion

The core finding of this study is the striking discrepancy between the caregivers’ and patients’ self-ratings regarding depressive symptoms. Specifically, a majority of 57.4% of AD patients were considered depressed by the caregiver despite normal self-rating results. This considerable proportion of discrepant ratings contrasts with earlier studies that found agreement in the patient and caregiver ratings for depressive symptoms (Kotler-Cope and Camp, 1995, Vasterling et al., 1997). It is thus

Conclusion

The results of the present study underline the high rate of comorbidity with depressive symptoms especially in AD. This is the case also in patients with decreased awareness of their illness. Noteworthy here is first and foremost the considerable discrepancy between caregiver and self-ratings of the affective state during the whole course of the disease from early stages on. It becomes clear that the phenomenon of anosognosia affects not only deficits in cognition and daily functioning but that

Conflict of interest statement

All authors deny any financial and personal relationships with other people or organizations that could inappropriately influence (bias) this work.

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    Present address: LVR-Klinikum Viersen, Johannisstr. 70, 41749 Viersen, Germany.

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