My mother’s first fall, at age ninety-two, seemed like an accident. Her rubber-soled sandals caught on the carpet in the activities room of her senior apartment complex and she plunged forward catching her arm on the piano bench. After minor surgery to repair the wound, and a short hospital stay, she began a course of physician therapy; but the falls continued. Injuries were rare and minor. Still the increasing frequency was distressing.
When I suggested a walker, Mom told me, “I don’t need one. I can walk perfectly well. I just lose my balance sometimes.” I puzzled over that response for days. Was it possible she didn’t remember all the falls? Did she really think she could walk safely without assistance?
It was not until after she died that I came upon the concept of anosognosia, from the Greek a-without, nosos-disease, gnosis-knowledge: without (lack of) knowledge of disease. People with anosognosia are unaware of their illness or deficits. It is most often associated with mental illness and is the primary reason for medication non-compliance in psychiatric patients.
It also affects seniors with age-related brain changes, including mild cognitive impairment. Unaware of her weakness and impaired balance, my mother had not understood that she couldn’t walk without falling. And because she did not believe she was impaired, she could not imagine why she should use a walker.
Anosognosia is often assessed with the Clinical Insight Rating (CIR) scale that identifies lack of knowledge/insight in four domains: understanding the reason for the visit (to the physician); awareness of cognitive deficit; awareness of functional deficit; and/or perception of disease progression. Mom’s lack of insight pertained to her functional deficit. Although her anosognosia resulted from an aging brain and associated (and increasing) cognitive impairment, she was sadly aware of her memory problems and disordered thoughts. People with more severe forms of dementia (including Alzheimer’s disease) are more likely to exhibit anosognosia of cognitive deficit, while those with mental illness, brain tumors, or stroke, often exhibit lack of awareness in multiple domains.
At the time, I thought my mother’s refusal to accept help stemmed from her fierce independence. I knew she had trouble thinking clearly, but I still tried to reason with her, hoping that in time she would acknowledge her functional decline and her need for assistance. But neuropsychological testing shows that patients with anosognosia score lower on composite indices of both memory and executive function. Facts and evidence are not persuasive to anyone with a pathological lack of insight.
Looking back, I now understand that Mom’s falls probably signaled her progression to “mild cognitive impairment” or MCI. The Mayo Clinic defines MCI as an intermediate stage between the expected cognitive decline of normal aging and the more-serious decline of dementia; it is often assessed using the Mini Mental Status Exam (MMSE). Studies have shown that the rate of falls increases with each unit decrease in the MMSE, and that insight can be equally impaired in persons with MCI or more advanced dementia.
I wish my mother had received a diagnosis of MCI, but it is not surprising that she didn’t. Most people with MCI can and do live independently, as my mother did, and are able to fulfill basic social roles. They are typically capable of most activities of daily living, although on close observation they take more time to complete them than unimpaired individuals. My mother’s mental decline was almost imperceptible at first, and as it progressed, I did not know enough to ask whether her symptoms were evidence of a specific diagnosis.
Knowing she had MCI would not have helped my mother, but it would have helped me. I would have done my research and uncovered her anosognosia. I would have realized that her reluctance to use a walker was grounded in her understanding of her abilities, wrong as that understanding was. I would have felt more comfortable taking over some of her decision-making.
Eventually, a physical therapist convinced my mother to use the walker for one week, promising that she could stop if she didn’t like it. Within two days, she began referring to it as her Cadillac. After that, her rate of falling decreased substantially.
De Carolis A, Corigliano V, Comparelli A, Sepe-Monti M, Cipollini V, Orzi F, Ferracuti S, Giubilei F: Neuropsychological patterns underlying anosognosia in people with cognitive impairment. Dement Geriatr Cogn Disord. 2012;34:216–223. doi:10.1159/000343488
De Carolis A, Cipollini V, Corigliano V, Comparelli A, Sepe-Monti M, Orzi F, Ferracuti S, Giubilei F: Anosognosia in people with cognitive impairment: Association with cognitive deficits and behavioral disturbances. Dement Geriatr Cogn Disord; 2015;5:42-50. doi:10.1159/000367987
Vogel A, Hasselbalch SG, Gade A, Ziebell M, Waldemar G: Cognitive and functional neuroimaging correlate for anosognosia in mild cognitive impairment and Alzheimer’s disease. Int J Geriatr Psychiatry 2005;20:238–246. doi:10.1002/gps.1272
Lin F, Vance DE, Gleason CE, Heidrich, SM: Taking care of older adults with mild cognitive impairment: An update for nurses. J Gerontol Nurs. 2012 December; 38(12): 22–37. doi:10.3928/00989134-20121106-02
Gleason CE, Gangnon RE, Fischer BL, Mahoney JE: Increased risk for falling associated with subtle cognitive impairment: Secondary analysis of a randomized clinical trial. Dement Geriatr Cogn Disord 2009;27:557–563. doi:10.1159/000228257
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