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Mental Health & Human Resilience International Journal Research Article 29 min read

Metacognitive Rehabilitation in the Elderly: the Mind the Gap Metacognitive Program

Orfei MD* and Porcari DE*
* Corresponding author
ISSN: 2578-5095  10.23880/mhrij-16000236  Received: November 12, 2023  Published: January 25, 2024
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Keywords
Metacognition Alzheimer’s Disease Rehabilitation Self-Awareness Anosognosia
Abstract

This paper introduces the Mind the Gap Metacognitive Program (MGM-P), an innovative rehabilitation approach to contrast and prevent anosognosia. Anosognosia, or impaired self-awareness of illness and related deficits, is a pretty frequent phenomenon in Alzheimer's Disease, even in pre-clinical stages, which may have detrimental effects on clinical course, therapy compliance, risky behaviors, not to say caregivers’ stress and burden. Stemming from a complex bio-psycho-social perspective and firmly rooted in accredited neuropsychological models on self-awareness and metacognition, the MGM-P aims at improving patients’ realistic self-appraisal, facilitating the adoption of self-safety behaviors and compensatory strategies, thus lessening patients’ and caregivers’ stress. Theoretical models, structure of sessions, and methodology are illustrated. The MGM-P can be administered to the Elderly with dementia but also with Mild Cognitive Impairment and Subjective Cognitive Complaint. Thus, the MGM-P has been developed as a therapeutic approach and as a preventive tool to buffer cognitive decline and facilitate identifying elderly at-risk subjects. Another original aspect of MGM-P is the presence of quantitative indices, which allow the clinician to objectively rate the patient’s progress in different metacognitive functions and make the MGM-P quite adaptable for research purposes. Last but not least, MGM-P shows a wide range of fruitful next ameliorants and applications in other neuropsychiatric conditions and different contexts, such as in educational and job formation fields.

Introduction

An increasing number of older adults has represented the last decade’s constant demographic trend worldwide. Although a positive sign of the times, the drawback of longer life expectancy is an increasing incidence of age-related Conceptual Paper health diseases, in particular, dementia due to Alzheimer’s Disease (AD). AD is thought to begin 20 years or more before overt symptoms, and it starts with changes in the brain that are unnoticeable to the person affected; only after years of brain changes may individuals experience symptoms such as progressive cognitive, functional, and neuropsychiatric impairment, severe enough to restrict an individual’s autonomy in daily life [1]. Long this continuum between hidden and overt symptoms, there are three broad phases: pre- clinical AD, Mild Cognitive Impairment (MCI), and dementia due to AD. Age, genetics, biological sex, and environmental factors affect the length of each continuum phase [2]. During pre-clinical AD, individuals have measurable brain changes that indicate the earliest signs of AD (biomarkers such as abnormal levels of beta-amyloid, decreased metabolism of glucose, and abnormal form of protein tau); despite the presence of these alterations, they have no obvious cognitive symptoms such as memory loss [3, 4]. MCI represents the prodromal phase, and it is characterized by the emergence of cognitive symptoms, which are noticeable by the subject and family members and they do not interfere with the individual’s ability to do activities of daily living [5, 6].

One of the earliest brain functions vulnerable to cognitive decline is self-awareness. In fact, the core neuropathological features of AD include widespread neurodegeneration encompassing cortical regions and brain-wise networks that are implicated in supporting aspects of self-awareness [7]. In this context, self-awareness is the reasonable or realistic appraisal of a given aspect of one’s situation, functioning, performance, or resulting implications [8]. In AD, alterations in self-awareness, or anosognosia, consist in the undervaluation, or even full unawareness, of impairments in activities of daily living, memory deficits, and behavioral changes [9, 10, 11]. Anosognosia has a detrimental effect on illness course, therapy compliance, and patient’s behavioral symptoms, not to say on patients’ and caregivers’ burden and care costs [12, 13, 14]. Moreover, anosognosia dramatically hampers the probability of risky behaviors, such as wandering, forgetfulness while preparing meals, inadequate medicine assumption, difficulties in money handling, and risky car driving [15, 16, 17, 18, 19, 20].

Notably, impairments in self-awareness have also been highlighted in MCI, where they may represent a predictor for conversion to AD and worse clinical outcome [7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30]. Even in Subjective Cognitive Decline (SCD) [31], alterations of realistic self-appraisal may precede and accelerate cognitive decline [32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42].

Far from being a trivial issue, a realistic understanding of new cognitive limitations can crucially contribute to a well-timed identification of subjects at risk of dementia to encourage patients to adopt self-safety behaviors and to better comply with medical treatment. Eventually, caregivers’ burden and patients’ quality of life would benefit. This is why self-appraisal rehabilitative programs for the Elderly, mostly if affected by cognitive decline, are strongly warranted.

Altered Mechanisms Underpinning Self- Awareness Deficits in the Elderly

Anosognosia is a failure in metacognition, i.e., the ability to self-reflect, self-monitor, and self-correct one’s performance [42, 43, 44]. Metacognition includes several sub- functions (e.g., semantic and episodic mnestic components, implicit awareness, online self-monitoring, self-correction, emotional relevance, etc). The abundance of clinical and neurological evidence has contributed to cast light on the multifaceted nature of metacognition and self-awareness, thus stimulating the development of multilevel models [45, 46]. Overall, evidence suggests a continuum of self- awareness phenomena across the stages of AD, ranging from realistic insight to hypernosognosia and anosognosia [35, 47].

Several studies have pointed out a relevant involvement in anosognosia of global cognitive impairment and memory deficits [29, 48, 49, 50, 51, 52] functional and/or structural alterations in the right anterior insula, prefrontal and temporal brain areas [42, 53, 54, 55, 56, 57, 58, 59, 60] and some neuropsychiatric symptoms, mainly psychotic symptoms, and apathy [25, 61, 62, 63, 64, 65, 66]. Last but not least, the role of environmental, motivational, and emotional factors [67, 68, 69, 70] cannot be overlooked when challenging such a multi-determined phenomenon [71, 72, 73].

Rehabilitative Interventions for Anosognosia

Most of the rehabilitative approaches to contrast anosognosia are based on education, experiential feedback, behavioral therapy approach, individual or group counseling, psychotherapy, strength and weakness lists, and rating task performances, while others are mainly centered on cognitive stimulation [74, 75, 76, 77]. Some studies selected specific classes of tasks and manipulated specific characteristics of information [78, 79, 80, 81], although sometimes disregarding ecological validity for the sake of a molecular understanding of the phenomena. Despite their relevance, these efforts have not yet merged into a systematic and standardized rehabilitation program specifically developed to boost metacognitive functions in older adults.

The Mind the Gap Metacognitive Program (MGM-P)

Reference background: In this paper, we introduce the model of the Mind the Gap Metacognitive Program (MGM-P), which is based on the most accredited contributions in neuropsychology and neuroscience. The core hypothesis of MGM-P is that self-awareness is the ultimate product of metacognitive activity, which, in turn, deals with autonoetic knowledge. Autonoetic knowledge can be defined as the pool of information, beliefs, and judgments related to the self and one’s abilities [82]. Throughout the lifespan, information drawn from personal experience and external feedback is stored in the episodic and semantic dimensions of autobiographical memory, thus merging with autonoetic knowledge [83].

Metacognitive function, to regulate actions and to make provisions about the self, not only gleans information from autonoetic knowledge but also deals with updating it based on incoming information. In the elderly, especially those with cognitive decline, metacognitive dysfunction prevents a correct update process so that autonoetic knowledge, and finally, self-awareness, relies on a sort of fixed-in-time concept [84].

In this perspective, we mainly referred to the Pyramidal Model of Awareness [81, 85]. Although initially developed concerning anosognosia following traumatic brain injury, it can be generalized to other neuropsychiatric conditions. It considers three interdependent levels of self-awareness: i) at the bottom of the pyramid there is Intellectual Awareness (IntAw), i.e., the cognitive capacity of the subject to conceive at least notionally that a particular function has diminished from premorbid activities; ii) at an intermediate level there is Emergent Awareness (EmAw), or the ability to recognize a deficit as it occurs, while the subject is making his/her performance or immediately after having completed the action; iii) at the top of the pyramid there is Anticipatory Awareness (AntAw), i.e. the ability to make realistic previsions about one’s performances also weighing impairments, thus adopting appropriate compensatory strategies. We postulate a circular and integrated relationship between these levels of awareness and hypothesize that deficits in self-appraisal may depend on failures occurring at each level (Figure 1).

Figure 1: ** Pyramidal Model of Awareness.
Click to enlarge
Figure 1: ** Pyramidal Model of Awareness.

Source: IntAw= Intellectual Awareness; EmAW= Emergent Awareness; AntAw= Anticipatory Awareness. Figure 1: Pyramidal Model of Awareness.

Another essential in the field is the Cognitive Awareness Model (CAM) [86], which suggests specific neural mechanisms to verify consistency between incoming data and self-representations stored in a personal database (PDB). In case of a mismatch, the PDB should be updated based on this comparison, and the product of this process is conveyed via the Metacognitive Awareness System to provide conscious decision-making. Further, Central Cognitive Comparator Mechanisms, underpinned by executive control, would be designated to detect current functional deficits compared to stored information. Thus, impairments in mental functions may prevent the consolidation of new information and, thus, the correct updating of self-image.

In addition to these models, we considered the previously cited evidence about neuropsychological and neuropsychiatric correlates of anosognosia in dementia. Last, we fully subscribed to the bio-psycho-social framework [71, 87] emphasizing the role in anosognosia development of the social environment, stigma, and caregivers.

Metacognitive Functions Involved

Each session starts with a pre-task procedure designed to elicit IntAw and AntAw, including:

  • Exhaustive instructions, also providing pre-task examples, so that the subject is enabled to frame a mental hypothesis of the situation.
  • A subject’s prevision about his/her future performance (e.g., the number of words expected to remember and a sort of vote from 0 to 10), which the clinician records.
  • An estimate of the same task performed ten years ago to stimulate a realistic update of self-image.

This phase stimulates ongoing self-monitoring, error learning, feeling-of-knowing, judgment of learning, and self- image adjustment. Once the task is completed, a post-task procedure is administered to boost EmAw: the subject is required to judge his/her performance again by the above- described twofold judgment system (e.g., the actual number of words he/she correctly recalled and a vote from 0 to 10). Also, some tasks include questions about possible mistakes made in the task (e.g., the inclusion of intrusive words in a list to recall).

After the post-task inquiry, the subject is informed about his/her actual results in terms of objective scores [88], number of errors, possible intrusions, and omissions, as well as objective terms of comparison (e.g., the minimum and maximum score reachable at each task). Thus, the subject is asked to re-estimate his/her result based on objective information received. The subject is also encouraged to compare his pre-task expectations and post-task judgments with actual results. This final stage of the session aims to improve the Integration of External Feedback (IEF), which in turn is hypothesized to improve IntAw and AntAw, thus a correct update of self-knowledge. The introduction of this IEF index is due to evidence of difficulty in efficiently using external corrective information in neuropsychiatric patients with poor awareness of deficits [89, 90, 91]. The pre-, post, and external feedback procedures are reported in Table 1.

Task StimuliDescriptionMetacognitive Function
Pre-Task
Inquiry		The subject is asked to decide about his next
task performance.		The subject is stimulated to rely on his present
knowledge about the self. Elicitation of IntAw. and AntAw.
Post-Task
Inquiry		The subject is asked to make a judgment after
his performance		The subject is stimulated to gain awareness about his/her
actions, regardless of previous expectations. Elicitation of
EmAw.
External
Feedback		The subject is informed about his objective
results and is asked to adjust his post-task
judgment and compare it with previous
estimations.		The subject is confronted with objective evidence and
his/her own subjective biases in self-appraisal. Elicitation
of Em.Aw. and IEF, an adjustment in IntAw and AntAw

Table 1: Metacognitive Indices, Task Description, and Related Awareness Functions Elicited.

Some sessions require the patient to watch a video with a third unknown person performing some tasks to stimulate the first-vs-third person appraisal. In the end, the patient is asked to express post-task judgments and to compare the third person’s result with his/her results. This type of intervention is justified by the evidence in the literature of the tendency of anosognosic patients to evaluate more correctly third- person performance than one’s own [43, 92, 93], supporting the hypothesis that perspective taking and agency represent independent but interacting constituents of self-awareness [94, 95]. Some sessions also include exercises of imagery boosting self-reflection and inner attention, which underpin self-awareness function [96, 97, 98, 99, 100].

The MGM-P Protocol

Before starting rehabilitative training, a comprehensive multidimensional assessment is strongly recommended. This information will then be used to formulate a diagnostic hypothesis and to tailor the sessions and the exercises according to individual needs. In particular, we suggest investigating: i) In addition to the global level of cognition, the presence of specific deficits in mnestic and executive function, working memory, abstract thinking, praxis, and language; ii) Residual functional abilities relative to daily life; iii) Depressive, apathetic or other neuropsychiatric symptoms frequently associated with anosognosia.

Note that, at this stage, a multifaceted awareness assessment is mandatory. Questionnaires investigating the main facets of self-awareness and anosognosia, e.g., semantic and episodic dimensions of illness, beliefs about memory and illness and related stigma, psychological denial, and implicit awareness, should always be considered [8, 78, 101, 102]. Also, a post-treatment re-administration would be desirable to verify changes in self-awareness and related constructs. Structure of the Sessions: The MGM-P consists of about twenty individual sessions of 60-90 minutes each, with a suggested frequency of twice a week for mild-to-moderate AD and once a week for SCC and MCI. In each session, the subject is presented with a minimum of one to a maximum of three tasks, according to his/her cognitive level. The tasks pertain to mnestic function (semantic, episodic/autobiographical, prospective, procedural, declarative), language (production, comprehension), executive function (selective and sustained attention, resistance to interferences, working memory), praxis skills and ideomotor learning and imitation (e.g., copy and recall of drawings, gestures imitation), cognitive control, cognitive flexibility (generation of alternative hypothesis, choice of the best alternative, stimulation of divergent thinking, problem-solving), spatial and temporal orientation, Theory of Mind. Verbal (auditory and written) and visual (e.g., pictures, videos) content are alternated. Some exercises are pen-and-pencil, while others require specific equipment. Touchscreen technology can also execute others.

This adaptation allows for lightening the equipment and recording results and data with greater precision. However, these exercises can be performed according to the patient’s cognitive level and cultural background. Some tasks are structured to facilitate an approach that is as ecological as possible, such as shopping, housekeeping, cooking, money handling, and orienting in space. Notably, the protocol can be subdivided into three stages: i) The awareness boosting stage, which represents the initial phase of the protocol. It is aimed to compel the patient to become aware of subjective biases in self-appraisal and to correct them; ii) The compensatory strategies stage: to overcome cognitive difficulties and to adjust to spared cognitive resources, compensatory cognitive strategies are introduced during each session. The therapist suggests various cognitive and pragmatic strategies to apply in different everyday contexts and situations to select and reinforce the best-fitting ones for the individual. In this stage, active cooperation between the therapist and the patient is crucial. Moreover, learning new ways to manage everyday difficulties and mainly focusing on makings rather than on failures promotes the patient’s empowerment, thus buffering possible anxious and depressive reactions; iii) Patient’s autonomy stage: the patient is asked to perform a series of tasks, not only estimating his/ her results but also applying the learned strategies without an active intervention of the therapist. The respective length of each of these stages of the protocol is only approximately fixed, as it is managed by the therapist based on individual cognitive demands and resources (Figure 2).

Figure 2: The Mgm-P Protocol. Description of the Three Main Stages of the Metacognitive Rehabilitation Protocol: Pre- Treatment Assessment and Session Planning, Implementation of Rehabilitative Sessions and Post-Treatment Elaboration Data.
Click to enlarge
Figure 2: The Mgm-P Protocol. Description of the Three Main Stages of the Metacognitive Rehabilitation Protocol: Pre- Treatment Assessment and Session Planning, Implementation of Rehabilitative Sessions and Post-Treatment Elaboration Data.

Active Involvement of Caregivers: Caregivers’ correct understanding of the patient’s deficits is fundamental for befitting assistance and proper preventative measures. However, judgments on patients’ deficits can be conditioned by burden and stress or by psychological denial, so some caregivers can overestimate or underestimate patients’ cognitive deficits and functional difficulties [45, 72, 103]. The first stage of the MGM-P includes six parallel sessions dedicated to the caregiver. Specifically, the caregiver is required to perform the same tasks the patient previously performed and formulate post-task judgments about his/her performance. Then, the caregiver has to guess the patient’s result at the same task. Eventually, the caregiver is told about the actual result obtained by the patient and is asked to make a new evaluation. This process is supposed to compel the caregiver to gain a realistic perspective on the patient’s capabilities.

Conclusion

In this paper, we have introduced the MGM-P model, an innovative rehabilitation protocol aimed at boosting self- awareness function and thus contrasting anosognosia in the elderly. The suggestion to intervene in self-awareness dysfunction in dementia had previously been highlighted [43, 45]. For instance, according to the CAM model [86], patients with executive anosognosia may benefit from treatments focused on error monitoring. In contrast, patients with mnemonic anosognosia may benefit from memory rehabilitation techniques enhancing recollection and consolidation of current personal knowledge. However, to our knowledge, this is the first rehabilitative approach to contrast anosognosia characterized by a scheduled program of sessions.

Furthermore, MGM-P can be fruitfully adopted as a preventive measure, too. The MGM-P protocols are specific not only for AD patients but also for pre-dementia subjects (i.e., SCD and MCI) have been developed. Given the increasing evidence of anosognosia as a predictor of conversion into AD [47, 104, 105], self-monitoring enhancement in pre-clinical and pre-symptomatic stages of the illness hampers the possibility to detect as early as possible changes in cognitive function.

The Specific Aims of the MGM-P are

• To stimulate correct self-image adjustments and

semantic knowledge about the self (IntAw). In turn, this is expected to overcome the frequent limit of previous approaches to unawareness, the temporary effect of rehabilitation.

  • To promote an aware and willful adoption of strategies to face and overcome deficits. We all learn some cognitive compensative strategies, but most can be used unconsciously [106]. We hypothesize that changes in cognitive resources due to aging make this automatic use of strategies progressively less efficient. Thus, encouraging the subject to adopt aware solutions best tailored to the new needs is expected to ameliorate his/ her adaption in daily life.
  • To favor better compliance to treatment and improved quality of life in terms of greater self-safety, autonomy in daily life activities, sense of self-efficacy, reduced self- stigma, and decreased caregivers’ stress and burden.

Although easily adoptable in different clinical contexts, the MGM-P administration requires a specialized training course, as it postulates specific knowledge in aging neuroscience and neuropsychology, high-order metacognitive processes, and self-awareness processes. Last but not least, it is characterized by a peculiar clinical attitude. The complex relationship between higher awareness of deficits and increased depression [45, 107] is frequently pointed out in AD [64, 101, 102, 108, 109] as well as in other neuropsychiatric conditions, such as Parkinson’s Disease [110], psychosis [111, 112, 113] and brain injured subjects [114, 115], cannot be disregarded. Depression may entail a negative bias when reporting problems, as subjects with low mood would better recall their failures and thus would tend to exaggerate the perception of deficit [116, 117, 118]. On the other hand, it is very intuitive that subjects aware of their new deficits may be more susceptible to depressive mood [72] and thus defensive denial. Thus, rehabilitation of metacognitive function must consider mood and motivational aspects [68, 119] and requires the ability to identify different components of denial of deficits. Experimental trials to provide data supporting the efficacy of MGM-P in clinical populations are required. Indeed, the inclusion in the protocol of quantitative indices (i.e., IntAw, EmAw. and IEF) facilitates the development of appropriate research designs.

Conflict of Interest Disclosure

The authors have no conflicts of interest to declare.

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@article{orfei2024,
  title   = {Metacognitive Rehabilitation in the Elderly: the Mind the Gap
Metacognitive Program},
  author  = {Orfei MD* and Porcari DE},
  journal = {Mental Health & Human Resilience International Journal},
  year    = {2024},
  volume  = {8},
  number  = {1},
  doi     = {10.23880/mhrij-16000236}
}
Orfei MD* and Porcari DE (2024). Metacognitive Rehabilitation in the Elderly: the Mind the Gap
Metacognitive Program. Mental Health & Human Resilience International Journal, 8(1). https://doi.org/10.23880/mhrij-16000236
TY  - JOUR
TI  - Metacognitive Rehabilitation in the Elderly: the Mind the Gap
Metacognitive Program
AU  - Orfei MD* and Porcari DE
JO  - Mental Health & Human Resilience International Journal
PY  - 2024
VL  - 8
IS  - 1
DO  - 10.23880/mhrij-16000236
ER  -