Awareness in Alzheimer's disease and associated dementias: Theoretical framework and clinical implications

Abstract

Background: Awareness can be defined as a reasonable or realistic perception or appraisal of a given aspect of one's situation, functioning or performance, or of the resulting implications, expressed explicitly or implicitly. Disturbances of awareness have significant implications for people with dementia and their caregivers. The construction of awareness has been extensively studied in dementia, but a lack of conceptual and methodological clarity in this area means that few clear findings have emerged.

Aims: This article presents a framework for conceptualizing awareness in people with Alzheimer's disease and associated dementias that can guide research and influence practice.

Overview: This article begins by considering the general concept of awareness and the ways in which neurological damage can place constraints on awareness. Within an integrative biopsychosocial model that acknowledges the influence of neurocognitive, psychological, and social variables on awareness, challenges for empirical research on awareness in dementia are addressed, and a ‘levels of awareness’ framework is presented within which awareness operates at four levels of increasing complexity, providing a means of differentiating among awareness phenomena. Approaches to mapping awareness phenomena are discussed, and directions for future research and clinical practice are outlined.

Conclusions: The levels of awareness framework should act as a stimulus to further research in this area, resulting in a more coherent understanding of the nature of awareness deficits, the implications of these for people with dementia and their caregivers, and the possibilities for targeted and effective interventions.

Keywords:

• anosognosia
• insight
• denial
• self-awareness
• metacognition

Acknowledgments

This study was supported by the UK Economic and Social Research Council (grant number RES-062-23-0371). We thank Stan Klein, Gordon Winocur, Fergus Craik, Morris Moscovitch, Brian Levine, Endel Tulving, and Daniel Mograbi for their helpful comments. We also thank Robert T Woods for his contribution to the overall research project, and Sharon Nelis and Anthony Martyr for their assistance with identifying relevant literature.