Skip to main content Accessibility help
×
Home

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

  • Anna Fischer (a1), Marcia Cristina Nascimento Dourado (a2), Jerson Laks (a2), Jesus Landeira-Fernandez (a1), Robin G. Morris (a3) and Daniel C. Mograbi (a3)...

Abstract

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.

Copyright

Corresponding author

Correspondence should be addressed to: Anna Fischer, MSc, Department of Psychology, Rua Marquês de São Vicente, 225, Gávea, Rio de Janeiro, RJ, 22451-900, Brasil. Email: annafischer87@gmx.net.

References

Hide All
Aalten, P., Van Valen, E., Clare, L., Kenny, G. and Verhey, F. (2005). Awareness in dementia: a review of clinical correlates. Aging and Mental Health, 9, 414422. doi: 10.1080/13607860500143075.
Aalten, P., Van Valen, E., De Vugt, M. E., Lousberg, R., Jolles, J. and Verhey, F. R. J. (2006). Awareness and behavioral problems in dementia patients: a prospective study. International Psychogeriatrics, 18, 317. doi: 10.1017/S1041610205002772.
Alexopoulos, G. S., Abrams, R. C., Young, R. C. and Shamoian, C. A. (1988). Cornell scale for depression in Dementia. Biological Psychiatry, 23, 271284. doi: 10.1016/0006-3223(88)90038-8.
American Psychiatric Association, (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: American Psychiatric Association.
Arkin, S. and Mahendra, N. (2001). Insight in Alzheimer’s patients: results of a longitudinal study using three assessment methods. American Journal of Alzheimer’s Disease and Other Dementias, 16, 211224. doi: 10.1177/153331750101600401.
Barrett, P. (2007). Structural equation modelling: adjudging model fit. Personality and Individual Differences, 42, 815824. doi: 10.1016/j.paid.2006.09.018.
Baune, B. T., Miller, R., McAfoose, J., Johnson, M., Quirk, F. and Mitchell, D. (2010). The role of cognitive impairment in general functioning in major depression. Psychiatry Research, 176, 183189. doi: 10.1016/j.psychres.2008.12.001.
Bertolucci, P. H., Brucki, S. M., Campacci, S. R. and Juliano, Y. (1994). The Mini-Mental State Examination in a general population: impact of educational status. Arquivos de Neuropsiquiatria, 52, 17. doi: 10.1590/S0004-282X1994000100001.
Bertrand, E., Dourado, M. C. N., Laks, J., Morris, R. G., Landeira-Fernandez, J. and Mograbi, D. C. (2016). Mood-congruent recollection and anosognosia in Alzheimer’s disease. Cortex, 84, 5562. doi: 10.1016/j.cortex.2016.09.001.
Byrne, B. M. (1998). Structural Equation Modeling with Lisrel, Prelis, and Simplis: Basic Concepts, Applications, and Programming. Multivariate applications book series (2nd ed.). Mahwah: Routledge.
Cines, S. et al. (2015). Examining the pathways between self-awareness and well-being in mild-moderate Alzheimer’s Disease. The American Journal of Geriatric Psychiatry, 23, 12971306. doi: 10.1016/j.jagp.2015.05.005.
Clare, L. et al. (2012a). Longitudinal trajectories of awareness in early-stage dementia. Alzheimer Disease & Associated Disorders, 26, 140147. doi: 10.1097/WAD.0b013e31822c55c4.
Clare, L. et al. (2012b). 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. doi: 10.1002/gps.2705.
Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences (2nd ed.). United States of America: Lawrence Erlbaum Associates. doi: 10.1234/12345678.
Cummings, J. L., Ross, W., Absher, J., Gornbein, J. and Hadjiaghai, L. (1995). Depressive symptoms in Alzheimer disease: assessment and determinants. Alzheimer Disease and Associated Disorders, 9, 8793. doi: 10.1097/00002093-199509020-00005.
David, A. S. (2004). The clinical importance of insight: an overview. In: Amador, X. F. E. and David, A. S. E. (Eds.), Insight and Psychosis: Awareness of Illness in Schizophrenia and Related Disorders (pp. 359392). New York: Oxford University Press.
Derouesne, C., Thibault, S., Lagha-Pierucci, S., Baudouin-Madec, V., Ancri, D. and Lacomblez, L. (1999). Decreased awareness of cognitive deficits in patients with mild dementia of the Alzheimer type. International Journal of Geriatric Psychiatry, 14, 10191030. doi: 10.1002/(SICI)1099-1166(199912)14:12<1019:AID-GPS61>3.0.CO;2-F.
Dourado, M. C. N. N., Laks, J. and Mograbi, D. (2016). Functional status predicts awareness in late-onset but not in early-onset Alzheimer Disease. Journal of Geriatric Psychiatry and Neurology, 29, 313319. doi: 10.1177/0891988716640372.
Dourado, M. C. N. et al. (2014). Awareness of disease in dementia: factor structure of the assessment scale of psychosocial impact of the diagnosis of dementia. Journal of Alzheimer’s Disease, 41, 947956. doi: 10.3233/JAD-140183.
Ecklund-Johnson, E. and Torres, I. (2005). Unawareness of deficits in Alzheimer’s disease and other dementias: operational definitions and empirical findings. Neuropsychology Review, 15, 147166. doi: 10.1007/s11065-005-9026-7.
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189198.
Horning, S. M., Melrose, R. and Sultzer, D. (2014). Insight in Alzheimer’s disease and its relation to psychiatric and behavioral disturbances. International Journal of Geriatric Psychiatry, 29, 7784. doi: 10.1002/gps.3972.
Hu, L. T. and Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Structural Equation Modeling, 6, 155. doi: 10.1080/10705519909540118.
Jackson, D. L. (2003). Revisiting sample size and number of parameter estimates: some support for the N:q hypothesis. Structural Equation Modeling, 10, 128141. doi: 10.1207/S15328007SEM1001_6.
Lacerda, I. B., Santos, R. L., Neto, J. P. S. and Dourado, M. C. N. (2017). Factors related to different objects of awareness in Alzheimer disease. Alzheimer Disease and Associated Disorders, 31, 335342. doi: 10.1097/WAD.0000000000000210.
Lehrner, J. et al. (2014). Awareness of memory deficits in subjective cognitive decline, mild cognitive impairment, Alzheimer’s disease and Parkinson’s disease. International Psychogeriatrics, 27, 357366. doi: 10.1017/S1041610214002245.
Lopez, O. L., Becker, J. T., Somsak, D., Dew, M. A. and DeKosky, S. T. (1994). Awareness of cognitive deficits and anosognosia in probable Alzheimer’s disease. European Neurology, 34, 277282. doi: 10.1159/000117056.
MacCallum, R. C. and Austin, J. T. (2000). Applications of structural equation modeling in psychological research. Annual Review of Psychology, 51, 201236. doi: 10.1146/annurev.psych.51.1.201.
Maia, A. L. G. et al. (2006). Application of the Brazilian version of the CDR scale in samples of dementia patients. Arquivos de Neuropsiquiatria, 64, 485489. doi: 10.1590/S0004-282X2006000300025.
McDonald, R. P. and Ho, M. H. R. (2002). Principles and practice in reporting structural equation analyses. Psychological Methods, 7, 6482. doi: 10.1037//1082-989X.7.1.64.
Michon, A., Deweer, B., Pillon, B., Agid, Y. and Dubois, B. (1994). Relation of anosognosia to frontal lobe dysfunction in Alzheimer’s disease. Journal of Neurology, Neurosurgery and Psychiatry, 57, 805809. doi: 10.1136/jnnp.57.7.805.
Mograbi, D. C., Brown, R. G. and Morris, R. G. (2009). Anosognosia in Alzheimer’s disease - The petrified self. Consciousness and Cognition, 18, 9891003. doi: 10.1016/j.concog.2009.07.005.
Mograbi, D. C. et al. (2012). Unawareness of memory impairment in dementia: a population-based study. International Psychogeriatrics, 24, 931939. doi: 10.1017/S1041610211002730.
Mograbi, D. C. and Morris, R. G. (2014). On the relation among mood, apathy, and anosognosia in Alzheimer’s disease. Journal of the International Neuropsychological Society, 20, 27. doi: 10.1017/S1355617713001276.
Mograbi, D. C. and Morris, R. G. (2018). Anosognosia. Cortex, 103, 385386. doi: 10.1016/j.cortex.2018.04.001.
Mograbi, D. C. et al. (2018). The impact of dementia, depression and awareness on activities of daily living in a sample from a middle-income country. International Journal of Geriatric Psychiatry, 33, 807813. doi: 10.1002/gps.4765.
Mondragón, J.D., Maurits, N.M. and De Deyn, P.P. (2019). Functional Neural correlates of anosognosia in mild cognitive impairment and Alzheimer’s disease: a systematic review. Neuropsychology Review, 29, 139165. doi: 10.1007/s11065-019-09410-x.
Morris, R. G. and Hannesdottir, K. (2004). Loss of “awareness” in Alzheimer’s disease. In: Morris, R. G. and Becker, J. T. (Eds.), The Cognitive Neuropsychology of Alzheimer’s Disease (pp. 275296). Oxford: Oxford University Press.
Morris, R. G. and Mograbi, D. C. (2013). Anosognosia, autobiographical memory and self knowledge in Alzheimer’s disease. Cortex, 49, 15531565. doi: 10.1016/j.cortex.2012.09.006.
Ott, B. R., Lafleche, G., Whelihan, W. M., Buongiorno, G. W., Albert, M. S. and Fogel, B. S. (1996). Impaired awareness of deficits in Alzheimer disease. Alzheimer Disease and Associated Disorders, 10, 6876. doi: 10.1097/00002093-199601020-00003.
Patel, V. and Prince, M. (2001). Ageing and mental health in a developing country: who cares? Qualitative studies from Goa, India. Psychological Medicine, 31, 2938. doi: 10.1017/S0033291799003098.
Pfeffer, R. I., Kurosaki, T. T., Harrah, C. H., Chance, J. M. and Filos, S. (1982). Measurement of functional activities in older adults in the community. Journal of Gerontology, 37, 323329. doi: 10.1093/geronj/37.3.323.
Portugal, M. G. et al. (2012). Validation of Montgomery-Åsberg rating scale and Cornell scale for depression in dementia in Brazilian elderly patients. International Psychogeriatrics, 24, 12911298. doi: 10.1017/S1041610211002250.
Reed, B. R., Jagust, W. J. and Coulter, L. (1993). Anosognosia in Alzheimer’s disease: relationships to depression, cognitive function, and cerebral perfusion. Journal of Clinical and Experimental Neuropsychology, 15, 231244. doi: 10.1080/01688639308402560.
Rosen, H. J. (2011). Anosognosia in neurodegenerative disease Anosognosia in neurodegenerative disease Anosognosia in neurodegenerative disease. Neurocase, 17, 231241. doi: 10.1080/13554794.2010.522588.
Rosen, H. J. et al. (2010). Neuroanatomical correlates of cognitive self-appraisal in neurodegenerative disease. NeuroImage, 49, 33583364. doi: 10.1016/j.neuroimage.2009.11.041.
Spalletta, G., Girardi, P., Caltagirone, C. and Orfei, M. D. (2012). Anosognosia and neuropsychiatric symptoms and disorders in mild Alzheimer disease and mild cognitive impairment. Journal of Alzheimer’s Disease, 29, 761772. doi: 10.3233/JAD-2012-111886.
Starkstein, S. E. (2014). Anosognosia in Alzheimer’s disease: diagnosis, frequency, mechanism and clinical correlates. Cortex, 61, 6473. doi: 10.1016/j.cortex.2014.07.019.
Starkstein, S. E., Jorge, R., Mizrahi, R., Adrian, J. and Robinson, R. G. (2007). Insight and danger in Alzheimer’s disease. European Journal of Neurology, 14, 455460. doi: 10.1111/j.1468-1331.2007.01745.x.
Starkstein, S. E., Jorge, R., Mizrahi, R. and Robinson, R. G. (2006). A diagnostic formulation for anosognosia in Alzheimer’s disease. Journal of Neurology, Neurosurgery and Psychiatry, 77, 719725. doi: 10.1136/jnnp.2005.085373.
Starkstein, S. E., Sabe, L., Chemerinski, E., Jason, L. and Leiguarda, R. (1996). Two domains of anosognosia in Alzheimer’s disease. Journal of Neurology Neurosurgery and Psychiatry, 61, 485490. doi: 10.1136/jnnp.61.5.485.
Starkstein, S. E., Petracca, G., Chemerinski, E. and Kremer, J. (2001). Syndromic validity of apathy in Alzheimer’s disease. American Journal of Psychiatry, 158, 872877. doi:10.1176/appi.ajp.158.6.872.
Starkstein, S. E., Vázquez, S., Migliorelli, R., Tesón, A., Sabe, L. and Leiguarda, R. (1995). A single-photon emission computed tomographic study of anosognosia in Alzheimer’s disease. Archives of Neurology, 52, 415420. doi: 10.1001/archneur.1995.00540280105024.
Sunderaraman, P. and Cosentino, S. (2017). Integrating the constructs of anosognosia and metacognition: a review of recent findings in dementia. Current Neurology and Neuroscience Reports, 17, 27. doi: 10.1007/s11910-017-0734-1.
Tabachnick, B. G. and Fidell, L. S. G. (2007). Using Multivariate Statistics (5th ed.). New Jersey: Pearson Education. doi: 10.1037/022267.
Troisi, A., Pasini, A., Gori, G., Sorbi, T., Baroni, A. and Ciani, N. (1996). Clinical predictors of somatic and psychological symptoms of depression in Alzheimer’s disease. International Journal of Geriatric Psychiatry, 11, 2327. doi: 10.1002/(SICI)1099-1166(199601)11:1<23:AID-GPS264>3.0.CO;2-4.
Vasterling, J. J., Seltzer, B., Foss, J. W. and Vanderbrook, V. (1995). Unawareness of deficits in Alzheimer’s disease: domain-specific differences and disease correlates. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 8, 2632.
Verhey, F. R. J., Rozendaal, N., Ponds, R. W. H. M. and Jolles, J. (1993). Dementia, awareness and depression. International Journal of Geriatric Psychiatry, 8, 851856. doi: 10.1002/gps.930081008.
Verhülsdonk, S., Quack, R., Höft, B., Lange-Asschenfeldt, C. and Supprian, T. (2013). Anosognosia and depression in patients with Alzheimer’s dementia. Archives of Gerontology and Geriatrics, 57, 282287. doi: 10.1016/j.archger.2013.03.012.
Vogel, A., Boch Waldorff, F. and Waldemar, G. (2015). Longitudinal changes in awareness over 36 months in patients with mild Alzheimer’s disease. International Psychogeriatrics, 27, 95102. doi: 10.1017/S1041610214001562.
Wheaton, B., Muthen, B., Alwin, D. F. and Summers, G. (1977). Assessing reliability and stability in panel models. Sociological Methodology, 8, 84136. doi: 10.2307/270754.
Wilson, R. S. et al. (2015). Temporal course and pathologic basis of unawareness of memory loss in dementia. Neurology, 85, 984991. doi: 10.1212/WNL.0000000000001935.
Zanetti, O. et al. (1999). Insight in dementia: when does it occur? Evidence for a nonlinear relationship between insight and cognitive status. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 54, 100106. doi: 10.1093/geronb/54B.2.P100.

Keywords

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

  • Anna Fischer (a1), Marcia Cristina Nascimento Dourado (a2), Jerson Laks (a2), Jesus Landeira-Fernandez (a1), Robin G. Morris (a3) and Daniel C. Mograbi (a3)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed