Error unawareness as a driver of cognitive decline in individuals at risk for Alzheimer’s disease

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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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The Early Alzheimer’s Symptom Doctors Say Women Should Never Ignore

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Occasionally forgetting a name or appointment is not typically cause for concern, explains Beth Battaglino, RN-C, CEO of HealthyWomen, an organization dedicated to women’s health in midlife. For example, if you forget the name of an old TV show but remember it a few minutes later, that is not consistent with the early stages of Alzheimer’s disease. However, persistent changes that interfere with your daily functioning, such as repeatedly asking the same question or getting lost in a familiar place, are reasons to start a conversation with your doctor, she says.

Battaglino explains that ruling out other medical reasons for cognitive issues, as well as addressing conditions that can increase dementia risk like high blood pressure, diabetes, high cholesterol, and atrial fibrillation, is a good place to start.

Getting a Diagnosis When Cognitive Problems Are a Concern

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Key takeaways

Primary care doctors may dismiss cognitive complaints as stress or normal aging.
Brief visits and limited dementia training for primary care physicians make a careful assessment hard to get.
Being persistent, switching doctors or seeking a specialist can help patients and their families get answers.