RESEARCH ARTICLE

Anosognosia for memory deficit in amnestic mild

cognitive impairment and Alzheimers disease
Filomena Galeone 1, Stella Pappalardo 1, Sergio Chief 2, Alessandro Iavarone 3,4 and Sergio Carlomagno 5
1

Dipartimento Assistenza Anziani, Napoli, Italy

Dipartimento di Medicina Clinica e Sperimentale, Seconda Universita` di Napoli, Napoli, Italy
3
UO Neurologia, Ospedale CTO, Napoli, Italy
4
Dipartimento di Scienze Relazionali, Universita` Federico II, Napoli, Italy
5
Dipartimento di Psicologia, Universita` di Trieste, Trieste, Italy
Correspondence to: S. Carlomagno, MD, E-mail: scarlomagno@units.it
2

Objective: to investigate patterns of anosognosia for memory decit in subjects with amnestic mild
cognitive impairment (MCI) and Alzheimers disease (AD).
Methods: the study involved twenty-ve subjects with MCI, 15 with mild AD and 21 normal controls
(NC). Subjective rating of memory functioning was assessed with a six-items questionnaire that was
administered before and after memory testing; an informant version from caregivers gave a discrepancy
score (SRD). In the Objective Judgement (OJ) task, aiming to evaluate memory-monitoring abilities,
subjects were requested three times to predict their memory performance in recalling words from a list of
ten. Then they had to recall the words. Prediction accuracy was computed by subtracting the predicted
performance from the actual performance.
Results: MCI and AD showed reduced awareness of memory difculties at the SRD and did not change
their rating of these difculties after memory testing. At the OJ task, MCI and AD consistently
overestimated their memory performances as compared with NC. The SRD and OJ measures were
not correlated with some patients being impaired on only one measure. Only the OJ measure was
signicantly related to executive functioning.
Conclusions: AD and MCI subjects show unawareness for memory decit and signicant memorymonitoring disorder. This conrms that anosognosia is an important symptom of MCI. Similarities of
patterns of impaired awareness between AD and MCI supports the view of a continuum of the
anosognosia phenomenon in MCI and AD. Copyright # 2010 John Wiley & Sons, Ltd.
Key words: anosognosia; memory; neuropsychology
History: Received 3 December 2009; Accepted 3 June 2010; Published online 23 December 2010 in Wiley Online Library
(wileyonlinelibrary.com).
DOI: 10.1002/gps.2583

Introduction
Mild cognitive impairment (MCI) is a condition
affecting older adults who, in spite of being free from
overt dementia, exhibit signicant decline in memory,
and often in other domains of cognition. This
condition has been shown conferring signicant risk
for Alzheimers disease (AD) (Petersen et al., 2001).
Unawareness for memory decit may be considered as
an important clinical symptom of MCI, being present
in a proportion of subjects approaching the level seen
Copyright # 2010 John Wiley & Sons, Ltd.

in AD (Duke et al., 2002; Vogel et al., 2004, 2005; Ries

et al., 2007). Like in the AD subjects, awareness for
memory decit in MCI can be quite variable, ranging
from full insight about memory difculties to severe
anosognosia, and factors underpinning such variability
are poorly dened (Vogel et al., 2005, 2006). Because of
these similarities, it has been proposed that anosognosia in MCI subjects is an early symptom of their
memory decit predicting greater conversion to AD
(Tabert et al., 2002). However, not all the studies agree
with these positions (Kalbe et al., 2005).
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F. Galeone et al.

696

Unawareness for memory decit in AD and MCI has

been usually evaluated by means of clinical rating scales
(Derouesne et al., 1999; Zanetti et al., 1999) or
discrepancy scores that reect the difference between
patients subjective report of their own memory
functioning and caregivers report (Tabert et al.,
2002; Kalbe et al., 2005; Vogel et al., 2005; Cosentino
et al., 2007). However, the subjectivity of these
measures limits their sensitivity to probe the extent
of disordered awareness overtime and to point out
components of such a decit (Cosentino et al., 2007;
Williamson et al., 2010). Indeed, unawareness for
memory decit in AD, and perhaps in MCI as well,
may have complex presentation with individuals
differing as a function of their neuro-cognitive, social
and cultural variables (Clare, 2004). Thus, it has been
suggested that methods for evaluating components of
awareness, such as memory monitoring tasks, may
provide objective measure(s) of disordered awareness
and this, in turn, may advance understanding of the
symptom. Accordingly, some authors have used objective
measure(s) of memory-monitoring abilities by modifying
meta-cognitive paradigms where participants were asked
to make predictions about their performance in a
particular memory task. Unawareness of decit was
evaluated in terms of prediction accuracy, i.e., predicted
performance
actual performance. A range of prediction
accuracy values were found in mild to moderate AD
patients, indicating that measures of memory monitoring
may offer relevant cues for describing components of the
disordered awareness (Moulin et al., 2000; Ansell and
Bucks, 2006; Cosentino et al., 2007; Gallo et al., 2007;
Souchay, 2007). Interestingly, methods based on subjective rating discrepancy (SRD) scores are assumed to
draw upon accumulated knowledge concerning success
or failure over a range of personal experiences.
Conversely, methods based on prediction accuracy
require the subjects to evaluate task difculty and to
adjust prediction of performance to the particular task.
Thus, the two measures probably tap into different
components of anosognosia. Ansell and Bucks (2006)
devised a simple memory-monitoring paradigm for
describing unawareness for memory decit in subjects
with early AD. In their study, patients were asked to
predict how many words they would recall from a list
of 10. Then, they had to recall the words. This was
repeated three times allowing the experimenters to
evaluate not only accuracy of prediction but also possible
changes following exposure to memory testing. Furthermore, before and after the task, patients were given a
subjective rating questionnaire allowing the experimenters to estimate explicit awareness of global memory
functioning and changes after memory testing.
Copyright # 2010 John Wiley & Sons, Ltd.

In the present study we investigated unawareness for

memory decit in MCI and AD subjects by examining:
(i) their discrepancy scores obtained at structured
patient-informant interviews; and (ii) their performance on a memory-monitoring task. It was predicted
that, if anosognosia for memory decit in MCI shares
similarities with that of AD, the two groups would
show the same pattern of impairment both on the
evaluation of memory-monitoring abilities and on the
self-rating of global memory functioning.

Methods
Participants

The study involved 25 subjects (8 men and 17 women)

with amnestic MCI, seen at the Department of Geriatrics
of ASL Napoli 1. All of them met on a criterion for
diagnosis of amnestic MCI according to the MCI
working group of the European Consortium on AD
(Portet et al., 2006). Subjects with multiple domains or
single non-memory domain MCI were not included.
Fifteen participants (4 men and 11 women) with
probable mild AD according to the NINCDS-ADRDA
criteria (McKhann et al., 1984) were also enrolled. All
patients underwent a complete clinical and instrumental evaluation according to Italian Neurological
Society guidelines for the diagnosis of dementia
(Musicco et al., 2004). Twenty-one healthy older
subjects (9 men and 12 women) served as normal
controls (NC). Exclusion criteria for all groups were
severe head trauma or prior neurological disorders,
major medical disease, alcohol or drug abuse and
major psychiatric disorder.
Table 1 reports demographic data of the three groups
of subjects, and their corrected mini-mental state
examination (MMSE) score (Folstein et al., 1975;
Measso et al., 1993). A signicant effect of group was
found on MMSE scores (F 20.2; df 2; p < 0.0001).
Table 1 Demographic data and MMSE mean score of the three groups of
participants

Age
Years of education
MMSE

NC (N 21)

MCI
(N 25)

AD
(N 15)

SD

SD

SD

73.6
9.7
26.3

6.3
5.0
2.4

74.9
6.9
22.4

5.4
4.3
3.0

76.3
9.9
27.1

8.2
5.4
1.5

MCI, mild cognitive impairment; AD, Alzheimers disease; NC, healthy

older adults; MMSE, mini-mental state examination.

Int J Geriatr Psychiatry 2011; 26: 695701.

Anosognosia in amnestic MCI and AD

Patients with AD performed worse than both MCI and

NC ( p < 0.0001; Scheffe post-hoc test). No difference
was found between MCI and NC. The three groups did
not differ for age and education. All persons gave
informed consent to the study, which was carried on
in agreement with the declaration of Helsinki and
approved by the local ethics committee.
Procedures

General neuropsychological assessment was performed

by means of procedures devised by Italian Interdisciplinary Network on AD (ITINAD, Perri et al.,
2007), including administration of the memory complaints assessment, MAC-Q (Crook et al., 1992). The
patients also received the Frontal Assessment Battery
(FAB, Dubois et al., 2001).
The subjective rating of memory functioning was
obtained by a six-items questionnaire derived from
Ansell and Bucks (2006). The subjects had to rate, for
every item, the presence of daily life memory failures on a
Likert scale ranging from 0 never to 4 always
(maximum score 24). Caregivers completed an informant version of the scale in order to obtain SRD score.
An objective judgment (OJ) task to assess memorymonitoring abilities was performed using three lists of 10
not-semantically related words, comparable for length.
These stimuli were individually printed on white cards in
2 cm high, black letters.
According to Ansell and Bucks (2006), at pre-trial,
subjects were required to complete the subjective
rating questionnaire concerning their memory functions. Then, the participants were informed that a 10-

697

word list would be presented and asked to predict how

many words they would be able to recall (pre-study
prediction). After, they studied the 10 words of the list,
one at time for 2 s each, reading each word aloud. Finally,
subjects were asked to predict again their performance
(post-study prediction) and then recalled the words of
the list. After the recall, the subject and the examiner
briey commented the task but no explicit feedback on
performance was given. This scheme was repeated for
three trials. After completing the third trial, a new
subjective rating was administered. The order of the lists
was counterbalanced across participants. Prediction
accuracy was calculated by subtracting, for each list,
the actual performance from the predicted performance.

Statistics

The statistics included ANOVA with post-hoc test

(Scheffe), repeated-measures ANOVA and partial
correlation matrix. A receiver operating curve
(ROC) analysis was performed to evaluate the
specicity of measures of SRD and OJ in distinguishing
patients from NC. Computation was supported by the
statistical packages StatView 5.0 and MedCalc.
Results
Objective judgment of memory functioning

The results of experimental testing on memorymonitoring abilities are reported in Figure 1. They
can be summarized as follows:

Figure 1 Mean values of the pre- post-study prediction and mean number of words recalled at the memory-monitoring task. AD, Alzheimers disease;
MCI, mild cognitive impairment; NC, healthy older adults. Error bars represent standard error.

Copyright # 2010 John Wiley & Sons, Ltd.

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F. Galeone et al.

698
Table 2 Mean values and standard deviations of subjective rating of
memory functioning (pre- and post-test evaluation) and discrepancy
score in the three groups of subjects
MCI

SR pre
SR post
SRD

AD

NC

SD

SD

SD

9.7
9.4
4.9

4.4
4.7
4.5

10.2
10.0
5.8

5.8
6.4
7.8

8.6
8.6

0.6

3.1
3.6
1.5

SR pre, subjective rating of memory functioning at the pre-test; SR post,

subjective rating of memory functioning at the post-test; SRD, subjective
rating discrepancy score (caregivers rating minus subjects rating).

Recall. A repeated measure ANOVA of list order (rst,

second, third) by group (NC, MCI, AD) for the
number of words recalled (see Figure 1) showed a
signicant group effect (F 54.5, df 2, p < 0.0001)
with the AD performing worse (x 1.2) than the MCI
(x 2.3, p < 0.005) and these, in turn, worse than the
NC (x 4.2, p < 0.001). Neither list order nor interaction effect was observed.
Accuracy in prediction. A repeated measure ANOVA of
group by phase (pre- and post-study) by list order
revealed signicant effect of group (F 36.8, df 2,
p < 0.001), with the AD performing worse than MCI
(p < 0.01) and MCI, in turn, worse than NC (p < 0.0001).
There was no list-order effect; however, a signicant group
by list order interaction (F 3.9, df 122, p < 0.005)
indicated that, while for MCI and AD accuracy did not
change across the three lists (Scheffe post-hoc, NS), the
accuracy of the NC increased from list 1 (x 1.8) to list 3
(x 0.2, p < 0.001). Furthermore, there was an effect of the
phase (F 1.55, df 1, p < 0.05). A signicant phase by list
order interaction (F 3.3, df 122, p < 0.04) indicated that
the three groups were more accurate at the post-list
judgment only for the rst list. There was no group by phase
by list order interaction.

On the whole, results showed that NC slightly

overestimated their performance at the beginning of
the trial, but progressively revised their prediction so
that, at the third list, this was virtually perfect. By
contrast, both AD and MCI subjects consistently
overestimated their performance across the three lists.
Consequently, the accuracy measure at the third list
(pre- and post-study accuracy) was chosen as the
more suitable OJ measure of unawareness. The worst
performance in NC subjects, i.e., 4; was used as cut-off
for identifying pathological performance. Accordingly,
11 AD subjects (73.3%) and nine MCI (36%) were
found to have signicant decit in memory monitoring. The ROC analysis on this measure conrmed the
specicity of the cut-off as it reached 85.7% in
distinguishing patients (AD and MCI) from NC (area
under the ROC curve 0.877; from 0.768 to 0.947 at
95% CI; p < 0.0001).
Subjective rating of memory function. The mean values

of the subjective rating and mean discrepancy scores of

the three groups are reported in Table 2. The subjective
rating of memory functioning from MCI and AD
patients was highly related with the MAC-Q scores
(r 0.66, p < 0.0001). A comparison of the pre- and
post-test subjective rating scores was made by means of
two-way (group  pre-/post-test) ANOVA. This failed
to show signicant difference between the three groups
in their memory dysfunction complaints (F 0.69,
df 2, NS), as well as signicant pre- and postvariation (F .39; df 1, NS) with no interaction
(F 0.11, df 2, NS). Lack of pre- and post-variation
indicated that all participants, after testing, had
maintained pre-existing ideas about their memory
functioning. This was conrmed by highly signicant
correlation between the pre- and post-testing subjective ratings (r 0.79, p < 0.0001). However, when
SRD scores were examined, a signicant group effect was
observed (F 9.9, df 2, p < 0.0002), with the MCI and
the AD showing reduced awareness of memory

Table 3 Partial correlation matrix between measures of anosognosia

SRD
OJ
MMSE
Memory score
Executive score

SRD

OJ

MMSE

Memory
score

Executive
score

1.000

0.036

0.090
0.063
0.074

0.036
1.000

0.445**

0.160

0.461**

0.090

0.445**
1.000
0.436**
0.355*

0.063

0.160
0.436**
1.000
0.009

0.074

0.461**
0.355*
0.009
1.000

SRD, subjective rating discrepancy score; OJ, objective judgment; MMSE, mini-mental state examination score. Executive and memory function composite
scores.
Values refer to Pearsons r coefcient: *p < 0.05, **p < 0.01.

Copyright # 2010 John Wiley & Sons, Ltd.

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Anosognosia in amnestic MCI and AD

difculties (mean SRD: x 5.6 for AD; x 4.9 for the

MCI) with respect to the NC (x
0.6). Furthermore,
there were 10/15 AD (66.6%) and 14/25 MCI subjects
(56%) who had such a discrepancy score 3 (the value
of 2 being the worst discrepancy score observed in NC).
This indicated that a consistent proportion of the AD
and MCI subjects had reduced awareness of their
memory disturbances at the clinical interview. The
ROC analysis on the SRD measure conrmed the
specicity of the cut-off, as it reached 100% in
distinguishing patients (AD and MCI) from NC (area
under the ROC curve 0.831; from 0.707 to 0.918 at
95% CI; p < 0.0001).
By comparing the 20 subjects found unaware at the
OJ measure and the 24 with pathological SRD score, 18
subjects (12 MCI and 6 AD) were found impaired on
only one measure.
Correlation analysis. In order to explore correlation

between the two measures of anosognosia (SRD and

OJ) and the relationship of these with cognitive
domains putatively involved in awareness of memory
functioning, the two measures, together with MMSE
score and memory and executive composite scores
entered a partial correlation matrix (Table 3). This
analysis allowed correcting for multiple correlations
evaluating the correlation between two variables after
removing the effect of the other variables (Norman and
Streiner, 1994). The composite memory score was
obtained by summing z-scores of immediate and
delayed recall at the Reys 15 words test (Caltagirone
et al., 1979) while the composite executive, the z-scores
of the FAB (Italian norms, Iavarone et al., 2004), and
the phonemic word uency (Caltagirone et al., 1979).
Only data from MCI and AD were included. The
limited number of subjects in the two groups made
necessary pooling data from the two groups of patients.
However, it was justied by the similar pattern of
anosognosia we had found in the two groups.
No correlation was found between the two measures
of anosognosia (OJ and SRD). The analysis showed
correlation between OJ and the composite score of
executive functioning even after removing the effect of
severity of cognitive impairment (MMSE). No
correlation was found between SRD and composite
scores of memory or executive functioning.
Discussion
In the present study, two main ndings support the
view that reduced awareness for memory decit in
Copyright # 2010 John Wiley & Sons, Ltd.

699

MCI subjects, shares important similarities with that of

AD.
First, a proportion of the MCI subjects showed clear
unawareness for memory decit when assessed by
subjective rating method (SRD score), and did not
revise their rating after memory testing. Furthermore,
the extent of such a phenomenon in the MCI
approached the level seen in the mild AD (66.7%
AD vs. 56% MCI). These results agree with previous
studies that found unawareness for memory decit in
both AD and MCI (Duke et al., 2002; Vogel et al., 2004,
2005). Other studies, e.g., Kalbe et al. (2005), did not
nd unawareness for memory decit in subjects with
MCI when assessed by SRD method. However, for the
MCI subjects enrolled in the study by Kalbe et al.
(2005) the criterium of subjective memory complaint
was crucial for inclusion. This likely constituted a
selection bias for MCI subjects with unawareness.
Furthermore, the complaint interview used by these
authors was likely less sensitive than the present one
since it included only one item concerning daily
memory difculties.
The second nding was that the unawareness for
memory decit in the MCI subjects, as well as that of
AD, was also evident on the OJ measure. This decit
was observed in the task requiring the subjects to
predict their own performance in recalling words. All
the participants, at the rst list, appeared to estimate
their memory ability simply using a mid-point
anchoring strategy. This strategy represents individuals tendency to anchor their prediction near to the
midpoint of performance, i.e., 5 for a list of 10, when
confronted with a new task (Connor et al., 1997). On
this account, the mild inaccuracy of the NC could be
due to difculties in facing a non-usual task, while the
marked inaccuracy of the AD and MCI subjects arose
because their memory performance was dramatically
different from the midpoint of possible performance
(Moulin et al., 2000). However, the NC subjects were
able to revise downward their prediction so that this
was quite correct at the third list. The NC subjects had
shifted from the midpoint anchoring prediction to a
prediction that took into account the actual performance (see Ref. Memory for past test heuristic, Finn and
Metcalfe, 2007). On the contrary, both the MCI and
the AD participants did not take into account their
memory failures and did not revise their prediction.
In the study by Ansell and Bucks (2006) the AD
subjects, although overcondent about their memory
abilities, were somehow able to improve prediction
accuracy following exposure to the memory task, and
such an improvement generalized to the post-test
subjective rating. However, in their study, the
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F. Galeone et al.

700

Key Points






Mild Cognitive Impairment.

Alzheimers disease.
Dementia.
Anosognosia.
Memory monitoring

participants were explicitly required to rate their

performance after recall. This step likely produced an
effect of increasing awareness due to examiners
feedback for facilitating judgment (see Hannesdottir
and Morris, 2007). Furthermore, the revision of
prediction by the AD subjects was limited to less than
one word (their accuracy error at the rst list being 2.75
words). Thus, the results by Ansell and Bucks (2006)
do not hamper the present nding of consistent decit
in both AD and MCI in taking into account actual
experiences of memory failure.
It has been observed that the OJ scores have poor
ecological validity, since neuropsychological tests may
have little relationship with everyday tasks (Moulin
et al., 2000; Williamson et al., 2010). However, the OJ
measure chosen for the diagnosis of unawareness in
MCI and AD subjects was obtained from performance
at the third list, i.e., after the subjects had experienced
repeated memory failures. Lack of revision in the AD
and MCI subjects indicate that they may not recognize
memory failure as aberrant occurrence (executive
anosognosia; Hannesdottir and Morris, 2007). This
agrees with our nding that the OJ measure was related
to executive functioning, even after controlling for
general cognitive impairment. In other words, such an
inability to revise prediction after memory failure may
be explained by the involvement of specic component(s) of the executive system. Note that the
relationships between executive functioning and
unawareness have been repeatedly underlined in many
neuropsychological (Mangone et al., 1991; Starkstein
et al., 1993; Auchus et al., 1994; Lopez et al., 1994;
Michon et al., 1994; Dalla Barba et al., 1995) or
functional neuro-imaging studies (Starkstein et al.,
1995; Vogel et al., 2005) and referred to the role of selfmonitoring, reasoning and problem solving in the
formation of awareness. On the other hand, as shown
by unchanged SRD scores, both the MCI and AD are
also unable to encode in more abstract representations
about themselves that their memory is poor by
comparison to their past abilities (amnestic anosognosia; Hannesdottir and Morris, 2007). In our sample,
there was no correlation between the two measures,
conrming that these measures explore different dimenCopyright # 2010 John Wiley & Sons, Ltd.

sions of the anosognosia phenomenon (Ansell and Bucks,

2006; Hannesdottir and Morris, 2007). Furthermore,
although these measures were both affected at group level,
dissociation between them was found, i.e., at single-case
level, particular subtypes of anosognosia could be
observed. Such heterogeneity of anosognosia presentation
was true for both AD and MCI.
Conclusion
The present results agree with the view that unawareness
for memory decit in AD subjects is an early symptom of
their memory disorder and can be seen even in the MCI.
As such, anosognosia might be a specic marker of the
MCI transition to AD. This, however, would not be a
sensitive marker since the number of AD patients
found unimpaired on the OJ or the SRD evaluation. In
any case, the aspects of unawareness for memory decit
tapped by the OJ measure, i.e., memory monitoring
decitas well as that by the SRD, i.e., poor knowledge
about oneself memory functioningmay be easily
identied in standard clinical setting and used to evaluate
the role of the anosognosia in predicting conversion from
MCI to AD.
Conflict of interest
None declared.
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