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Impaired Awareness of Deficits in Alzheimer's Disease: The Role of Everyday Executive Dysfunction

  • Martina Amanzio (a1) (a2), Lene Vase (a3) (a4), Daniela Leotta (a5), Renato Miceli (a1), Sara Palermo (a1) and Giuliano Geminiani (a1) (a2)...


The present study analyzed the awareness of deficits in 117 mild Alzheimer's disease participants. Since few studies have examined the cognitive and behavioral domains of reduced awareness in detail, we performed a domain-specific assessment using the Awareness of deficit Questionnaire – Dementia scale with the novel aim of describing the relationship with everyday executive dysfunction. Through the use of the subtests of the Behavioral Assessment of the Dysexecutive Syndrome, we hypothesized that executive cognitive functions may play an important role in the reduced awareness of deficits. We also considered other variables of interest to provide a novel comprehensive explanation of this phenomenon. Our first approach to the study was a factor analysis considering the role of these variables in the awareness of deficits; subsequently, regression analysis models were used to define which variables were associated with a reduction of awareness in cognitive and behavioral domains. In particular, the factors retained from the factor analysis, in terms of inhibition, self-monitoring, set-shifting, and mood orientation changes, appear to be important skills for awareness of instrumental activities of daily living (R2 = .32). We also found hypo manic mood orientation and a tendency through apathy to be prominent indications of reduced behavioral awareness (R2 = .13). (JINS, 2013, 18, –)


Corresponding author

Correspondence and reprint requests to: Martina Amanzio, Department of Psychology, University of Turin, Via Verdi 10, 10123 Turin, Italy. E-mail:


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Agnew, S.K., Morris, R.G. (1998). The heterogeneity of anosognosia for memory impairment in Alzheimer's disease: A review of the literature and a proposed model. Aging and Mental Health, 2, 915.
Allain, P., Chaudet, H., Nicoleau, S., Etcharry-Bouyx, F., Barr, J., Dubas, F., Le Gall, D. (2007). [A study of action planning in patients with Alzheimer's disease using the zoo map test]. Revue Neurologique (Paris), 163(2), 222230.
Amanzio, M., Geminiani, G., Leotta, D., Cappa, S. (2008). Metaphor comprehension in Alzheimer's disease: Novelty matters. Brain and Language, 107, 110.
Amanzio, M., Torta, D.M., Sacco, K., Cauda, F., D'Agata, F., Duca, S., Geminiani, G.C. (2011). Unawareness of deficits in Alzheimer's disease: Role of the cingulate cortex. Brain, 134, 10611076.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorder (4th ed.). Washington, DC: American Psychiatric Association Press.
Assal, F., Cummings, J.L. (2002). Neuropsychiatric symptoms in the dementias. Current Opinion in Neurology, 15, 445450.
Auchus, A.P., Goldstein, F.C., Green, J., Green, R.C. (1994). Anosognosia in Alzheimer's disease. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 7, 2529.
Baddeley, A.D. (1986). Working memory. Oxford: Clarendon Press.
Barrett, A.M., Eslinger, P.J., Ballentine, N.H., Heilman, K.M. (2005). Unawareness of cognitive deficit (cognitive anosognosia) in probable AD and control subjects. Neurology, 64, 693699.
Bech, P., Rafaelsen, O.J., Kramp, P., Bolwing, T.G. (1978). The mania rating scale: Scale construction and inter-observer agreement. Neuropharmacology, 17, 430431.
Buckner, R.L. (2004). Memory and executive function in aging AD: Multiple factors that cause decline and reserve factors that compensate. Neuron, 44(1), 195208.
Chen, P., Ratcliff, G., Belle, S.H., Cauley, J.A., DeKosky, S.T., Ganguli, M. (2000). Cognitive tests that best discriminate between presymptomatic AD and those who remain non demented. Neurology, 55(12), 18471853.
Clare, L. (2004a). The construction of awareness in early-stage Alzheimer's disease: A review of concepts and models. British Journal of Clinical Psychology, 43, 155175.
Clare, L. (2004b). Awareness in early-stage Alzheimer's disease: A review of methods and evidence. British Journal of Clinical Psychology, 43, 177196.
Clare, L., Nelis, S.M., Martyr, A., Roberts, J., Whitaker, C.J., Markova, I.S., Morris, R.G. (2012). The influence of psychological, social and contextual factors on the expression and measurement of awareness in early stage dementia: Testing a biopsychosocial model. International Journal of Geriatric Psychiatry, 27, 167177.
Cools, R., Brouwer, W.H., de Jong, R., Slooff, C. (2000). Flexibility, inhibition, and planning: Frontal dysfunctioning in schizophrenia. Brain and Cognition, 43(1-3), 108112.
Derouesne, C., Poitreneau, J., Hugonot, L., Kalafat, M., Dubois, B., Laurent, B. (1999). Mini-Mental State Examination: A useful method for the evaluation of the cognitive status of patients by the clinician. Consensual French version. Presse Médicale, 28(21), 11411148.
Drewe, E. (1985). Go-no-go learning after frontal lobe lesions in humans. Cortex, 11, 816.
Duke, L.M., Kaszniak, A.W. (2000). Executive control functions in degenerative dementias: A comparative review. Neuropsychology Review, 10(2), 7599.
Eslinger, P.J., Moore, P., Troiani, V., Antani, S., Cross, K., Kwok, S., Grossman, M. (2007). Oops! Resolving social dilemmas in frontotemporal dementia. Journal of Neurology, and Neurosurgery, and Psychiatry, 78, 457460.
Espinosa, A., Alegret, M., Boada, M., Vinyes, G., Valero, S., Martinez-Lage, P., Tirraga, L. (2009). Ecological assessment of executive functions in mild cognitive impairment and mild Alzheimer's disease. Journal of the International Neuropsychological Society, 15(5), 751757.
Feher, E.P., Larrabee, G.J., Sudilovsky, A., Crook, T.H. (1994). Memory self-report in Alzheimer's disease and in age-associated memory impairment. Journal of Geriatric Psychiatry and Neurology, 7, 5865.
Folstein, M.F., Folstein, S.E., McHugh, P.R. (1975). Mini-mental state. Journal of Psychiatric Research, 12, 189198.
Galeone, F., Pappalardo, S., Chieffi, S., Iavarone, A., Carlomagno, S. (2011). Anosognosia for memory deficit in amnestic mild cognitive impairment and Alzheimer's disease. International Journal of Geriatric Psychiatry, 26(7), 695701. doi:10.1002/gps.2583
Gil, R., Arroyo-Anllo, E.M., Ingrand, P., Gil, M., Neau, J.P., Ornon, C., Bonnaud, V. (2001). Self-consciousness and Alzheimer's disease. Acta Neurologica Scandinavica, 104, 296300.
Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 5055.
Hamilton, M.A. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 5662.
Hannesdottir, K., Morris, R.G. (2007). Primary and secondary anosognosia for memory impairment in patients with Alzheimer's disease. Cortex, 43, 10201030.
Harwood, D.G., Sultzer, D.L., Wheatley, M.A. (2000). Impaired insight in Alzheimer's disease: Association with cognitive deficits, psychiatric symptoms, behavioral disturbances. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 13, 8388.
Kashiwa, Y., Kitabayashi, Y., Narumoto, J., Nakamura, K., Ueda, H., Fukui, K. (2005). Anosognosia in Alzheimer's disease: Association with patient characteristics, psychiatric symptoms and cognitive deficits. Psychiatry and Clinical Neuroscience, 59, 697704.
Kaszniak, A.W., Zak, M.G. (1996). On the neuropsychology of metamemory: Contributions from the study of amnesia and dementia. Learning and Individual Differences, 8, 355381.
Katz, S., Ford, A.B., Moskovitz, R.W., Jackson, B.A., Jaffe, M.W. (1963). Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychological function. Journal of the American Medical Association, 185, 914919.
Kotler-Cope, S., Camp, C.J. (1995). Anosognosia in Alzheimer disease. Alzheimer Disease and Associated Disorders, 9(1), 5256.
Lawton, M.P., Brody, E.M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9, 179186.
Lezak, M.D., Howieson, D.B., Loring, D.W. (2004). Neuropsychological assessment. (4th ed., pp. 636637). Oxford: Oxford University Press.
Litvan, I., Agid, Y., Calne, D., Campbell, G., Dubois, B., Duvoisin, R.C., Zee, D.S. (1996). Clinical research criteria for the diagnosis of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome): Report of the NINDS-SPSP international workshop. Neurology, 47, 19.
Litvan, I., Agid, Y., Goetz, C., Jankovic, J., Wenning, G.K., Brandel, J.P., Bartko, J.J. (1997). Accuracy of the clinical diagnosis of corticobasal degeneration: A clinicopathologic study. Neurology, 48, 119125.
Lyon, G.R., Krasnegor, N.A. (Eds.) (1996). Attention, memory and executive function. Baltimore: Brookes.
Loebel, J.P., Dager, S.R., Berg, G., Hyde, T.S. (1990). Fluency of speech and self-awareness of memory deficit in Alzheimer's disease. International Journal of Geriatric Psychiatry, 5, 4145.
Logan, G.D. (1985). Executive control of thought and action. Acta Psychologica, 60, 193210.
Lopez, O.L., Becker, J.T., Somsak, D., Dew, M.A., DeKosky, S.T. (1994). Awareness of cognitive deficits and anosognosia in probable Alzheimer's disease. European Journal of Neurology, 34, 277282.
Mangone, C.A., Hier, D.B., Gorelick, P.B., Ganellen, R.J., Langenberg, P., Boarman, R., Dollear, W.C. (1991). Impaired insight in Alzheimer's disease. Journal of Geriatric Psychiatry and Neurology, 4, 189193.
McKhann, G., Drachman, D., Folstein, M., Katzman, M., Price, D., Stadlan, E.M. (1984). Clinical diagnosis of Alzheimer's disease. Neurology, 34, 939944.
Michon, A., Deweer, B., Pillon, B., Agid, Y., Dubois, B. (1994). Relation of anosognosia to frontal lobe dysfunction in Alzheimer's disease. Journal of Neurology, Neurosurgery, and Psychiatry, 57, 805809.
Migliorelli, R., Tenson, A., Sabe, L., Petracca, G., Petracchi, M., Leiguarda, R., Starkstein, S. (1995). Anosognosia in Alzheimer's disease: A study of associated factors. The Journal of Neuropsychiatry and Clinical Neurosciences, 7, 338344.
Millar, D., Griffiths, P., Zermansky, A.J., Burn, D.J. (2006). Characterizing behavioral and cognitive dysexecutive changes in progressive supranuclear palsy. Movement Disorders, 21, 199207.
Miyake, A., Friedman, N.P., Emerson, A.H.W., Howerter, A., Wager, T.D. (2000). The unity and diversity of executive functions and their contributions to complex frontal lobe tasks: A latent variable analysis. Cognitive Psychology, 41, 49100.
Morris, R., Hannesdottir, G.K. (2004). Loss of “awareness” in Alzheimer's disease. In R.G. Morris & J.T. Becker (Eds.), Cognitive neuropsychology of Alzheimer's. Oxford: Oxford University Press.
Ott, B.R., Lafleche, G., Whelihan, W.M., Buongiorno, G.W., Albert, M.S., Fogel, B.S. (1996). Impaired awareness of deficits in Alzheimer disease. Alzheimer Disease and Associated Disorder, 10, 6876.
Piquard, A., Derouesné, C., Lacomblez, L., Siéroff, E. (2004). Planning and activities of daily living in Alzheimer's disease and frontotemporal dementia. Psychologie Neuropsychiatrie du Vieillissement, 2(2), 147156.
Rabbit, P. (Ed.). (1997). Methodology of frontal and executive function. Hove, UK: Psychology Press.
Reed, B.R., Jagust, W.J., Coulter, L. (1993). Anosognosia in Alzheimer's disease: Relationships to depression, cognitive function, and cerebral perfusion. Journal of Clinical and Experimental Neuropsychology, 15, 231244.
Reisberg, B., Ferris, S.H., de Leon, M.J., Crook, T. (1982). The Global Deterioration Scale for assessment of primary degenerative dementia. The American Journal of Psychiatry, 139, 11361139.
Rodrigues Gouveia, P.A., Dozzi Brucki, S.M., Fleury Malheiros, S.M., Bueno, O.F.A. (2007). Disorders in planning and strategy application in frontal lobe lesion patients. Brain and Cognition, 63, 240246.
Rosen, W.G., Mohs, R.C., Davis, K.L. (1984). A new rating scale for Alzheimer's Disease. The American Journal of Psychiatry, 141, 13561364.
Rymer, S., Salloway, S., Norton, L., Malloy, P., Correia, S., Monast, D. (2002). Impaired awareness, behavior disturbance, and caregiver burden in Alzheimer disease. Alzheimer Disease and Associate Disorders, 16(4), 248253.
Sebastian, M.V., Menor, J., Elosua, M.R. (2006). Attentional dysfunction of the central executive in AD: Evidence from dual task and perseveration errors. Cortex, 42(7), 10151020.
Seltzer, B., Vasterling, J.J., Mathias, C.W., Brennan, A. (2001). Clinical and neuropsychological correlates of impaired awareness of deficits in Alzheimer disease and Parkinson disease: A comparative study. Journal of Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 14, 122129.
Seltzer, B., Vasterling, J.J., Yoder, J.A., Thompson, K.A. (1997). Awareness of deficit in Alzheimer's disease: Relation to caregiver burden. Gerontologist, 37(1), 2024.
Sevush, S. (1999). Relationship between denial of memory deficit and dementia severity in Alzheimer's disease. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 12, 8894.
Sevush, S., Leve, N. (1993). Denial of memory deficit in Alzheimer's disease. American Journal of Psychiatry, 150, 748751.
Shallice, T., Burgess, P.W. (1991). Deficits in strategy application following frontal lobe damage in man. Brain, 114, 727741.
Smith, E.E., Jonides, J. (1999). Storage and executive processes in the frontal lobes. Science, 283, 16571661.
Spinnler, H., Tognoni, G. (1987). Standardizzazione e taratura italiana di test neuropsicologici. Italian Journal of Neurological Sciences, (Suppl. 8 to 6).
Starkstein, S.E., Chemerinski, E., Sabe, L., Kuzis, G., Petracca, G., Tesòn, A., Leiguarda, R. (1997). Prospective longitudinal study of depression and anosognosia in Alzheimer's disease. The British Journal of Psychiatry, 171, 4752.
Starkstein, S.E., Garau, M.L., Cao, A. (2004). Prevalence and clinical correlates of disinhibition in dementia. Cognitive and Behavioral Neurology, 17, 139147.
Starkstein, S.E., Jorge, R., Mizrahi, R., Robinson, R.G. (2006). A diagnostic formulation for anosognosia in Alzheimer's disease. Journal of Neurology, Neurosurgery, and Psychiatry, 77, 719725.
Starkstein, S.E., Migliorelli, R., Teson, A., Petracca, G., Chemerinsky, E., Manes, F., Leiguarda, R. (1995). Prevalence and correlates of pathological affective display in Alzheimer's disease. Journal of Neurology, Neurosurgery, and Psychiatry, 59, 5560.
Starkstein, S.E., Sabe, L., Chemerinski, E., Jason, L., Leigarda, R. (1996). Two domains of anosognosia in Alzheimer's disease. Journal of Neurology, Neurosurgery, and Psychiatry, 61, 485490.
Vasterling, J.J., Seltzer, B., Foss, J.W., Vanderbrook, V. (1995). Unawareness of deficit in Alzheimer's disease: Domain-specific differences and disease correlates. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 8, 2632.
Verhey, F.R., Ponds, R.W., Rozendaal, N., Jolles, J. (1995). Depression, insight, and personality changes in Alzheimer's disease and vascular dementia. Journal of Geriatric Psychiatry and Neurology, 8(1), 2327.
Vogel, A., Hasselbalch, S.G., Gade, A., Ziebell, M., Waldemar, G. (2005). Cognitive and functional neuroimaging correlate for anosognosia in mild cognitive impairment and Alzheimer's disease. International Journal of Geriatric Psychiatry, 20, 238246.
Weinstein, E.A., Friedland, R.P., Wagner, E.E. (1994). Denial/unawareness of impairment and symbolic behavior in Alzheimer's disease. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 7, 176184.
Wilson, B.A., Alderman, N., Burgess, P.W., Emslie, H., Evans, J.J. (1996). BADS: Behavioural assessment of the dysexecutive syndrome. Bury St. Edmonds, UK: Thames Valley Test Company.
Wood, R.L., Liossi, C. (2007). The relationship between general intellectual ability and performance on ecologically valid executive tests in a severe brain injury sample. Journal of the International Neuropsychological Society, 13(1), 9098.
Zanetti, O., Vallotti, B., Frisoni, G.B., Geroldi, C., Bianchetti, A., Pasqualetti, P., Trabucchi, M. (1999). Insight in dementia: When does it occur? Evidence for a nonlinear relationship between insight and cognitive status. Journal of Gerontology, 54, 100106.



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