Unawareness of cognitive deficit

(cognitive anosognosia) in probable

AD and control subjects
Anna M. Barrett, MD; Paul J. Eslinger, PhD; Noel H. Ballentine, MD; and Kenneth M. Heilman, MD

Abstract—Objective: To develop a quantitative method of assessing cognitive anosognosia in six cognitive and two
noncognitive domains. Methods: Control (n ⫽ 32) and probable Alzheimer disease (pAD) (n ⫽ 14) subjects self-estimated
memory, attention, generative behavior, naming, visuospatial skill, limb praxis, mood, and uncorrected vision, both before
and after these abilities were assessed. Based on this estimate and their performance the authors calculated an anosog-
nosia ratio (AR) by dividing the difference between estimated and actual performance by an estimated and actual
performance sum. With perfect awareness, AR ⫽ 0. Overestimating abilities would yield a positive AR (ⱕ1); underestima-
tion would yield a negative AR (ⱖ⫺1). Results: Relative to controls, pAD subjects demonstrated anosognosia. Pre-testing
(off-line), pAD subjects overestimated their visuospatial skill; post-testing (on-line), pAD subjects overestimated their
memory. Control subjects also made self-rating errors, underestimating their attention pre-testing and overestimating
limb praxis and vision post-testing. Conclusions: This anosognosia assessment method may allow more detailed examina-
tion of distorted self-awareness. These results suggest that screening for anosognosia in probable Alzheimer disease (pAD)
should include self-estimates of visuospatial function, and that, in pAD, it may be useful to assess anosognosia for amnesia
both before and after memory testing.
NEUROLOGY 2005;64:693–699

Cognitive anosognosia (hereafter, anosognosia, liter-
ally “no knowledge of disease”), or unawareness of
cognitive deficits, is common in probable Alzheimer
disease (pAD), and may predict which patients with
early memory impairment progress to dementia.1
Anosognosia may increase morbidity in pAD by de-
laying patient self-identification to healthcare pro-
viders,2 and by adversely affecting safety, medication
compliance, use of compensatory strategies, and
caregiver burden.3 It has been suggested to protect
patients’ psychological well-being,4 but research does
not uniformly support this contention.5
Anosognosia may occur more frequently in pAD
than other dementing disorders,6,7 and its prevalence
increases as pAD progresses.8-10 However, despite its
diagnostic and functional importance, methods for
assessing anosognosia are not widely used clinically.
Since cognitive anosognosia may also dissociate from
Additional material related to this article can be found on the Neurology
Web site. Go to www.neurology.org and scroll down the Table of Con-
tents for the February 22 issue to find the title link for this article.
anosognosia for behavioral deficits,11 suggesting it
may be domain-specific, it is unclear if domain-
specific assessment may be indicated in pAD. Thus,
in this study, we examined whether we could detect
differences in cognitive anosognosia between pAD
and control subjects by using a clinical screening
instrument as well as post-test assessment, compar-
ing subjects’ self-estimates to objective performance.
We also wished to learn which cognitive domains are
most strongly affected by anosognosia in pAD.
Methods. Subjects. We tested 14 subjects diagnosed with pAD
(5 women, 9 men, mean age 75.9 years, SD 9.68, mean education
15.1 years, SD 2.70) using National Institute of Neurological and
Communicative Disorders and Stroke (NINCDS) criteria,12 who
had no language impairment beyond naming abnormalities, had
mild to moderate impairment on the Mini-Mental State Examina-
tion (MMSE13: mean 20.5, SD 5.08, range 10 to 26), and on verbal
memory tests.14 No pAD subjects had a premorbid history of neu-
rologic or psychiatric disorders. Twelve pAD subjects were right-
handed and 2 were left-handed. Six pAD subjects (42.9%) were
taking cholinesterase inhibitors (three: 5.0 mg donepezil daily,
three: donepezil, dose unknown). Thirty-two aged control subjects
(20 women, 12 men, mean age 75.2 years, SD 5.84, mean educa-
tion 14.7 years, SD 2.39) also participated. The pAD and control

From the Departments of Neurology (Drs. Barrett and Eslinger) and Medicine (Dr. Ballentine), the Pennsylvania State University College of Medicine,
Hershey; and the Department of Neurology (Dr. Heilman), University of Florida College of Medicine, and the Neurology Service, Department of Veteran
Affairs Medical Center, Gainesville, FL.
Supported by the Alzheimer’s Disease and Related Disorders Association (PRG-99 –1702, A.M.B.) and the General Clinical Research Center of the Penn State
University College of Medicine (NIH/NCRR C06 RR016499 and M01 RR010732).
Dr. Barrett received medication/pharmacy fees from Pfizer/Eisai for a follow-up study based on these results, and has received three lecture honoraria
(Pfizer, Novartis, total amount ⬍$10,000).
Preliminary results presented in part to the International Neuropsychological Society and the American Academy of Neurology (published in abstract form:
JINS 2001;7:124; Neurology 2002;58[suppl 3]: A354).
Received April 5, 2004. Accepted in final form October 26, 2004.
Address correspondence and reprint requests to Dr. A.M. Barrett, Kessler Medical Rehabilitation Research and Education Corporation, 1199 Pleasant Valley
Way, West Orange, NJ 07052; e-mail: abarrett@kmrrec.org

Copyright © 2005 by AAN Enterprises, Inc. 693

Table Performance of probable Alzheimer disease (pAD) and control subjects on standardized neuropsychological tasks included in the
current study protocol
BNT (of 30) JLO (of 15)
pAD subjects, n ⫽ 14, 19.5 (5.43) 6.1 (6.21)
mean score (SD)
Mean age ⫽ 75.9 y,
SD ⫽ 9.68
Mean education ⫽
15.1 y, SD ⫽ 2.70
Controls, n ⫽ 32, mean 27.2 (2.40) 11.7 (2.28)
score (SD)
Mean age ⫽ 75.2 y,
SD ⫽ 5.84
Mean education ⫽
14.7 y, SD 2.39
Group difference p ⬍0.001 p ⫽ 0.005
(independent-samples
t-test, two-tailed)
Scores indicate mean items correct, except for GDS, in which scores indicate items endorsed consistent with depression.
BNT ⫽ Boston Naming Test, odd items only18; JLO ⫽ Judgment of Line Orientation, odd items, form H19; HVLT ⫽ Hopkins Verbal
Learning Test, immediate spontaneous recall14; FAST-R ⫽ Florida Apraxia Screening Test–Revised20; COWA ⫽ Controlled Oral Word
Association task17; GDS ⫽ Geriatric Depression Scale.21
subjects did not differ with respect to age or years of education
(independent samples t test with adjustment for unequal vari-
ance, both p ⬎ 0.8, NS). No controls had any neurologic or psychi-
atric history, or impairment on the MMSE (mean 29.0, SD 0.94,
range 28 to 30).
Procedure. Informed consent was obtained from all subjects
as well as from pAD subjects’ caregivers. Subjects were advised
that their thinking, memory, and other abilities would be tested.
Subjects were then asked to estimate their memory, attention,
generative behavior (ability to generate words and movements),
naming to confrontation, visuospatial skill, limb praxis, mood, and
uncorrected visual acuity (pre-test or “offline” ratings, not linked
directly to performance). Subjects performed self-assessments us-
ing Likert scales; they marked each of 10 vertical (23.5 cm) lines
centered on white paper to indicate their ability. Each line was
labeled for each domain. For example, for estimates of naming
ability, subjects were asked “how well they could name objects and
pictures,” and the vertical line they marked to indicate their abil-
ity was labeled “Naming is perfect” at the top and “Cannot name
at all” at the bottom. The top end of each line indicated best task
performance, and the bottom, inability to perform the task. A
standard protocol was developed for the examiners in this study,
explaining each domain with specific types of tasks, and subjects
were given practical hypothetical examples of good and poor
performance.
We then tested subjects on a protocol incorporating standard-
ized and common bedside tasks, including the cognitive domains
of memory (orientation from the MMSE,13 previous five presidents
recall, Hopkins Verbal Learning test immediate and delayed spon-
taneous recall14), attention (attention items from the Florida Men-
tal Status Exam,15 including a letter version of the Albert
cancellation16), generative behavior (Controlled Oral Word Associ-
ation test using three letter stimuli with arbitrary maximum score
of 36,17 rating of overall body kinesis, rated by our examiners
based on subjective observation of subjects’ spontaneous move-
ments from “very slow” to “normal/fast” on a 1 to 5 Likert scale15),
confrontation naming (Boston Naming Test, odd items only18),
visuospatial function (Judgment of Line Orientation [short ver-
sion: odd items, Form H],19 intersecting pentagon copy,13 Map
orientation task15), and limb praxis (Florida Apraxia Screening
Test–Revised, with norms available for poststroke, pAD, and
age-matched control subjects20). Mood was assessed with the
Geriatric Depression Scale.21 Vision without glasses (reading
standard near card) was included as a control measure (per-
694 NEUROLOGY 64 February (2 of 2) 2005
FAST-R COWA
HVLT (of 36) (of 30) (letters FAS) GDS (of 30)
9.8 (6.18) 17.8 (7.44) 19.2 (10.47) 5.9 (3.63)
25.3 (3.85) 22.7 (4.35) 30.2 (6.51) 2.6 (2.64)
p ⬍0.001 p ⫽ 0.008 p ⫽ 0.002 p ⫽ 0.001
centage scored as no. of letters named/total letters ⫻ 100).
Limb praxis data for one pAD subject were incorrectly collected
and not analyzed. Performance of all subjects on clinical instru-
ments in the protocol is summarized in the table.
For the post-testing (online, directly linked to preceding per-
formance) anosognosia assessment, subjects repeated all
domain-specific self-ratings. One pAD subject did not complete
post-testing visuospatial self-rating, due to examiner error, and
another subject was unable to understand the praxis testing
situation despite instruction, and so post-testing self-rating
was not analyzed. The behavior of pAD subjects during Likert
ratings suggested that they understood the concept of self-
rating cognitive domains.
We compared subject ratings to objective performance on neu-
ropsychological tests in each domain by using the following ratio
score:
Estimated ⫺ actual performance
Anosognosia ratio 共AR兲 ⫽
Estimated ⫹ actual performance
Estimated and actual performance were expressed as a per-
centage of best possible score. We used the estimated ⫹ actual
summary score in the denominator to adjust the estimated ⫺
actual difference to correct for overall task performance. We in-
cluded both estimated and actual scores in the denominator so
that an anosognosia ratio (AR) could be computed for tasks sub-
jects could not perform at all, for which overestimation errors are
very important.
The AR, as above, always falls between ⫺1 and 1, such that
with perfect awareness, estimated ⫽ actual performance, and the
AR ⫽ 0. With overestimation, estimated exceeds actual perfor-
mance and the AR is positive; with underestimation, actual per-
formance exceeds estimated performance, and the AR is negative.
Calculating the AR can thus identify underestimation errors, pre-
viously not widely included in anosognosia research. Underesti-
mating cognitive abilities may result in over-reporting memory
complaints, and may be a marker for depression.22
We examined subjects’ ability to estimate their own overall
awareness/self-judgment, pre- and post-testing (meta-judgment).
This self-rating was performed on the same kind of Likert scale as
previous self-ratings, and subjects marked the top of the scale to
indicate they were “completely aware” of their errors, and the
bottom of the scale if they were “not at all aware” of their errors.
When performing the meta-judgment rating (rating their own
awareness or unawareness), some subjects with pAD indicated
they were uncertain of what was being rated. If a standard expla-
nation including hypothetical examples of problems recognizing or
not recognizing poor performance did not resolve this uncertainty,
subjects were excluded.
Data analysis. We analyzed ARs across control and pAD
groups using multivariate analyses of variance (MANOVAs) calcu-
lated with SPSS 11.01. Between-subjects variables included group
(control, pAD) and sex, and within-subjects variables included
domain (memory, attention, generative behavior, confrontation
naming, visuospatial skill, limb praxis, mood, uncorrected vision)
and session (pre- vs post-testing). Identification of significant in-
teractions was followed by pairwise comparisons using a Bonfer-
roni correction. Where homogeneity of variance assumptions was
violated, we report p values after applying the appropriate correc-
tion. All p values reported are those appropriate for two-tailed
comparisons.
Meta-judgment pre- and post-testing ratings were percentage
scored 0 to 100%. We examined the correlation between this self-
rating and mean AR (over all domains, above), with Pearson’s r.
To further address domain-specific relations of anosognosia to cog-
nition, we correlated mean AR in pAD and control groups with
scores in each cognitive and noncognitive domain.
Results. Demographic variables and performance on cog-
nitive and noncognitive testing. There were no age differ-
ences across group or sex. Women in the study reported
fewer years of education than men (women mean 14.0
years, SD 2.05; men mean 15.6 years, SD 2.73; p ⫽ 0.019).
No correlations between age, education, and percent cor-
rect performance in any domain were observed with Pear-
son’s r, and so these were not included as secondary
variables in any further analyses.
Control subject MMSE scores exceeded those for pAD
subjects (p ⬍ 0.001). Controls outperformed pAD subjects
on the neuropsychological tests included in the protocol
(see the table). Subjects with pAD endorsed more Geriatric
Depression Scale items than controls (p ⫽ 0.001), although
only three pAD subjects and two controls scored in a range
(9 to 19) consistent with mild depression. No subjects en-
dorsed ⱖ20 items (severe depression).
Subjects with pAD also performed more poorly than
controls in each of the cognitive domains, even those
(memory, attention, generative behavior, visuospatial skill,
uncorrected vision) integrating portions of several stan-
dardized and bedside tasks, or using nonstandardized as-
sessment methods. Memory (pAD 31.4% correct, SD 17.15;
control 75.0%, SD 9.07; p ⬍ 0.001) and visuospatial testing
(pAD 51.6% correct, SD 28.73; control 83.5%, SD 9.43; p ⬍
0.001) was deficient in pAD subjects vs controls. Although
we had not specifically predicted attentional and genera-
tive behavior deficits in pAD subjects, because, as con-
trasted with early frontal-subcortical dementias,23
attention and initiation may be relatively normal in early
pAD, both the attentional (pAD 85.7% correct, SD 13.92;
control 96.95% correct, SD 3.82; p ⫽ 0.01) and generative
domains (pAD 56.6%, SD 26.38; controls 85.4%, SD 16.38;
p ⫽ 0.001) were impaired in the pAD subjects. The gener-
ative behavior domain score incorporated a word genera-
tion task,17 and thus poor performance in our pAD subjects
might have been related to an impoverished lexicon, or a
linguistic deficit in lexical retrieval, rather than a primary
generativity or persistence deficit. There was no group dif-
ference in vision assessment (p ⫽ 0.463, NS).
Overall sex differences were sought with independent-
samples t tests. The sexes performed comparably on all
domains (see table E-1 on the Neurology Web site at www.
neurology.org). Men endorsed more Geriatric Depression
Scale items (mean 4.9 items, SD 3.72) than women (mean
2.5 items, SD 2.52; p ⫽ 0.018, NS after correction for
multiple comparisons; four of five study subjects endorsing
9 to 12 Geriatric Depression Scale items were men).
Awareness of deficit. All subjects estimated their per-
formance at cognitive and noncognitive tasks, pre- and
post-testing (see Methods), and we calculated an AR, as
noted, by dividing an estimated ⫺ actual difference by the
estimated ⫹ actual sum.
We performed a MANOVA comparing subject ARs with
the following factors: group (control, pAD), sex, domain
(memory, attention, generative behavior, confrontation
naming, visuospatial skill, limb praxis, mood, uncorrected
vision), and session (pre- vs post-testing self-estimates),
and present results of pairwise follow-up comparisons with
appropriate correction.
Evidence supporting valid task performance by sub-
jects. Random self-ratings (e.g., due to unclear instruc-
tion), or variable ratings due to poor subject understanding
of task instructions (e.g., if they rated on non-task-related
criteria), might not demonstrate a main effect of domain;
however, such a main effect was observed (F ⫽ 0.611; p ⬍
0.001), suggesting that subjects rated their performance
differently for different tasks.
Evidence against group differences due to global impair-
ment or psychological denial. Subjects with pAD might
self-rate differently than normal subjects because of a
global deficit in cognitive performance. If this were the
case, we might have expected to observe a group difference
in self-rating, but no higher level interactions. Though a
main effect of group was observed (pAD mean AR 0.071,
SD 0.12; control mean AR 0.003, SD 0.08; p ⫽ 0.023), with
control ARs closer to zero (more accurate), we also identi-
fied a domain by session by group interaction (p ⫽ 0.005,
domain by group interaction p ⫽ 0.092, NS). It is difficult
to explain how global impairment in self-rating from pAD
would produce different patterns of group differences be-
fore vs after testing.
Psychological denial might produce a main effect of do-
main. As a need for ego defense may only be triggered by
abnormal performance, denial may be present for im-
paired, but not unimpaired domains. As noted above (de-
mographic variables and performance on cognitive and
noncognitive testing), vision testing was comparable be-
tween pAD and control subjects. We repeated the
MANOVA, excluding vision self-ratings. A main effect of do-
main (p ⬍ 0.001) and a domain by session by group interac-
tion (p ⫽ 0.002) persisted when only impaired domains were
included in the analysis. This does not support psychological
denial as the sole explanation for these effects.
Psychological denial might specifically affect post-
testing self-ratings in pAD subjects, or in both pAD sub-
jects and aged controls: a need for ego defense might
increase immediately after demonstrating impairment to
an examiner. Thus one may expect to observe a main effect
of session, or a session by group interaction, but these were
not present (session p ⫽ 0.883, NS; session by group p ⫽
0.544, NS).
Evidence for domain-specific cognitive anosognosia in
pAD. We explored the domain by session by group inter-
action by examining pre-testing (offline) self-ratings and
post-testing (online) self-ratings separately. Anosognosia
in pAD may be especially noticeable immediately post-
February (2 of 2) 2005 NEUROLOGY 64 695
Figure 1. Self-estimated cognitive abilities in probable
Alzheimer disease (pAD) subjects (hatched bars) and con-
trols (white bars) in the current experiment, expressed as
anosognosia ratios pre-testing (offline). Cognitive and non-
cognitive domains for which performance was self-rated
are noted on the x-axis. Vis-spatial ⫽ visuospatial skill;
Gen behavior ⫽ generative behavior. Anosognosia ratios
(minimum value ⫺1.0 to maximum value ⫹1.0, see text)
are noted on the y-axis. A single asterisk denotes a domain
with significant pAD vs control self-ratings. A dual aster-
isk denotes a domain for which controls’ self-ratings were
significantly inaccurate compared with perfect self-
estimation performance. Lines on graph bars indicate
standard error.
testing, when normal awareness of poor performance may
be optimal. A pre-testing group difference was noted for
self-rated visuospatial abilities (pAD mean AR ⫽ 0.256, SD
0.370; control mean AR ⫽ 0.030, SD 0.157; p ⫽ 0.001), but
self-rated memory only tended to differ after a Bonferroni
correction (pAD mean AR ⫽ 0.217, SD 0.458; control mean
AR ⫽ ⫺0.006, SD 0.154; p ⫽ 0.009; corrected p ⫽ 0.072).
No other pre-testing group self-rating differences reached
significance (see table E-1 at www.neurology.org and fig-
ure 1). In contrast, when subjects rated post-testing (on-
line), a group difference was noted in self-rated memory
(pAD overestimated relative to controls, mean AR ⫽ 0.184,
SD 0.278; control mean AR 0.087, SD 0.137; p ⫽ 0.005). No
other post-testing group differences reached significance
(p ⱖ 0.45 after a Bonferroni correction, NS, figure 2).
Sex differences. We had no specific hypotheses regard-
ing sex differences in self-ratings. Although there was no
main effect of sex on self-rating, we observed marginal
interactions between session and sex (p ⫽ 0.015) and do-
main and sex (p ⫽ 0.019). We included small subject num-
bers, and women were underrepresented relative to the
pAD population; thus our results must be regarded as pre-
liminary. Self-rating sex differences by domain are re-
viewed in table E-1.
When pre–post self-estimates were compared in women
and men separately, though men demonstrated no pre–
post differences, women improved in visuospatial (p ⫽
0.001) and attentional domains (p ⫽ 0.002; all other pre–
post comparisons after Bonferroni correction p ⱖ 0.3, NS).
Thus, observed session effects or interactions in the study
may have disproportionately represented women’s
mis-estimates.
Regarding the domain by sex interaction, there was a
sex difference in self-rated attention (p ⫽ 0.003), both com-
bined over sessions and for the post-testing session alone.
696 NEUROLOGY 64 February (2 of 2) 2005
Figure 2. Self-estimated cognitive abilities in probable
Alzheimer disease (pAD) subjects (hatched bars) and con-
trols (white bars) in the current experiment, expressed as
anosognosia ratios post-testing (online). Cognitive and
noncognitive domains for which performance was self-
rated are noted on the x-axis. Vis-spatial ⫽ visuospatial
skill; Gen behavior ⫽ generative behavior. Anosognosia
ratios (minimum value ⫺1.0 to maximum value ⫹1.0, see
text) are noted on the y-axis. A single asterisk denotes a
domain with significant pAD vs control self-ratings. A
dual asterisk denotes a domain for which controls’ self-
ratings were significantly inaccurate compared with per-
fect self-estimation performance. Lines on graph bars
indicate standard error.
This appeared to derive from men underestimating atten-
tional performance over both sessions (mean AR ⫽ ⫺0.122,
SD 0.116, differs from perfect estimation, one-sample t test
p ⬍ 0.001; women without attention underestimation,
mean AR ⫺0.021, SD 0.098, p ⫽ 0.31, NS). No other
domain-specific sex differences reached significance (p ⱖ
0.9 after Bonferroni correction for all, NS).
Overall awareness (meta-judgment). Subjects judged
how accurately they self-rated on a Likert scale pre- and
post-testing. This overall pre- and post-test meta-
judgment, expressed as a percentage as noted (Methods),
was correlated with a mean AR over all domains using
Pearson’s r. We posited a relationship between domain-
specific awareness and overall awareness in controls, but
not pAD subjects. In the pre-testing condition, though no
correlation for the group as a whole was observed (r ⫽
0.081, p ⫽ 0.59, NS), this may have reflected performance
of the pAD group (r ⫽ 0.011, p ⫽ 0.970, NS), rather than
controls (r ⫽ 0.514, p ⫽ 0.003). Control subjects who self-
estimated their abilities more optimistically (higher ARs)
also had higher awareness self-estimates. Post-testing,
there was again no correlation between overall rating and
mean AR for the group as a whole (r ⫽ ⫺0.178, p ⫽ 0.236),
but again this appeared to reflect pAD subjects (r ⫽
⫺0.410, p ⫽ 0.146) and not controls, in whom higher over-
all awareness (better meta-judgment) correlated with
higher (online) ARs (r ⫽ 0.617, p ⬍ 0.001).
Self-rating errors made by aged controls. Some func-
tions may be more accessible to conscious monitoring than
others. Thus, even normal controls may make self-rating
errors. In order to assess controls’ rating accuracy, we com-
pared pre- and post-testing ARs in each domain tested to
zero using one-sample Student t tests with Bonferroni cor-
rection. Pre-testing, controls underestimated their atten-
tion (mean AR ⫽ ⫺0.10, SD 0.170; p ⫽ 0.002). Post-testing,
controls overestimated both limb praxis performance
(mean AR ⫽ 0.087, SD 0.137, p ⫽ 0.001) and near card
vision performance (mean AR ⫽ 0.138, SD 0.228, p ⫽
0.002). The remaining comparisons indicated no signifi-
cant performance under- or overestimations by aged con-
trols. See figures 1 and 2.
A domain by session interaction over the subject group
as a whole (p ⬍ 0.001), with self-rating accuracy improved
post-testing in the visuospatial (paired t test, p ⬍ 0.001)
and attentional domains (paired t test p ⫽ 0.003), ap-
peared to disproportionately reflect control subject self-
rating improvements (pAD subjects after Bonferroni
correction, all pre–post comparisons p ⱖ 0.18, NS; controls
visuospatial, p ⫽ 0.001, attentional domain, p ⫽ 0.01, cor-
rected p ⫽ 0.08; all others NS).
Relationship of anosognosia to cognitive and noncogni-
tive test performance. Previous studies suggested that
anosognosia is not protective against depression,5 and oc-
curs more commonly in more severe dementia.8-10 In non-
demented aged people, underestimation of memory may be
linked to depression.22 To determine if our data supported
these contentions, and to investigate other associations of
focal cognitive deficit with anosognosia, we correlated
mean ARs (both pre- and post-testing) for all subjects with
performance in each domain.
Anosognosia did seem related to dementia severity, as it
correlated with memory performance in pAD subjects (r ⫽
0.755, p ⫽ 0.002). There was no correlation between self-
reported depression symptoms and mean AR (r ⫽ ⫺0.105,
p ⫽ 0.721, NS), providing further support for the postulate
that anosognosia is not protective against depression, and
therefore less likely to be caused by psychological denial.
Anosognosia increased with increasing anomia (r ⫽ 0.571,
p ⫽ 0.033), visuospatial dysfunction (r ⫽ 0.767, p ⫽ 0.001),
limb apraxia (r ⫽ 0.557, p ⫽ 0.048), and attention deficit
(r ⫽ 0.567, p ⫽ 0.035) in pAD subjects, but not with near
card vision impairment (r ⫽ 0.264, p ⫽ 0.362). Correlation
between mean AR and generative behavior deficit did not
reach significance (r ⫽ 0.515, p ⫽ 0.060).
In controls, there was a negative depression–anosogno-
sia correlation (r ⫽ ⫺0.563, p ⫽ 0.001, see figure 3), sup-
porting an association between underestimation errors and
reported depression symptoms. No associations between
other deficits and anosognosia were identified for controls
(p ⱖ 0.5 for all, NS).
Discussion. We demonstrated that pAD subjects
demonstrated anosognosia (unawareness of cognitive
deficit) for visuospatial and memory disability.
Anosognosia for amnesia reached significance when
pAD subjects self-rated after memory testing, but
not pre-testing. Although it is unclear why pAD sub-
jects had anosognosia, the domain-specific deficit we
observed, which may have different features when
pre- and post-testing self-ratings are elicited, ap-
pears inconsistent with a global deficit in judgment.
The deficit observed could not be completely ex-
plained by psychological denial. A need for ego de-
fense by denial should not be triggered when
subjects perform normally. Thus, psychologically me-
Figure 3. Relationship between self-reported depression
symptoms and awareness of deficit (controls). Mean
anosognosia ratio (including both pre- and post-testing
data) is plotted on the x-axis for 32 controls: positive val-
ues ⫽ overestimation errors, negative values ⫽ underesti-
mation errors (see text). Geriatric Depression Scale score
(of 30 possible points21) is plotted on the y-axis with mean
trend line. More reported GDS symptoms of depression are
associated with underestimation of self-rated abilities (p ⫽
0.001, see text).
diated denial would be expected to occur in impaired
but not in unimpaired domains. We observed defi-
cient self-monitoring in visuospatial and memory do-
mains, but not other impaired domains such as
naming, limb praxis, attention, or generative
behaviors.
A number of previous studies investigated aware-
ness of deficits in pAD, but in many of these reports
the conclusions were limited by exclusive use of cat-
egorical methodology, and scoring by caregiver re-
port. The current method of assessment generates
quantitative data (the AR), and may permit investi-
gators to examine smaller intersubject differences in
anosognosia, as well as more detailed relationships
between anosognosia and cognition. Varying care-
giver ability to report/recognize cognitive symptoms
does not confound our results, and, unlike some pre-
vious studies, we included patients who either did
not have primary caregivers or whose primary care-
givers were not available to take part in the study.
This assessment method has two other benefits.
We tested anosognosia both pre-testing, or offline,
and postperformance (online assessment). The
former ratings may be closely related to knowledge
synthesis or self-semantics (abstract knowledge
about oneself). The latter ability to track task perfor-
mance, however, may be related more closely to
arousal/vigilance and monitoring abilities.24 We ob-
served that offline (pre-testing), pAD subjects overes-
timated visuospatial abilities compared to controls.
Further studies are needed replicating this finding
in order to assess its potential clinical significance,
as anosognosia for visuospatial deficits is rarely clin-
ically assessed, but may have diagnostic or prognos-
tic correlates.
Previous researchers25 reported that in pAD post-
testing memory self-estimates were more accurate
than pre-testing judgments, but we did not observe
February (2 of 2) 2005 NEUROLOGY 64 697
this in our subjects. In fact, anosognosia for amnesia
was present post-testing (online), but pre-testing (of-
fline) a group difference did not reach significance
(perhaps because small subject numbers limited the
power of our observation). Further research is
needed investigating whether assessing anosognosia
for amnesia in pAD is more sensitive online or off-
line. Whether a deficit in continuous self-monitoring,
rather than in a static representation of self-abilities
(self-knowledge), may underlie anosognosia for am-
nesia in pAD also deserves investigation.
This method of anosognosia assessment allows de-
tection of both overestimation and underestimation
errors. Although not as relevant in pAD, underesti-
mation errors may co-occur with depression in nor-
mal aging (the “worried well”22), and may help to
detect depressive pseudodementia. The relationship
of underestimation errors to future risk of developing
dementia, however, is not known. We observed an
association in controls, but not pAD subjects, be-
tween reported depression symptoms and underesti-
mation errors (see figure 3). Additionally, controls
underestimated attentional ability pre-testing, per-
haps rating against a high self-standard. Controls
made overestimation errors, however, immediately
after observing (online) their own limb praxis perfor-
mance and their uncorrected vision testing. Older
persons may overestimate performance for psycho-
logical reasons or because of age-related cognitive
impairment.26 Some cognitive functions, however,
may not be as amenable to ongoing monitoring as
others. Functions associated with the dorsal visual
stream or “where” network, vital to coordinating vi-
sual–motor activities, may not be consciously acces-
sible. Comparison with younger controls would be
necessary to determine if the overestimation errors
we observed may be age-related.
We identified interactions between female/male
performance differences and testing session (pre- vs
post-testing judgments), as well as domain tested.
The female:male subject ratio was higher in the con-
trol group than in the pAD group in this study.
Women were underrepresented in our pAD group
relative to the pAD population. Our subject groups
are small and this study preliminary. Thus, we feel
that we cannot make conclusions either about sex
differences in cognitive anosognosia in the larger
population of pAD subjects or in aged subjects in
general. We cannot eliminate the possibility, how-
ever, that differences in female:male ratio between
pAD and control groups contributed to our results.
Further study of large groups of control and pAD
subjects, female and male, is needed in order to es-
tablish whether apparently small effects of sex dif-
ferences may actually play a significant role in our
reported pAD/control differences.
We assessed overall self-awareness, or subjects’
ability to make meta-judgments of their self-ratings.
These higher-level judgments appeared to be associ-
ated with mean self-ratings in controls, but not in
698 NEUROLOGY 64 February (2 of 2) 2005
pAD subjects, and it is likely that pAD subjects sim-
ply cannot perform self-reflective judgments above
one level of abstraction.
Several issues pertaining to validity will need to
be addressed in further research using this assess-
ment method. It is important to understand how this
method of assessment correlates with caregiver as-
sessments, although aged people may not always de-
tect cognitive impairment in their partners.27
Correlation with observed impaired performance on
functional tasks, and expert rating of cognitive im-
pairment by clinicians, are also important to ascer-
tain in assessment of validity.
Unlike previously used questionnaires and other
instruments for assessing anosognosia, this method
makes it possible to assess pAD patients without
caregivers, and may be useful for examining small
differences in awareness over pAD treatment groups,
or within subjects over time. Based on these results,
we recommend that future research on anosognosia
in pAD include self-rating visuospatial function. Fur-
ther research evaluating online vs offline awareness
of amnesia is also important in order to determine
whether assessing awareness after memory testing
may improve sensitivity of clinical detection of
anosognosia.
Acknowledgment
The authors thank study participants; J. Kenneth Brubaker, MD,
and the medical administrative staff, Elizabethtown Masonic
Homes, for recruiting control subjects; David Mauger, PhD, for
assistance with data analysis; Kerri Hansell, Susan Bachman,
Keri Muniz, Christopher Spofford, and Lynn Leidig, for data col-
lection and preparing data summaries; Vanessa Madeira, for cod-
ing praxis data; and Gregory P. Crucian, for theoretical
suggestions based on preliminary results. The authors thank two
anonymous reviewers for their suggestions on a preliminary ver-
sion of this manuscript.
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