Journal of the International Neuropsychological Society


Metacognitive theory and assessment in dementia: Do we recognize our areas of weakness?

S.  COSENTINO  a1 a2 and Y.  STERN  a1 a2 a3 c1
a1 Cognitive Neuroscience Division of the Taub Institute for Research in Alzheimer's Disease and the Aging Brain, Columbia University Medical Center, New York, New York
a2 Gertrude H. Sergievsky Center, Columbia University Medical Center, New York, New York
a3 Department of Neurology, Columbia University Medical Center, New York, New York

Article author query
cosentino s   [PubMed][Google Scholar] 
stern y   [PubMed][Google Scholar] 


Anosognosia, disordered awareness of cognitive and behavioral deficits, is a striking and common symptom of Alzheimer's disease (AD), yet its etiology, clinical correlates, and prognostic value are unclear. Historically, disordered awareness has been a conceptually challenging phenomenon, evidenced by the numerous and diverse theories that aim to explain the manner in which this syndrome arises. We review many of these theories, focusing on the neuroanatomic substrates of awareness, and highlighting the potential roles of critical regions such as the right prefrontal and parietal cortices in enabling self-awareness. We then address methodological limitations such as use of subjective measurement tools that likely contribute to the conceptual ambiguity surrounding anosognosia. We argue that metacognitive techniques used in healthy adults, such as the Feeling of Knowing task, offer models for dissecting awareness into clear and identifiable cognitive components in patients with AD. We critique several studies that have pioneered such tasks in AD, and offer guidelines for future implementation of such methods. A final goal of this review is to advocate for a multidimensional approach to studying metacognitive skills that will facilitate the objective investigation of deficit awareness as it relates to a variety of disease variables such as prognosis, neuropsychological profile, neuropathological distribution, psychiatric symptoms, and clinical course. (JINS, 2005, 11, 910–919.)

(Received April 15 2005)
(Revised August 15 2005)
(Accepted August 15 2005)

Key Words: Metacognition; Anosognosia; Dementia; Insight; Awareness; Alzheimer's disease.

c1 Address correspondence to: Yaakov Stern, Cognitive Neuroscience Division of the Taub Institute, Columbia University Medical Center, 630 West 168th Street, P&S Box 16, New York, NY, 10032. E-mail: