Anosognosia, or unawareness of one’s deficits, predicts faster clinical progression in Alzheimer’s disease (AD), though its mechanisms remain unclear. We investigated five-year trajectories of response awareness and error-monitoring efficiency using second-order judgments from an annual word recognition memory task in cognitively unimpaired individuals at risk for AD from the INSIGHT-preAD cohort. Participants were divided into three groups according to amyloid status at baseline (positive, A + ; negative, A–) and clinical progression (controls, CTRL A+ or A–; and progressors, PROG). Task accuracy declined in PROG, while CTRL A+ showed continued learning, and CTRL A– remained accurate. Inefficient error-monitoring predicted subsequent performance decline in the PROG, with a strong interaction between accuracy and error-monitoring already at baseline. This effect was primarily driven by error unawareness. These findings provide first evidence that error unawareness — a core feature of anosognosia — may foster cognitive decline through the disruption of error-feedback learning mechanisms, potentially accelerating AD progression.

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