Modelling the impact of functionality, cognition, and mood state on awareness in people with Alzheimer's disease.

OBJECTIVES: To investigate the nature of the relationship between cognitive function, mood state, and functionality in predicting awareness in a non-clinically depressed sample of participants with mild to moderate Alzheimer's disease (AD) in Brazil. METHODS: People with AD (PwAD) aged 60 years or older were recruited from an outpatient unit at the Center of AD of the Federal University of Rio de Janeiro, Brazil. Measures of awareness of condition (Assessment Scale of the Psychosocial Impact of the Diagnosis of Dementia), cognitive function (Mini-Mental State Examination), mood state (Cornell Scale for Depression in Dementia), and functionality (Pfeffer Functional Activities Questionnaire) were applied to 264 people with mild to moderate AD and their caregivers. Hypotheses were tested statistically using SEM approach. Three competing models were compared. RESULTS: The first model, in which the influence of mood state and cognitive function on awareness was mediated by functionality, showed a very good fit to the data and a medium effect size. The competing models, in which the mediating variables were mood state and cognitive function, respectively, only showed poor model fit. CONCLUSION: Our model supports the notion that the relationship between different factors and awareness in AD is mediated by functionality and not by depressive mood state or cognitive level. The proposed direct and indirect effects on awareness are discussed, as well as the missing direct influence of mood state on awareness. The understanding of awareness in dementia is crucial and our model gives one possible explanation of its underlying structure in AD.

Self- and Other-Evaluation in Alzheimer's Disease.

BACKGROUND: Impaired awareness of ability is common in dementia and has important clinical implications. Evidence from different clinical groups has shown that awareness can vary according to whether evaluation refers to self or other performance. OBJECTIVE: The present study aimed to investigate awareness for self- and other-performance in Alzheimer's disease (AD) patients, exploring if results vary according to cognitive domain of the tasks. It was hypothesized that, particularly for memory tasks, AD patients would be inaccurate in relation to self-but not other-performance. METHODS: Twenty-two mild to moderate AD patients and twenty-two healthy older adults participated. Two tasks, with reaction time and working memory tasks, were carried out, and each had a success and a failure condition. Participants were asked to estimate their own performance, as well as the performance of another person they observed. Awareness of performance was measured comparing participant estimations of performance with actual performance. RESULTS: For both the reaction time and working memory tasks, results indicate that participants from both groups overestimated the performance in the failure condition and underestimated the performance in the success condition. They tended to overestimate more the performance of the other person compared to themselves. Additionally, for the working memory task, AD patients tended to overestimate more performances compared to controls. CONCLUSION: Findings suggest that the AD and control groups present the same pattern, with attribution of better performance to another person. For the AD group, the pattern of response was different for memory tasks, which may suggest domain-specific limited awareness.

The Seven Selves of Dementia.

The self is a complex and multifaceted phenomenon, encompassing a variety of cognitive processes and psychosocial influences. Considering this, there is a multiplicity of "selves," the current review suggesting that seven fundamental self-processes can be identified that further our understanding of the experience of dementia. These include (1) an embodied self, manifest as corporeal awareness; (2) an agentic self, related to being an agent and influencing life circumstances; (3) an implicit self, linked to non-conscious self-processing; (4) a critical self, which defines the core of self-identity; (5) a surrogate self, based on third-person perspective information; (6) an extended self, including external objects or existences that are incorporated into the self; and, finally, (7) an emergent self, a property of the self-processes that give rise to the sense of a unified self. These are discussed in relation to self-awareness and their use in making sense of the experience of dementia.

The Petrified Self 10 Years After: Current Evidence for Mnemonic anosognosia.

Lack of awareness about disease, its symptoms and consequences, also termed anosognosia, is a common feature of Alzheimer's disease (AD). It has been hypothesized that memory disorder may be a key contributing factor to anosognosia, with people with AD not being able to update their personal information about performance and relying on older consolidated material about ability. This potentially outdated sense of self has been named, as a metaphor, the petrified self. In the current review, evidence from the past 10 years in relation to this concept is critically appraised. In particular, focus is given to empirical evidence produced on anterograde memory deficits about performance, the profile of autobiographical retrograde memory loss and the role of frontal lobes in anosognosia in AD. Finally, wider consequences of this metaphor for the understanding of selfhood in dementia are discussed.

Implicit Behavioral Change in Response to Cognitive Tasks in Alzheimer Disease.

BACKGROUND AND OBJECTIVE: Lack of awareness about impairments is commonly found in Alzheimer disease (AD), but recent evidence suggests that patients may respond to the experience of illness despite limited awareness. In this study, we explored whether implicit emotional responses to experiences of failure in cognitive tasks would result in longer-term change in behavior. METHODS: Twenty-two patients with AD were seen 1 week after a previous session in which they performed computer tasks that had been manipulated to be either too difficult (failure condition) or very easy (success condition) for them. At the second session, both types of tasks were set to have medium difficulty and were administered so that the participants decided how long to persist on each task. Task persistence was determined by relative time spent doing the tasks, considering that participants would be more likely to stop performing tasks in which they had experienced failure during the first session. RESULTS: Task persistence in the second session was not affected by performance in the first session. However, when participants' awareness of performance in the first session was taken into account, differences were found in persistence between tasks in the second session. During the second session, participants stopped performing tasks after a sequence of errors. There were no self-reported changes in motivation or enjoyment in response to task failure. CONCLUSIONS: These findings suggest that implicit learning of task valence may be compromised in AD, but that initial moments of awareness of performance may influence long-term adaptation in unaware patients.

The impact of dementia, depression and awareness on activities of daily living in a sample from a middle-income country.

OBJECTIVE: Previous studies have indicated that dementia and depression have a considerable impact on the functional capacity of older adults, also influencing awareness about ability. The purpose of the current study was to investigate the impact of dementia, depression and awareness on activities of daily living (ADL) in a sample from a middle-income country. METHODS: The current study explored impairments in basic, instrumental and advanced ADL using a factorial design comparing four groups: people with dementia and depression, people with dementia without depression, older adults with depression but no dementia and healthy older adults. For each type of ADL, self-report and informant report was contrasted in order to investigate the issue of lack of awareness in relation to ADL. RESULTS: Results indicate that dementia is associated with impairments in all types of ADL. Advanced ADL were also reduced in depressed participants. In addition, in the case of instrumental and basic ADL, informant report indicated less preserved abilities than participant self-report, particularly in people with dementia. CONCLUSIONS: The findings highlight the importance of developing interventions and compensatory strategies to prevent loss of ADL in dementia, also suggesting that early intervention in older adults with depression should focus on advanced ADL to prevent social isolation and withdrawal. Finally, the findings indicate that self-information about ADL may be compromised in dementia, so clinicians exploring disability should consider fully different aspects of ADL in this group. Copyright © 2017 John Wiley & Sons, Ltd.

The influence of current mood state, number of previous affective episodes and predominant polarity on insight in bipolar disorder.

BACKGROUND: Although many studies have explored the effect of current affective episodes on insight into bipolar disorder, the potential interaction between current mood state and previous affective episodes has not been consistently investigated. OBJECTIVE: To explore the influence of dominant polarity, number of previous affective episodes and current affective state on insight in bipolar disorder patients in euthymia or mania. METHODS: A total of 101 patients with bipolar disorder were recruited for the study, including 58 patients in euthymia (30 with no defined predominant polarity and 28 with manic predominant polarity) and 43 in mania (26 with no defined predominant polarity and 17 with manic predominant polarity). Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders. RESULTS: Bipolar disorder patients in mania had worse insight than those in euthymia, with no effect of dominant polarity. In addition, positive psychotic symptoms showed a significant effect on insight and its inclusion as a covariate eliminated differences related to mood state. Finally, the number of previous manic or depressive episodes did not correlate with insight level. CONCLUSIONS: Mania is a predictor of loss of insight into bipolar disorder. However, it is possible that its contribution is linked to the more frequent presence of psychotic symptoms in this state. Dominant polarity and number/type of previous affective episodes have a limited impact on insight.

Effect of unawareness on rehabilitation outcome in a randomised controlled trial of multicomponent intervention for patients with mild Alzheimer's disease.

Unawareness of deficit has been shown to affect the outcome of targeted cognitive intervention programmes applied to patients with Alzheimer' disease (AD), but the effects on multimodal therapeutic approaches have not yet been explored. This research investigated the efficacy of the Multi-Intervention Programme (MIP) approach on improving cognitive, functional, affective, and behavioural symptoms in people with mild AD. In addition, we examined whether the presence of unawareness influences the MIP outcomes. Sixty-one mild stage AD patients were randomly assigned to either an experimental group which carried out an MIP individually (48 sessions, 16 weeks duration), combining diverse cognitive tasks, training in daily life and recreational activities, or a waiting list group which did not receive any treatment for the same time period. The efficacy of MIP (vs. waiting list) was tested using various standardised neuropsychological, functional, and behavioural outcome measures. Planned analyses were carried out to determine the effect of unawareness versus awareness on such outcomes. The results showed that patients overall benefited from the MIP in terms of both cognitive and non-cognitive symptoms. AD patients with awareness of deficits showed positive effects on all outcome measures in comparison with the waiting list group, while AD patients with unawareness showed improvements in non-cognitive symptoms only. In conclusion, the presence of unawareness reduces the cognitive and functional effects of MIP in patients with mild AD.

The development of computerised success-failure manipulation paradigms for the experimental study of metacognition in neurological patients / Desenvolvimento de paradigmas computadorizados de manipulação de sucesso-fracasso para o estudo experimental da metacognição em pacientes neurológicos / Desarrollo de paradigmas computadorizados de manipulación de éxito-fracaso para el estudio experimental de la meta-cognición en pacientes neurológicos

Research into metacognitive abilities of clinical populations has indicated pervasive deficits in terms of monitoring of cognitive performance. Nevertheless, there are important methodological issues regarding the validity of these findings. In the current paper, we describe the development of novel experimental procedures to mitigate some of these limitations. Specifically, we report the creation of computerised tasks based on success-failure manipulation (SFM), which allow experimental control over the performance of participants. We discuss the theoretical implications of this new procedure and also results obtained so far with the tasks. Finally, we present future research directions stemming from the use of the tasks. (AU).

Pesquisas sobre habilidades metacognitivas em grupos clínicos indicaram uma série de déficits em termos de monitoramento de desempenho cognitivo. No entanto, existem importantes questões metodológicas que questionam a validade destes achados. Neste artigo, descrevemos o desenvolvimento de procedimentos experimentais novos para minorar algumas destas limitações. Especificamente, reportamos a criação de tarefas computadorizadas baseadas em manipulação de sucesso-fracasso, que permitem o controle experimental sobre o desempenho de participantes. Discutimos as implicações teóricas deste novo procedimento, bem como os resultados obtidos até então com estas tarefas. Finalmente, indicamos futuras direções de pesquisa partindo do uso destas tarefas.(AU).

Investigaciones sobre habilidades meta-cognitivas en grupos clínicos han indicado una serie de déficits en términos de monitoreo (o monitorización) de desempeño cognitivo. Sin embargo hay cuestiones metodológicas importantes que cuestionan la validez de estas descubiertas. En este artículo, describimos el desarrollo de procedimientos experimentales nuevos para aminorar algunas de esas limitaciones. Específicamente, reportamos la creación de tareas computadorizadas basadas en la manipulación de éxito-fracaso, que permiten el control experimental sobre el desempeño de participantes. Discutimos las implicaciones teóricas de este nuevo procedimiento, así como los resultados obtenidos hasta ahora con estas tareas. Finalmente, indicamos futuras direcciones de investigación partiendo de el uso de estas tareas. (AU)

The development of computerised success-failure manipulation paradigms for the experimental study of metacognition in neurological patients / Desenvolvimento de paradigmas computadorizados de manipulação de sucesso-fracasso para o estudo experimental da metacognição em pacientes neurológicos / Desarrollo de paradigmas computadorizados de manipulación de éxito-fracaso para el estudio experimental de la meta-cognición en pacientes neurológicos

Research into metacognitive abilities of clinical populations has indicated pervasive deficits in terms of monitoring of cognitive performance. Nevertheless, there are important methodological issues regarding the validity of these findings. In the current paper, we describe the development of novel experimental procedures to mitigate some of these limitations. Specifically, we report the creation of computerised tasks based on success-failure manipulation (SFM), which allow experimental control over the performance of participants. We discuss the theoretical implications of this new procedure and also results obtained so far with the tasks. Finally, we present future research directions stemming from the use of the tasks.

Pesquisas sobre habilidades metacognitivas em grupos clínicos indicaram uma série de déficits em termos de monitoramento de desempenho cognitivo. No entanto, existem importantes questões metodológicas que questionam a validade destes achados. Neste artigo, descrevemos o desenvolvimento de procedimentos experimentais novos para minorar algumas destas limitações. Especificamente, reportamos a criação de tarefas computadorizadas baseadas em manipulação de sucesso-fracasso, que permitem o controle experimental sobre o desempenho de participantes. Discutimos as implicações teóricas deste novo procedimento, bem como os resultados obtidos até então com estas tarefas. Finalmente, indicamos futuras direções de pesquisa partindo do uso destas tarefas.

Investigaciones sobre habilidades meta-cognitivas en grupos clínicos han indicado una serie de déficits en términos de monitoreo (o monitorización) de desempeño cognitivo. Sin embargo hay cuestiones metodológicas importantes que cuestionan la validez de estas descubiertas. En este artículo, describimos el desarrollo de procedimientos experimentales nuevos para aminorar algunas de esas limitaciones. Específicamente, reportamos la creación de tareas computadorizadas basadas en la manipulación de éxito-fracaso, que permiten el control experimental sobre el desempeño de participantes. Discutimos las implicaciones teóricas de este nuevo procedimiento, así como los resultados obtenidos hasta ahora con estas tareas. Finalmente, indicamos futuras direcciones de investigación partiendo de el uso de estas tareas.