Anosognosia and depression in patients with Alzheimer's dementia
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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2016, CortexCitation Excerpt :The relationship with mood is an important aspect of anosognosia and has been explored using three main approaches (Mograbi & Morris, 2014). First, studies show mixed results when exploring awareness for different objects in dementia, with some findings suggesting that patients with AD present greater unawareness for cognitive deficits relative to behavioral changes (Kotler-Cope & Camp, 1995) and others results indicating also an “affective anosognosia” (Verhülsdonk, Quack, Höft, Lange-Asschenfeldt, & Supprian, 2013), that is, a lack of awareness for mood disturbance. Second, the literature suggests that people with AD may present an emotional response to failure situations even in the absence of explicit awareness.
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2015, American Journal of Geriatric PsychiatryCitation Excerpt :It is thus plausible that an early and disproportionate burden of right hemisphere pathology in AD could have clinical manifestations, including lower levels of both awareness and depressive symptoms, whereas a disproportionate burden of left hemisphere pathology could underlie increased levels of both. It has also been posited that reduced awareness and depression occur independently but may converge to generate an “affective anosognosia”55 such that patients who are unaware of memory impairment may also be unaware of depressive symptoms, particularly in the later stages of the disease. We examined the extent to which and mechanisms by which awareness of memory symptoms in mild to moderate AD is associated with reduced psychological well-being.
Conscience des déficits dans le cadre de la maladie d'Alzheimer: représentations et vécu des professionnels soignants
2024, Canadian Journal on Aging
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Present address: LVR-Klinikum Viersen, Johannisstr. 70, 41749 Viersen, Germany.