Anosognosia


Article Author:
Aninda Acharya


Article Editor:
Juan Carlos Sánchez-Manso


Editors In Chief:
Evelyn Metz
Julie Sewell
Aditya Arya


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/10/2019 7:42:18 AM

Introduction

Anosognosia is a neurological condition where the patient is unaware of his or her neurological deficit or psychiatric condition. The French neurologist, Joseph Babinski, first described anosognosia in 1914[1]. It is associated with mental illness, dementia, and structural brain lesion, as in right hemisphere stroke patients. It can affect the patient’s conscious awareness of deficits involving judgment, emotions, memory, executive function, language skills, and motor ability.

Etiology

Typically, anosognosia appears when there is a lesion in the right parietal lobe but can occur with temporoparietal, thalamic, or basal ganglia lesions. The exact cause of anosognosia is unknown but is likely due to a derangement of the anatomical or functional monitoring unit that mediates the conscious awareness of deficits. The most likely physiopathologic mechanism is that the brain lesion that causes anosognosia disrupts neurocognitive, secondary integration areas[2]. Damage to these areas can lead to a lack of conscious awareness of the cognitive or sensorimotor function loss.

Epidemiology

Anosognosia can occur after acute brain injuries such as stroke or traumatic brain injury but also can occur in other conditions that damage the brain. In stroke patients with hemiparesis, the incidence of anosognosia is 10% to 18%[3]. The term anosognosia can also refer to the lack of awareness seen in psychiatric conditions when patients deny or minimize psychiatric symptoms. It is estimated that 50% of patients with schizophrenia and 40% of patients with bipolar disorder have anosognosia, or the so-called poor or lack of insight of their disease. In the setting of dementia, 60% of patients with mild cognitive impairment[4] and 81% of patients with Alzheimer disease appear to have some form of anosognosia: patients suffering from these conditions deny or minimize their memory impairment[5].

Pathophysiology

Patients with anosognosia due to brain injury often exhibit a lack of awareness of hemiparesis, hemisensory deficits, neglect, memory deficits, and language deficits. Patients may be unaware of one deficit while recognizing others. Anosognosia can co-occur with somatosensory neglect (asomatognosia), which also localizes to the right parietal lobe. The latter consists of the patient's denial that part of their body belongs to them.

Although anosognosia usually accompanies a right parietal, temporoparietal, thalamic, or basal ganglia lesion, recent studies suggest that the deficit sometimes can relate to non-structural changes. These changes cause problems with the connectivity of different parts of the brain[6].

The fundamental neurophysiologic or psychopathologic problem in anosognosia relates probably to an inability of the patient to update their self-image. Because of a lesion in the brain or dysfunction due to illness, the patient cannot incorporate new information regarding their deficits into their self-image. Therefore, they deny their illness or deficit or downplay its significance.

History and Physical

Typically, the health professionals diagnose anosognosia at the bedside by assessing the patient’s knowledge of their deficits. In subtle cases, it takes time and a longer conversation with the patient to note anosognosia when patients make excuses for not performing activities on the affected side or do not acknowledge the paralysis or other deficits. In the setting of dementia, patients do not acknowledge or minimize their memory deficits. In the setting of mental illness, patients rationalize aberrant behavior or psychiatric symptoms and often confabulate. This involves the creation of a false answer or response by combining real and imagined details.

Evaluation

When anosognosia is due to structural brain damage, neuroradiological findings typically show damage to the right parietal or right temporoparietal region. Less common are lesions in the thalamus, basal ganglia, or left parietal region. Neuroimaging in dementia typically shows a more global brain atrophy. Neuroimaging in psychiatric disorders usually show non-specific findings.

There are publications on an anosognosia rating scale, which rates the level of unawareness of patients with dementia suffering from this condition:

  1. Patients easily admit memory loss.
  2. Patients admit, sometimes inconsistently, to a small amount of memory loss.
  3. Patients are not aware of any impairment in memory.
  4. Patients angrily insist that no memory problem exist.

Treatment / Management

There is no specific treatment for anosognosia, but vestibular stimulation seems to improve this condition temporarily. This maneuver probably influences awareness of the neglected side temporarily. Where anosognosia persists, cognitive therapy can help patients better understand and compensate for their deficit.

Differential Diagnosis

Anosognosia differs from denial, a psychological defense mechanism that involves avoiding or rejecting information that provokes stress or pain. With denial, the patient may acknowledge a deficit but minimize its consequences and avoid treatments geared to remedy the deficits. Anosognosia also differs from a more global derangement such as encephalopathy where there may be problems with wakefulness and attention. It differs lastly from other deficits such as visual, sensory and cognitive deficits which limits the ability of patients to realize their deficit.

Prognosis

When anosognosia is due to a focal structural lesion of the brain, it typically resolves over time, though it can persist over the long-term. When anosognosia is due to mental illness or dementing illness, it may persist and lead to poor compliance with medication regimens.

Complications

Anosognosia can impair rehabilitation and recovery because patients that lack awareness of a deficit may show less inclination to take part in rehabilitation therapy to tackle the neurological dysfunction. Patients with anosognosia also may suffer more frequent falls due to their lack of awareness of their deficits. Health providers need take the safety precautions they see fit to avoid injury.

Postoperative and Rehabilitation Care

Recently A.R. Egbert described an ethical framework to involve patients with anosognosia in their rehabilitation treatment[7]. Rehabilitation specialists must always think of and consider this condition because it may affect the outcome of their treatment plan.

Deterrence and Patient Education

Education on how to deal with and help avoid problems related to anosognosia for patients and family members of the patients with this dysfunction is of utter importance, and lack of collaboration from the sufferer is typical due to the patient's failure to acknowledge or minimization of their condition. Issues such as driving, handling money, and walking without help may become areas of conflict. It is important to do a thorough safety evaluation to avoid injury to the patient suffering from anosognosia. Simplifying tasks, maintaining a positive approach, showing concern and empathy, and providing a structured environment are helpful to avoid negative outcomes.

Pearls and Other Issues

It is very important for emergency medicine clinicians to know of anosognosia. For example, in the setting of acute stroke, the timing of symptom onset is crucial to the administration of thrombolytic therapy. If the patient is unaware of their deficit, they may not give accurate information of the exact time of stroke symptom onset. In this situation, collateral history from a family member is crucial to making an informed treatment decision.

Enhancing Healthcare Team Outcomes

The management of anosognosia is very difficult. Because there are many causes, the management is with a multidisciplinary team that includes a neurologist, psychiatrist, mental health nurse, primary care physician, and a psychotherapist. There is no specific treatment for anosognosia, but vestibular stimulation seems to improve this condition temporarily. This maneuver probably influences awareness of the neglected side temporarily. Where anosognosia persists, cognitive therapy can help patients better understand and compensate for their deficit. If the cause is stroke, dementia or a mass lesion, the prognosis in most cases is poor. If the cause is related to a mental health disorder, the condition leads to difficulty in medication compliance. The overall quality of life is poor.[8]


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Anosognosia - Questions

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A patient has had a cerebrovascular accident and wants to work with the occupational therapist. Many sessions focusing on activities of daily living fail to produce safe compensation for deficits. The patient seems unaware of the disabilities. What is the term for this condition?



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A 70-year-old male is brought in with left-sided hemiplegia and right gaze preference. When asked when the symptoms started, the patient reports he has no symptoms. He says his family thinks he had a stroke, but he feels just fine and wants to go home. Which structure is likely involved causing him to be unaware of his neurological deficit?



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A 75-year-old female is brought in by her family because of memory problems. She lives by herself, and the family is worried because she has been getting lost while driving over the last year. Also, she could not manage her money and has many overdue bills. The patient minimizes these problems and says she is feeling fine. She says she is a little forgetful at times, but she certainly doesn’t have Alzheimer disease. On examination, she is alert but not oriented to person, place, or time. Her mini-mental status exam score is 18 out of 30. She had difficulty with recall, orientation, and naming on the exam. The rest of her exam is unremarkable. At the end of the interview, she continues to insist that she is just fine. Which of the following best describes her condition?



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A 65-year-old male has a right middle cerebral artery stroke with left-sided weakness and neglect. He seems unaware of his deficit (anosognosia) and has had multiple falls in the hospital. They have sent him for inpatient rehabilitation. What is the best approach in rehabilitating patients with this deficit?



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A 37-year-old male with bipolar I disorder stopped taking his psychiatric medications one week prior. He has been up for three days in a row working on his business plans. His wife calls his provider and explains that the patient feels he is cured of his bipolar disorder and that he is speaking endless nonsense. His psychiatrist speaks to the patient on the phone, and the patient minimizes his aberrant behavior, says that everything is fine and that he is very busy starting a billion dollar company. How would the patient’s appraisal of his symptoms best be described?



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Anosognosia - References

References

Course and Determinants of Anosognosia in Alzheimer's Disease: A 12-Month Follow-up., Turró-Garriga O,Garre-Olmo J,Calvó-Perxas L,Reñé-Ramírez R,Gascón-Bayarri J,Conde-Sala JL,, Journal of Alzheimer's disease : JAD, 2016 Jan 22     [PubMed]
Functional cerebral space theory: Towards an integration of theory and mechanisms of left hemineglect, anosognosia, and anosodiaphoria., Smith AJ,Campbell RW,Harrison PK,Harrison DW,, NeuroRehabilitation, 2016 Feb 12     [PubMed]
Incidence and diagnosis of anosognosia for hemiparesis revisited., Baier B,Karnath HO,, Journal of neurology, neurosurgery, and psychiatry, 2005 Mar     [PubMed]
A Framework for Ethical Decision Making in the Rehabilitation of Patients with Anosognosia., Egbert AR,, The Journal of clinical ethics, 2017 Spring     [PubMed]
Awareness of deficits in mild cognitive impairment and Alzheimer's disease: do MCI patients have impaired insight?, Vogel A,Stokholm J,Gade A,Andersen BB,Hejl AM,Waldemar G,, Dementia and geriatric cognitive disorders, 2004     [PubMed]
Prigatano GP, Anosognosia and patterns of impaired self-awareness observed in clinical practice. Cortex; a journal devoted to the study of the nervous system and behavior. 2014 Dec;     [PubMed]
Ptak R,Lazeyras F, Functional connectivity and the failure to retrieve meaning from shape in visual object agnosia. Brain and cognition. 2018 Dec 24     [PubMed]
Abela E,Missimer JH,Pastore-Wapp M,Krammer W,Wiest R,Weder BJ, Early prediction of long-term tactile object recognition performance after sensorimotor stroke. Cortex; a journal devoted to the study of the nervous system and behavior. 2019 Feb 7;     [PubMed]

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