Anosognosia in Alzheimer´s disease: A neuropsychological approach

Zilli, Bárbara Bomfim Caiado de Castro; Damasceno, Benito Pereira

doi:10.1590/S1980-57642008DN10100013

Abstract

Anosognosia is often found in Alzheimer´s disease (AD), but its relationship with cognitivebehavioral changes is not well established.

Objective:

To verify if anosognosia is related to cognitive-behavioral disturbances, and to regional brain dysfunction as evaluated by neuroimaging.

Methods:

We included AD patients with Mini-Mental State Examination (MMSE) scores of 12 through 24, and Clinical Dementia Rating (CDR) scores of 1 or 2. Dementia diagnosis was based on DSM-IV and NINCDS-ADRDA criteria. We used Self-Consciousness Questionnaire (SCQ) and Denial of Illness Scale (DIS), and following neuropsychological counterproofs: WAIS-R digit span, Rey auditory verbal learning, verbal fluency test (category: animals), Cummings´ neuropsychiatric inventory (NPI) and Cornell scale for depression in dementia (CSDD).

Results:

We studied 21 patients (12 men, 9 women) with AD (14 mild, 7 moderate), age 72.4±8.5 years, education 4.9± 4.2 years, and MMSE score 18.2±5. SCQ and DIS did not correlate to age, education, or regional cerebral perfusion defects, but they tended to correlate to disease duration (and only SCQ also to MMSE). SCQ and DIS were correlated neither to CSDD, NPI, CDR, nor to any neuropsychological test. Significant correlations were found between SCQ and DIS, as well as between SCQ domain of "moral judgment" and MMSE.

Conclusion:

SCQ and DIS were not correlated to age, education, disease duration, cognitive-behavioral measures, dementia severity, or regional cerebral perfusion defects, but were correlated to each other, suggesting SCQ and DIS evaluate similar mental functions.

Key words:
Alzheimers disease; dementia; anosognosia; agnosia; awareness.

Resumo

Anosognosia é freqüentemente encontrada na doença de Alzheimer (DA), porém sua relação com alterações cognitivo-comportamentais não está bem estabelecida.

Objetivo:

Verificar correlações entre anosognosia, alterações cognitivo-comportamentais e disfunções encontradas na neuroimagem (SPECT) da perfusão cerebral.

Métodos:

Incluimos pacientes com DA apresentando escores de 12 a 24 no Mini-Exame Mental (MEM) e 1 ou 2 na escala CDR (Clinical Dementia Rating). O diagnóstico de demência baseou-se nos critérios DSM-IV e NINCDS-ADRDA. Usamos o Questionário de Auto-Consciência (SCQ), a Escala de Negação de Doença (DIS); e contra-provas: span numérico do WAIS-R, aprendizado auditivo-verbal de Rey, fluência verbal (categoria: animais), inventário neuropsiquiátrico de Cummings (NPI) e a escala Cornell para depressão na demência (CSDD).

Resultados:

Estudamos 21 pacientes (12 homens, 9 mulheres) com DA (14 leve, 7 moderada), idade de 72,4±8,5 anos, educação 4,9±4,2 anos e escore do MEM 18,2 ± 5. SCQ e DIS não relacionaram-se com idade, educação, defeito perfusional cerebral, CSDD, NPI, CDR ou testes neuropsicológicos, mas tenderam a relacionar-se com duração da doença (e apenas o SCQ também com o MEM). Correlações significativas foram encontradas entre o SCQ e a DIS, bem como entre o domínio de "julgamento moral" do SCQ e o MEM.

Conclusão:

O SCQ e a DIS não se correlacionaram com idade, educação, duração da doença, alterações cognitivo-comportamentais, gravidade da demência ou defeito regional da perfusão cerebral, mas tenderam a correlacionar-se entre si, sugerindo que SCQ e DIS avaliam funções mentais similares.

Palavras-chave:
doença de Alzheimer; demência; anasognosia; agnosia; consciência.

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References

¹
Prigatano GP, Schacter DL. Awareness of deficit after braininjury: clinical and theoretical issues. New York, NY: Oxford University Press; 1991.
²
Gil R, Arroyo-Anllo EM, Ingrand P, et al. Self-consciousnessand Alzheimer's disease.Acta Neurol Scand 2001;104:296-300.
³
Dennett DC. Consciousness explained. Boston: Little, Brownand Company; 1991.
⁴
Reed BR, Jagust WJ, Coulter L. Anosognosia in Alzheimer'sdisease: relationships to depression, cognitive function, and cerebral perfusion. J Clin Exp Neuropsychol 1993;15:231-244.
⁵
Sevush S, Leve N. Denial of memory deficit in Alzheimer'sdisease. Am J Psychiatry 1993;150:748-751.
⁶
Smith CA, Henderson VW, McCleary CA, Murdock GA,Buckwalter JG. Anosognosia and Alzheimer's disease: the role of depressive symptoms in mediating impaired insight. J Clin Exp Neuropsychol 2000;22:437-444.
⁷
Dourado M, Laks J, Rocha M, Soares C, Leibing A, Engelhardt E. Awareness of disease in dementia: preliminary results in patients with mild and moderate Alzheimer´s disease. Arq Neuropsiquiatr 2005;63:114-118.
⁸
Feher EP, Mahurin RK, Inbody SB, Crook TH, Pirozzolo FJ.Anosognosia in Alzheimer's disease. Neuropsychiatry Neuropsychol Behav Neurol 1991;4:136-146.
⁹
Migliorelli R, Teson A, Sabe L, Petracchi M, Leiguarda R,Starkstein SE. Prevalence and correlates of dysthymia and major depression among patients with Alzheimer's disease. Am J Psychiatry 1995;152:37-44.
¹⁰
Starkstein SE, Chemerinski E, Sabe L, et al. Prospective longitudinal study of depression and anosognosia in Alzheimer's disease. Br J Psychiatry 1997;171:47-52.
¹¹
Almeida OP, Crocco EI. Perception of cognitive deficits andbehavior disorders in patients with Alzheimer´s disease. Arq Neuropsiquiatr 2000;58:292-299.
¹²
Starkstein SE, Sabe L, Chemerinski E, Jason L, Leiguarda R.Two domains of anosognosia in Alzheimer's disease. J Neurol Neurosurg Psychiatry 1996;61:485-490.
¹³
Heilman KM. Anosognosia: possible neuropsychologicalmechanisms. In: G. P. Prigatano, D. L. Schacter, editors. Awareness of deficit after brain injury. New York, NY: Oxford University Press; 1991:53-62.
¹⁴
Starkstein SE, Fedoroff JP, Price TR, et al. Anosognosia inpatients with cerebrovascular lesions: a study of causative factors. Stroke 1992;23:1446-1453.
¹⁵
Lopez OL, Becker JT, Somsak D, Dew MA, Dekorsky ST. Awareness of cognitive deficits in probable Alzheimer's disease. Eur Neurol 1993;34:277-282.
¹⁶
Ott BR, Lafleche G, Whellihan WM, Buongiorno GW, Albert MS, Fogel BS. Impaired awareness of deficits in Alzheimer disease. Alzheimer Dis Assoc Disord 1996;10:68-76.
¹⁷
Michon A, Deweer B, Pillon B, Agid Y, Dubois B. Relation ofanosognosia to frontal lobe dysfunction in Alzheimer´s disease. J Neurol Neurosurg Psychiatry 1994;57:805-809.
¹⁸
Starkstein SE, Robinson RG. Neuropsychiatric aspects ofstroke. In: Coffey CE, Cummings JL, editors. Textbook of Geriatric Neuropsychiatry. Washington, DC: American Psychiatric Press; 1994.
¹⁹
Starkstein SE, Vázquez S, Migliorelli R, Tesón A, Sabe L,Leiguarda R. A single-photon emission computed tomographic study of anosognosia in Alzheimer's disease. Arch Neurol 1995;52:415-420.
²⁰
Stuss DT, Benson DF. The frontal lobes. New York, NY: Raven Press; 1986.
²¹
Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: apractical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.
²²
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do Mini-exame do estado mental no Brasil. Arq Neuropsiquiatr 2003;61:777-781.
²³
Morris JC. The Clinical Dementia Rating (CDR): currentversion and scoring rules. Neurology 1993;43:2412-2414.
²⁴
American Psychiatric Association. Diagnostic and statisticalmanual of mental disorders, 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association; 1994.
²⁵
McKhann G, Drachman D, Folstein M, Katzman R, Price D,Stadlan EM. Clinical diagnosis of Alzheimer´s disease: report of the NINCDS-ADRDA Work Group under the auspices of the Department of Health and Human Services Task Force on Alzheimer´s disease. Neurology 1984;34:939-944.
²⁶
Holman BL, Johnson KA, Gerada B, Carvalho PA, Satlin A.The scintigraphic appearance of Alzheimer´s disease: a prospective study using Technetium-99m-HMPAO SPECT. J Nucl Med 1992;33:181-185.
²⁷
Wechsler D. WAIS-R Manual. New York, NY: The Psychological Corporation; 1981.
²⁸
Lezak MD. Neuropsychological assessment. New York, NY: Oxford University Press; 1995.
²⁹
Rey A. L'examen clinique em psychologie. Paris: PressUniversitaire de France; 1958.
³⁰
Cummings JL, Mega M, Gray K, Rosenberg-Thompson S,Carusi DA, Gornbein J. The Neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-2314.
³¹
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA.Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284.
³²
Moll J, Zahn R, de Oliveira-Souza R, Krueger F, Grafman J.Opinion: the neural basis of human moral cognition. Nat Rev Neurosci 2005;6:799-809.

Publication Dates

Publication in this collection
Jan-Mar 2007

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Prigatano GP, Schacter DL. Awareness of deficit after braininjury: clinical and theoretical issues. New York, NY: Oxford University Press; 1991.

[2] ²
Gil R, Arroyo-Anllo EM, Ingrand P, et al. Self-consciousnessand Alzheimer's disease.Acta Neurol Scand 2001;104:296-300.

[3] ³
Dennett DC. Consciousness explained. Boston: Little, Brownand Company; 1991.

[4] ⁴
Reed BR, Jagust WJ, Coulter L. Anosognosia in Alzheimer'sdisease: relationships to depression, cognitive function, and cerebral perfusion. J Clin Exp Neuropsychol 1993;15:231-244.

[5] ⁵
Sevush S, Leve N. Denial of memory deficit in Alzheimer'sdisease. Am J Psychiatry 1993;150:748-751.

[6] ⁶
Smith CA, Henderson VW, McCleary CA, Murdock GA,Buckwalter JG. Anosognosia and Alzheimer's disease: the role of depressive symptoms in mediating impaired insight. J Clin Exp Neuropsychol 2000;22:437-444.

[7] ⁷
Dourado M, Laks J, Rocha M, Soares C, Leibing A, Engelhardt E. Awareness of disease in dementia: preliminary results in patients with mild and moderate Alzheimer´s disease. Arq Neuropsiquiatr 2005;63:114-118.

[8] ⁸
Feher EP, Mahurin RK, Inbody SB, Crook TH, Pirozzolo FJ.Anosognosia in Alzheimer's disease. Neuropsychiatry Neuropsychol Behav Neurol 1991;4:136-146.

[9] ⁹
Migliorelli R, Teson A, Sabe L, Petracchi M, Leiguarda R,Starkstein SE. Prevalence and correlates of dysthymia and major depression among patients with Alzheimer's disease. Am J Psychiatry 1995;152:37-44.

[10] ¹⁰
Starkstein SE, Chemerinski E, Sabe L, et al. Prospective longitudinal study of depression and anosognosia in Alzheimer's disease. Br J Psychiatry 1997;171:47-52.

[11] ¹¹
Almeida OP, Crocco EI. Perception of cognitive deficits andbehavior disorders in patients with Alzheimer´s disease. Arq Neuropsiquiatr 2000;58:292-299.

[12] ¹²
Starkstein SE, Sabe L, Chemerinski E, Jason L, Leiguarda R.Two domains of anosognosia in Alzheimer's disease. J Neurol Neurosurg Psychiatry 1996;61:485-490.

[13] ¹³
Heilman KM. Anosognosia: possible neuropsychologicalmechanisms. In: G. P. Prigatano, D. L. Schacter, editors. Awareness of deficit after brain injury. New York, NY: Oxford University Press; 1991:53-62.

[14] ¹⁴
Starkstein SE, Fedoroff JP, Price TR, et al. Anosognosia inpatients with cerebrovascular lesions: a study of causative factors. Stroke 1992;23:1446-1453.

[15] ¹⁵
Lopez OL, Becker JT, Somsak D, Dew MA, Dekorsky ST. Awareness of cognitive deficits in probable Alzheimer's disease. Eur Neurol 1993;34:277-282.

[16] ¹⁶
Ott BR, Lafleche G, Whellihan WM, Buongiorno GW, Albert MS, Fogel BS. Impaired awareness of deficits in Alzheimer disease. Alzheimer Dis Assoc Disord 1996;10:68-76.

[17] ¹⁷
Michon A, Deweer B, Pillon B, Agid Y, Dubois B. Relation ofanosognosia to frontal lobe dysfunction in Alzheimer´s disease. J Neurol Neurosurg Psychiatry 1994;57:805-809.

[18] ¹⁸
Starkstein SE, Robinson RG. Neuropsychiatric aspects ofstroke. In: Coffey CE, Cummings JL, editors. Textbook of Geriatric Neuropsychiatry. Washington, DC: American Psychiatric Press; 1994.

[19] ¹⁹
Starkstein SE, Vázquez S, Migliorelli R, Tesón A, Sabe L,Leiguarda R. A single-photon emission computed tomographic study of anosognosia in Alzheimer's disease. Arch Neurol 1995;52:415-420.

[20] ²⁰
Stuss DT, Benson DF. The frontal lobes. New York, NY: Raven Press; 1986.

[21] ²¹
Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: apractical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.

[22] ²²
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do Mini-exame do estado mental no Brasil. Arq Neuropsiquiatr 2003;61:777-781.

[23] ²³
Morris JC. The Clinical Dementia Rating (CDR): currentversion and scoring rules. Neurology 1993;43:2412-2414.

[24] ²⁴
American Psychiatric Association. Diagnostic and statisticalmanual of mental disorders, 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association; 1994.

[25] ²⁵
McKhann G, Drachman D, Folstein M, Katzman R, Price D,Stadlan EM. Clinical diagnosis of Alzheimer´s disease: report of the NINCDS-ADRDA Work Group under the auspices of the Department of Health and Human Services Task Force on Alzheimer´s disease. Neurology 1984;34:939-944.

[26] ²⁶
Holman BL, Johnson KA, Gerada B, Carvalho PA, Satlin A.The scintigraphic appearance of Alzheimer´s disease: a prospective study using Technetium-99m-HMPAO SPECT. J Nucl Med 1992;33:181-185.

[27] ²⁷
Wechsler D. WAIS-R Manual. New York, NY: The Psychological Corporation; 1981.

[28] ²⁸
Lezak MD. Neuropsychological assessment. New York, NY: Oxford University Press; 1995.

[29] ²⁹
Rey A. L'examen clinique em psychologie. Paris: PressUniversitaire de France; 1958.

[30] ³⁰
Cummings JL, Mega M, Gray K, Rosenberg-Thompson S,Carusi DA, Gornbein J. The Neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-2314.

[31] ³¹
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA.Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284.

[32] ³²
Moll J, Zahn R, de Oliveira-Souza R, Krueger F, Grafman J.Opinion: the neural basis of human moral cognition. Nat Rev Neurosci 2005;6:799-809.

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