Journal of Gerontology: PSYCHOLOGICAL SCIENCES Copyright 1999 by The Gerontological Society ofAmerica

1999, Vol. 54B, No. 2, P100-P106

Insight in Dementia: When Does It Occur?

Evidence for a Nonlinear Relationship
Between Insight and Cognitive Status
Orazio Zanetti,1 Barbara Vallotti,2 Giovanni B. Frisoni,1 Cristina Geroldi,1
Angelo Bianchetti,1 Patrizio Pasqualetti,3 and Marco Trabucchi4

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'Alzheimer Disease Unit IRCCS, "S. Giovanni di Dio," "S. Cuore Fatebenefratelli" Hospital, Brescia, Italy.
institute of Geriatrics and Gerontology, University of Florence, Florence, Italy.
3
AFaR-CRCCS, Neurological Division, "S. Giovanni Calibita" Hospital, Isola Tiberina, Rome, Italy.
4
Geriatric Research Group, Brescia, Italy.

Lack of insight or impaired awareness of deficits in patients with dementia is a relatively neglected area of study. The aim of
this study was to evaluate insight in a group of demented patients with two assessment scales and to assess their relationship
with the cognitive level of disease severity. Sixty-nine consecutive patients affected by Alzheimer's disease (n = 37) and vas-
cular dementia (n = 32) with a wide range of cognitive impairment (MMSE = 17.0 ± 6.4) were recruited. Insight was evalu-
ated with the Guidelines for the Rating of Awareness Deficits (GRAD)—specifically targeted to memory deficits—and the
Clinical Insight Rating scale (CIR), evaluating a broader spectrum of insight (reason for the visit, cognitive deficits, func-
tional deficits, and perception of the progression of the disease). In the whole sample, GRAD and CIR were significantly as-
sociated with MMSE (Spearman's coefficient = .57, p < .001; and r = -.55, p < .001) and with Clinical Dementia Rating
scale (-.57, p < .001; and r = .57, p < .001) respectively. The shape of the relationship of MMSE with CIR and GRAD scales
was assessed with spline smoothers suggesting that the relationship follows a tritinear pattern and is similar for both scales.
Insight was uniformly high for MMSE scores > 24, showed a linear decrease between MMSE scores of 23 and 13, and was
uniformly low for MMSE scores < 12. The tritinear model of the association between insight and cognitive status reflects
more closely the observable decline of insight and can provide estimates of when the decline of insight begins and ends.

L ACK of insight or impaired awareness of deficits in persons

-/ with dementia is a relatively neglected area of study
(McDaniel et al., 1995). Most of the current research on dementia
focuses primarily on biological issues, like etiology or pathogene-
sis, and more recently on behavioral and therapeutical aspects.
Little attention has been paid to the phenomenology of the de-
mented individual's subjective experience, or serf-perception of
illness (Bahro, Silber, & Sunderland, 1995). It is therefore not sur-
prising that insight is a concept lacking precise operational defini-
tion (Mullen, Howard, David, & Levy, 1996). The terms insight
or awareness of deficits have been used interchangeably, referring
to lack of knowledge or recognition of one's deficits (McGlynn &
Schacter, 1989). Anosognosia similarly means lack of knowledge
of disease, but has been used more often to describe a failure to
acknowledge a particular deficit, usually the motor (McGlynn &
Schacter, 1989; Babinski, 1914). Babinski first used the term in
1914 to describe an absence of awareness in a hemiplegic patient
who had suffered a stroke (Prigatano & Schacter, 1991).
However, the term is now used more generally to include all neu-
ropsychological and neurological deficits (Cotrell, 1997). Some
authors use the terms anosognosia and unawareness interchange-
ably (McGlynn & Schacter, 1989). Recently, David (1990),
analyzing the association between insight and psychosis, has pro-
moted a complex concept of insight as an amalgam of three con-
structs: the ability to identify certain mental events as pathologi-
cal, the recognition by the individual that he or she has a mental
illness, and the degree of compliance with treatment Insight was
also defined as the ability to judge the presence and the severity of
dementia (DeBettignies, Mahurina, & Pirozzolo, 1990) and, more
recently, as the awareness of and attitudes toward one's mental
symptoms (Mullen et al., 1996). A practical definition considers
insight as the ability to judge both the presence (symptoms) and
the severity (functional impairment) of illness (Babinski, 1914;
Critchley, 1953; DeBettignies et al., 1990; Fisher, 1989; Gainotti,
1972; Mangone et al., 1991). Foley (1992) defines awareness or
insight as "the capacity to discern the true nature of the situation,
or as applied to dementia, the recognition of the fact, degree, and
implications of one's own illness."
The mechanism of insight in demented patients is still un-
known (Mullen et al., 1996). Attempts to define the causative
mechanisms of insight have shifted from the initial focus on the
biological explanation to a psychodynamic interpretation; re-
cently, interest has shifted back to awareness deficits as a neu-
ropathological problem (Prigatano & Schacter, 1991). Several
studies showed that patients with Alzheimer's disease (AD) and
poor insight had significantly more severe deficits on a frontal
lobe-related neuropsychological test (Auchus, Goldstein, Green,
& Green, 1994; Lopez, Becher, Sumsak, Dew, & Dekosky,
1994; Mangone et al., 1991; Michon, Deweer, Pillon, Agid, &
Dubois, 1994; Ott et al., 1996; Starkstein, Federoff, Price,
Leiguarda, & Robinson, 1992). Other studies did not replicate
these findings, suggesting the main involvement of right hemi-
sphere dysfunction (Migliorelli et al., 1995; Reed, Jagust, &
Coulter, 1993). Usually, impaired insight due to frontal lobe dys-
function is termed confabulation whereas impaired insight after
right hemisphere dysfunction is termed anosognosia. Both con-

P100
 INSIGHT IN
tabulation and anosognosia may contribute to the impaired in-
sight in AD (Mangone et al., 1991).
Schacter and Prigatano (1991) warn that unawareness is not a
unitary entity but probably consists of various forms or types.
Recently, Starkstein, Sabe, Chemerinski, Jason, and Leiguarda
(1996) have suggested that insight may be a complex function:
Unawareness of cognitive deficits and unawareness of behavioral
problems may constitute independent phenomena in Alzheimer's
disease, the former related to the severity of intellectual impairment
and the latter probably associated with the disinhibition syndrome.
The level of insight has been shown to be significantly associated
with the severity of dementia. A number of studies, in fact, confirm
the generally accepted belief that patients with Alzheimer's disease
experience a progressive loss of insight as the severity of dementia
increases (Mangone et al., 1991; McDaniel et al., 1995; Starkstein
et al., 1996). However, as insight is not an "all-or-nothing" phe-
nomenon, little is known about the shape and the kind of relation-
ship between insight and degree of cognitive impairment The aim
of this study was to evaluate the level of insight in a group of de-
mented patients with two assessment scales, one (Verhey,
Rozentaal, Ponds, & Jolles, 1993) specifically targeted to memory
deficits, the other (Ott & Fogel, 1992) evaluating a broader spec-
trum of insight, and to examine their relationship with die level of
cognitive impairment
METHODS
Sixty-nine patients affected by Alzheimer's disease (AD) and
vascular dementia (VD) according to DSM-PV criteria (American
Psychiatric Association, 1994) were consecutively recruited at the
Alzheimer Dementia Unit of Sacro-Cuore Fatebenefratelli Institute
of Brescia, Italy. Thirty-seven patients were affected by AD proba-
ble or possible according to N1NCDS-ADRDA criteria (McKhann
et al., 1984) and 32 were affected by VD probable or possible ac-
cording to NINDS-AIREN criteria (Roman et al., 1993).
Laboratory and neuroimaging evaluation (e.g., computed tomo-
graphic scan, thyroid hormones, folate and vitamin B12 levels,
syphilis serology) were conducted to rule out specific neurology,
neoplastic, infectious and metabolic causes of dementia. Patients
with delirium, aphasia, or comprehension deficits that might com-
promise the administration of insight rating scales were excluded.
Patients with history of severe head injury, alcoholism, major psy-
chiatric illness, and epilepsy were also excluded from the study.
Patients underwent a multidimensional assessment of cogni-
tive, physical, and social health; for the present study, the follow-
ing variables were assessed:
1. Sociodemographic variables (gender, age, education) were
recorded.
2. Cognitive status was measured with the Mini-Mental State
Examination (MMSE) (Folstein, Folstein, & McHugh, 1975).
3. Clinical Dementia Rating scale (CDR; Hughes, Berg,
Danziger, Coben, & Martin, 1982) was used to provide a score
ranging from 0 to 3 (0 = normal, 0.5 = questionable dementia, 1
= mild, 2 = moderate, 3 = severe dementia), which is based on
combined ratings of psychic, social, and functional aspects of the
patient by a clinician and give a global dementia severity level.
4. Functional status: patients underwent indirect assessment of
their functional competence. The indirect assessment included
six basic and eight instrumental activities of daily living (BADL
DEMENTIA P101
and I A D L ) , assessed with the Katz index (Katz, Ford,
Moskowitz, & Jackson, 1963) and the Lawton and Brody (1969)
scale, respectively. Dependency was defined as the inability to
carry out activities of daily living without regular help of another
person. Information was collected from the primary caregiver.
5. Behavioral disturbances were evaluated with the
Neuropsychiatric Inventory Scale (NPI; Cummings et al., 1994).
6. Depressive symptoms were assessed using the Geriatric
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Depression Scale (GDS; Yesavage et al., 1983).
7. Assessment of insight was done by means of two assessment
instruments: the Guidelines for the Rating of Awareness Deficits
(GRAD; Verhey et al., 1993; Verhey, Ponds, Rozendaal, & Jolles,
1995) and the Clinical Insight Rating scale (CIR; Ott and Fogel,
1992; Ott et al., 19%). Both scales are in a semistructured inter-
view format and are preceded by an interview with the patient's
primary caregiver during which the reason of visit, duration of ill-
ness, rate of progression of cognitive deficits, functional impair-
ment (BADL and IADL), and behavioral disturbances (NPI) are
investigated. Before insight assessment, the clinician evaluates the
patient's global disease severity (MMSE and CDR). Insight scores
are derived by the comparison of the patient's responses and the
clinical information gathered with the help of the caregiver.
The GRAD is composed of the following four questions: (a)
"Please tell me about the problems you are here for." (b) When
the patient has other complaints, not directly related to demen-
tia: "Do you have other complaints?" (c) When the patient has
no spontaneous complaints about his or her cognitive functions:
"How is your memory functioning? Do you think you have a
poor memory?" And (d) when the patient denies deficits of
memory or other cognitive functions: "So, there are no memory
problems at all? Is everything going all right for you?" After
these questions the complaints are discussed more extensively in
an open interview, in which the clinician tries to get an impres-
sion of the degree and the nature of cognitive symptoms.
Scoring is made directly after the interview. Awareness is judged
to be intact (score = 4) when the cognitive problems were men-
tioned spontaneously by the patient in reply to the opening ques-
tion and when history of the caregiver corresponds to that of the
patient. When the patient commented spontaneously about his
or her memory in reply to the opening question, but there were
apparent discrepancies between the patient's and caregiver's
anamnesis, awareness was scored as mildly impaired (score =
3). Awareness was scored as 2 (severely impaired) when the pa-
tient uttered no complaints in response to the opening question,
and when there were clear discrepancies between the patient's
and the caregiver's history. When the patient denied any explicit
awareness, insight was scored as 1 (absent).
The CIR is a scale that assesses the patient's awareness re-
garding the following aspects: (a) the reason for the visit to see
doctor; (b) his or her cognitive deficits; (c) his or her functional
deficits; and (d) his or her perception of the progression of the
disease. Each item is ranked from 0 to 2, yielding a total rating
that ranges from 0 (insight fully preserved) to 8 (insight totally
absent). Ratings on the insight scales were carried out by a clin-
ician (B.V.) based on her judgement of the patient's degree of
awareness on each item after an interview with the patient and
the primary caregiver.
The Italian version of the two scales has been previously vali-
dated in a group of 20 demented subjects, 10 affected by AD and
P102 ZANETTIETAL.

10 affected by VD (Vallotti, Zanetti, Bianchetti, & Trabucchi,
1997). The interrater intra-class correlation coefficient was .73
for the GRAD and .80 for the CTR. The test-retest coefficient was
.73 for GRAD and .89 forCTR.Both scales proved to be reliable
for the rating of insight.
8. A subgroup of 36 participating patients underwent an ex-
tensive neuropsychological assessment (for details of the tests,
see Binetti et al., 1993). Short-term memory was assessed by
auditory-verbal forward digit span and visuospatial span
compared to conventional linear models by usual methods (test-
ing the significance of the increase of fitting, i.e., the decrease of
deviance, by chi-square test). In the present study, we compared
spline smoothers with piecewise linear models. Different piece-
wise linear models were also compared. The optimal point of
discontinuity in piecewise linear models was chosen on die basis
of the best-fit, that is, the lowest deviance. In this analysis the
level of statistical significance was set at/? = .05.

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RESULTS
(Corsi's block-tapping test). Episodic memory was tested with
Table 1 shows the clinical and sociodemographic character-
the logical memory test (recall of a short story) and with the 20-
istics of the sample. No statistical differences were found be-
minutes delayed recall of the Rey complex figure. A 30-item
tween the AD and the VD patients, except for age (p < .05). In
version of the Boston naming test provided a measure of nam-
particular, no significant differences were found for the GRAD
ing and semantic memory. The copy of the Rey figure was used
and the CIR in the two groups. The great majority of patients
to assess visuospatial abilities. The Raven's colored progressive
(94%) were in the mild to moderate stage of dementia severity.
matrices test, the attentional matrices test, and the token test
were also included in the neuropsychogical battery. "Executive" The goal of thefirststep of the analysis was to confirm the as-
function was evaluated by the Wisconsin Card-Sorting Test sociation of insight with disease severity and with psychological
(WCST), and PEL verbal fluency test. The WCST is a problem- variables. This preliminary data analysis was performed assuming
solving task that measures the ability to identify abstract cate- a linear association between insight and cognitive impairment.
gories and shift cognitive set. A shortened version of WCST In the whole sample, the level of insight as measured by the
with 64 cards was adopted, computing an index of perseveration GRAD was significantly associated with dementia severity as
(number of errors/number of perseveration). The verbal fluency measured by the MMSE (Spearman's coefficient = .51, p <
for letters (PEL) was assessed by recording the number of words .001) and the CDR (Spearman's coefficient = -.57, p < .001).
produced in the course of one minute for each letter. The CIR scores also showed a good correlation with disease
severity (r = -.55, p < .001 and r = .57, p < .001, respectively).
No relationship was found between insight and the presence of
Statistical Analysis
depressive symptoms with both the GRAD (r = .15, p = .24)
Descriptive and correlation analysis was carried out with
and the CIR (r = -.22, p = .09) scales.
SPSS Software (version 5.0). The relationships among variables
After Bonferroni correction for multiple comparisons, both
were assessed with Pearson's r and the Spearman correlation co-
the GRAD and CIR scales showed a significant correlation (p <
efficient. The associations between neuropsychological tests and
.005) with tests measuring planning and abstract thinking
insight as measured with GRAD and CIR have been corrected
(Wisconsin Card-Sorting Test), and language comprehension
for Bonferroni multiple (n = 10) comparisons test, and the criti-
(Token test). Moreover, the CIR was significantly associated
cal p value for statistical significance was set at p = .005. The
with attentional matrix score (r = -.40) and constructional
following statistical analysis was carried out with S+ (version 4)
apraxia (Rey'sfigure;r = .41), and the GRAD was significantly
for Windows. The relationship of insight scales with cognition
associated with the Boston Naming Test score (r = .50).
was explored with cubic spline smoothers (Hastie & Tibshirani,
1990). A smoother is a tool for summarizing the trend of a de-
pendent variable (in the present case, insight scales) as a func-
tion of one or more predictors (here cognitive performance). Table 1. Sociodemographic and Clinical Characteristics
Smoothers produce an estimate of the trend that is less variable of Alzheimer's Disease (AD) and Vascular Dementia (VD) Patients
than the dependent variable itself (Hastie & Tibshirani, 1990). In AD (n = 37) VD (n = 32) Total (n = 69)
the case of spline smoothers, points called knots divide the Female 28 (75.7) 24 (75.0) 52 (75.4)
"real" shape of the association, and a number of cubic functions Age (years) 74.8 ± 8.5 78.8 ±6.1 76.7 ±7.8
are fitted between the knots. The algorithm identifies where the Education (years) 6.2 + 3.9 5.2 ± 2.7 5.7 ± 3.4
knots that allow maximization of the fitting lie. The higher the Disease duration (months) 33.4 ± 22.5 30.3 ± 16.9 32.0 ± 2.0
number of knots, the higher the fitting of the resulting function, Mini-Mental State Examination 16.1 + 6.2 18.0 ±6.7 17.0 ±6.4
but the more uneven its shape. The lower the number of knots, BADL (functions lost) 1.2 ± 1.7 1.7 ± 1.6 1.4 ±1.7
the lower the fitting of the function but the smoother its shape. IADL (functions lost) 3.9 ± 2.7 4.7 ± 2.5 4.3 ± 2.6
The exploration process of the relationship between two vari- Neuropsychiatric Inventory Scale 23.1 ±22.8 30.4 ± 22.3 26.5 ± 22.7
ables consists of finding out the number of knots that gives, at Geriatric Depression Scalea 8.1 ±5.2 10.1 ±5.7 9.1 ±5.5
GRAD b 2.7 ±1.1 2.5 ± 1.1 2.6 ± 1.1
the same time, the highest possible fitting with the smoothest
CIRC 3.1 ±2.6 2.9 ± 2.4 3.0 ±2.5
function. Similarly to the usual generalized linear models, spline Clinical Dementia Rating Scale
smoothers allow one to test the effect of covariates on the rela- 1 24 (64.9) 17 (53.2) 41 (59.4)
tionship between the dependent and the independent variables. 2 11 (29.7) 13 (40.5) 24 (34.8)
The effect of diagnosis (AD or VD) on the shape of the rela- 3 2 (5.4) 2 (6.3) 4 (5.8)
tionship between insight scales and MMSE was assessed in a
Note: Data are means + and SD or n (%).
multivariate generalized additive model with a spline smoother of Performed in 30 AD and 28 VD patients.
MMSE, diagnosis (coded as a dichotomous variable), and their b
Guidelines for the Rating of Awareness Deficits.
c
interaction as independent variables. Spline smoothers can be Clinical Insight Rating Scale.
 INSIGHT IN DEMENTIA
However, as shown in Figures 1A and IB, the association be-
tween insight and cognitive status was not linear. An exploratory
analysis with spline smoothers showed that the relationship was
roughly trilinear, with no association between insight and cogni-
tion at both ends of the MMSE distribution, and a linear associa-
tion in between.
The GRAD scale scores distribution into only 4 levels pre-
vented any further analysis assuming a normal distribution of
the response variable. However, the CIR scale scores distribu-
tion, albeit into 9 levels, could be better approximated to a nor-
mal distribution. Therefore, the following analysis was carried
out on the CIR scale only.
A multivariate generalized additive model with the spline
smoother of MMSE and diagnosis (AD or VD) as the indepen-
dent variable indicated that the relationship was not different in
the two subgroups (difference of deviances = 1.5; df= I; p =
.23), indicating mat the intercept of the smoother was not dif-
ferent in the two groups. The addition in the model of the inter-
action between the spline smoother and MMSE also failed to
reach significance (difference of deviances = 2.2; df = 2; p =
.33), indicating that the shape of the smoother was not different
in the two groups. These observations supported the following
joint analyses of the two groups. The fitting of piecewise linear
models of MMSE on CIR was tested and models of increasing
complexity and descriptiveness of the data were compared.
The cutoff points of 12 and 24 for the MMSE were chosen by
comparing two-segment piecewise linear models with cutoffs
ranging from 9 to 15 and from 21 to 27, and by choosing the
cutoff associated with the lowest deviance (Figure 2). Deviance
ranged between 249.3 and 268.5 for MMSE scores between 9
and 15, with the lowest deviance (247.3) being observed for the
MMSE score of 12. Deviance ranged between 256.6 and 249.6
Alzheimer's
Vascular
All
8
CO
CO
a: \
\ •~
\ Vascular
10 15 20 25
Mini Mental State Examination
Figure 1. Relationship of Clinical Insight Rating scale (A) and Guidelines for the Rating of Awareness Deficits (B) with MMSE score in Alzheimer's and vascular
dementia patients. Note: The lines denote a smoother function (cubic spline, 4 knots) in all patients and in the two subgroups. Error bars of the smoother function for
all patients are also shown.
P103
for MMSE scores between 21 and 27, with the lowest deviance
(242.7) being observed for the MMSE score of 24.
Table 2 shows fittings of linear and spline smoothers. The
first model assumes a linear relationship between MMSE and
CIR scales. The second and third models assume that the left-
most andrightmostportions of the MMSE distribution (MMSE
<12 and MMSE >24, respectively) are flat and that the remain-
ing portion of the MMSE distribution has a linear relationship
with the CIR scale. Both the second and third models had a sig-
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nificantly lower deviance (i.e., better fit) than the first one. The
fourth model was built to compound the second and third ones,
and assumes that the relationship between MMSE and CIR
scales is flat at both ends of the MMSE distribution and is lin-
ear in between. Table 2 shows that this trilinear model has a sig-
nificantly better fit than both previous models. The last two to
be tested were generalized additive models with a spline
smoother. Generalized additive models often have a better fit
than linear models because no a priori assumption regarding
the shape of the relationship is made. Indeed, thefifthmodel, in
which a spline is fitted, has lower deviance than the trilinear
model, which, however, was not significant. This indicates that
the latter does not perform significantly worse than the best
possible model.
DISCUSSION
This study demonstrates that the association of disease insight
with cognitive functions follows a nonlinear pattern and MMSE
cutoff points can be identified between preserved, moderately
impaired and absent insight. The trilinear model describes the as-
sociation between insight and cognition as proceeding through
three periods: an initial period of stability before detectable de-
cline, a period of decline, and a final period of stability during
B
Alzheimer's
- All
30 10 15 20 25 30
Mini Mental State Examination
P104 ZANETTIETAL.

0.415
r square reduced awareness of deficits (DeBettignies et al., 1990; Feher,
Mahurin, Inbody, Crook, & Pirozzolo, 1991; Reed et al., 1993).
However, the main results of our study suggest that the a pri-
ori assumption of a linear association between insight and cog-
nition, or disease severity, cannot be the correct one, and sug-
gest that this association follows a trilinear pattern. The trilinear
model reflects more closely the observable decline of insight.
The second advantage is that the trilinear model can provide es-
timates of when the decline of insight begins and ends.

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0.355
11 12 13
Insight as measured with CIR is nearly preserved in the ini-
MMSE tial stages of disease; afterwards, between MMSE scores of 24
and 12, insight shows a linear progressive decay, followed by a
plateau, at MMSE scores of 12 and less, of severe impaired in-
r square sight. Interestingly, the cutoff associated with preserved insight
0.42
is set at MMSE score of 24 or more. A score of 23 or less—a
cutoff score evolving from research findings recommended in
the original article—has generally been accepted as indicating
the presence of cognitive impairment (Tombaugh & Mclntyre,
1992). However, it should be emphasized that, although per-
sons with MMSE scores between 24 and 12 are impaired, these
demented patients preserve some degree of disease insight. On
the other hand, CIR scores between 0 and 1 can be associated
with good insight, CIR scores between 2 and 4 with relatively
23 24 25
MMSE
impaired insight, and CIR scores higher than 4 are associated
with poor insight.
Figure 2. Identification of the two cutoff scores with the best piecewise linear Thesefindingscould have important implications for research
fitting of Mini Mental State Examination score on Clinical Insight Rating scores. with cognitively impaired subjects and the emerging problem
Note: Higher r squares indicate better model fitting.
of patient autonomy and decisional capacity. The criteria for in-
formed consent for medical research that could be beneficial
Table 2. Comparisons of Models Describing the Association Between for the patient imply a demanding test of capacity because they
Mini-Mental State Examination and Clinical Insight Rating Scale envision a fully informed and reasoned decision by the subject.
Scores in 69 Dementia Patients
However, many demented subjects do not have the capacity to
Model Shape Deviance r2 df P satisfy this heroic standard (Bonnie, 1996), and investigators are
left without a realistic standard of decisional capacity that can be
1. Linear Nv 251.4 .3986 67 used in cases involving subjects with cognitive impairment.
From a clinical perspective, knowledge of the point at which
AfiQA decline of insight may begin would allow health care profes-
-.0002 sionals and patients' families to plan for the future course of a
3. Linear ^V 244.5 .4151 67-i patient's disease (Brooks et al., 1993; Mullen et al., 1996).
kooi Our data confirm that the level of depressive symptoms and
4. Linear ^ \ 230.6 .4483 lack of insight occur in AD and VD with comparable frequency.
Y-n.s. Depression did not contribute independently to disease insight,
5. Additive ~~"\ 228.9 64 J confirming previous findings by Cummings, Ross, Absher,
Gornbein, and Hadjiaghai (1995) and Ott and colleagues (1996),
who suggested that depression in AD is unrelated to patient self-
awareness of illness. Our data confirm previousfindingsof Verey
which there is no further detectable decline. Our data confirm and colleagues (1995), who evaluated 48 AD patients and 48 VD
previous findings by Brooks, Kraemer, Tanke, and Yesavage patients, suggesting that depression, insight, and personality do
(1993) who suggested that the trilinear model for analyzing lon- not favor etiology of AD over that of VD. On the contrary, com-
gitudinal data in a sample of Alzheimer's is superior to the com- paring AD, VD, and controls, Wagner, Spangenberg, Bachman,
monly used linear model that includes the flawed assumption & O'Connel (1997) suggest that, independent of dementia sever-
that decline is uniform throughout the course of the disease. ity, unawareness of cognitive deficits is disease specific. Wagner
Following a simple correlation analysis and considering an a and colleagues suggest that there is a disproportional degree of
priori linear association between insight and cognition led to a unawareness associated with AD when compared with VD.
confirmation of previous research findings (Mangone et al., The main result of our study—the nonlinear pattern of the
1991; Lopez et al., 1994; Ott et al., 1996). Decreased level of association between disease insight and cognitive functions—
insight was significantly associated with severity of dementia as might explain some of the discordant findings of previous re-
measured by MMSE and CDR, irrespective of its etiology search carried out with correlation analysis assuming an a priori
(Verhey et al., 1995). Some studies, however, have failed to linear association.
show a significant relationship between dementia severity and Meanwhile, some limitations of the instruments for insight
 INSIGHT IN
assessment used in the present study need to be addressed.
Although the GRAD appears to be a measure of awareness of
memory, given the restricted range of scores, the observed pat-
tern of relationship with MMSE might be related to ceiling and
floor effects; moreover, the restricted range of scores makes this
tool not sensitive enough to detect small changes. On the other
hand, the CIR, although less prone to ceiling or floor effects, is
a general measure of awareness because responses to questions
regarding a number of different areas (reason for the visit, cog-
nitive and functional deficits, and perception of the progression
of the disease) are collapsed into a single score.
Schacter and Prigatano (1991) warn that unawareness is not a
unitary entity but probably consists of various forms or types.
Loss of awareness for various skills may decline at different rates
and may be associated with loss of specific cognitive abilities.
This is consistent with the finding that individuals are often aware
of some deficits but not others; moreover, patients may be aware
of the existence of a deficit but unaware of the consequences of
the deficit (Feher et al., 1991; Schacter & Prigatano, 1991). Along
the same line, Kotler-Cope and Camp (1995) suggest that aware-
ness of behavioral problems may be relatively preserved com-
pared with awareness of cognitive problems. Recently Starkstein
and colleagues (1996) demonstrated the presence of two domains
of insight, one related to cognitive deficits and the other related to
behavioral problems. Starskstein and colleagues (1996), along
with Vasterling, Seltzer, Foss, and Vanderbrook (1995), suggest
that insight may be a complex multifaceted function. The different
pattern of association found in our study, which was obtained as-
suming a linear association between insight and cognitive impair-
ment, supports the view that insight might not be a unitary entity
(Schacter, 1991; Schacter & Prigatano, 1991). In fact, poor insight
was associated (in both scales) with frontal lobe dysfunction, but
the GRAD also showed association with naming and semantic
memory and the CIR with visuospatial abilities (right parietal dys-
function), which suggests the presence of different domains of in-
sight for memory and insight related to other aspects of disease
such as functional impairment, or awareness of disease progres-
sion. Other authors, however, demonstrated that patients with AD
have impaired awareness of both memory and functional deficits
and suggested that there may be a close relationship between
these two aspects. Ott and colleagues (1996) suggest the presence
of a common cognitive defect of self-monitoring that accounts for
the reduced-awareness phenomenon.
Further studies into the relationship between insight and local-
izing neuropsychological measures with functional brain imag-
ing are needed in order to better identify the nature of neu-
ropathology involved in reduced insight in demented patients
(Ott et al., 1996). Certainly we still need "reliable information
concerning the degree and the quality of awareness in various pa-
tient groups" (McGlynn & Schacter, 1989). As suggested by
Neundorfer (1997), more attention should be paid to the variabil-
ity in awareness within individuals and within diagnostic groups.
In conclusion, our data suggest that the shape of the associa-
tion between insight and cognitive impairment is not a linear
one but, on the contrary, follows a trilinear pattern with pre-
served insight in the mild stages of the dementia, followed by a
progressive loss of insight, and finally by a plateau of severe in-
sight impairment in the latest stages of dementia. Our findings
suggest the presence of MMSE cutoff points that can be used in
association with insight scales, in order to differentiate full in-
DEMENTIA P105
sight from declining to absent insight. The trilinear model of
the association between insight and cognitive status reflects
more closely the observable decline of insight and can provide
estimates of when the decline of insight begins and ends. These
results could be useful in developing instruments devised to as-
sess patient autonomy.
ACKNOWLEDGMENTS
Address correspondence to Orazio Zanetti, MD, Alzheimer Disease Unit
Downloaded from https://academic.oup.com/psychsocgerontology/article/54B/2/P100/709965 by guest on 22 August 2022
I.R.C.C.S. "S. Giovanni di Dio," "S. Cuore - Fatebenefratelli" Hospital, Via
Pilastroni, 4, 25123 Brescia, Italy. E-mail: ozanetti@master.cci.unibs.it
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Received February 6, 1998
Accepted October 27, 1998