Anosognosia of Neglect During Performance of Daily Activities

PURPOSE: Neglect (inattention to one side of body or environment) and anosognosia (lack of awareness of one’s deficits) are common after stroke and often co-occur (Vossel, Weiss, Eschenbeck, & Fink, 2013). Anosognosia of neglect is a significant predictor of disability (Vossel et al., 2013). The Catherine Bergego Scale (CBS) assesses neglect through observation of 10 activities and anosognosia through a parallel participant questionnaire (Azouvi et al., 2003). Although overall neglect severity (CBS) is strongly correlated (r = .79) (Azouvi et al., 2003) with anosognosia, the degree to which neglect and anosognosia overlap during performance of functional tasks is unclear. It is important to examine this overlap to design treatment to reduce neglect and anosognosia.

The purpose of this study was to examine the level of agreement between assessor and participant rating scores on CBS items. Given the link between neglect and anosognosia, we hypothesized that participants would have some but not complete awareness of their deficits during performance of tasks as evidenced by a lack of agreement (p > .05) between participant self-ratings and assessor ratings. We also hypothesized that there would be significant differences (p < .05) between assessor and participant total CBS scores.

DESIGN: We conducted a secondary analysis of existing data from two neglect studies. Participants (N = 29) were recruited through research registries, stroke support groups, and therapist referrals. Participants were eligible to participate if they were age ≥18 yr, experienced a stroke, had neglect (Behavioral Inattention Test [Wilson, Cockburn, & Halligan, 1987] or Virtual Reality Lateralized Attention Test [Buxbaum, Dawson, & Linsley, 2012]), and followed commands consistently.

METHOD: Trained assessors administered the CBS and anosognosia questionnaire in a standardized manner during a single session. The CBS assesses neglect during performance of various activities (e.g., dressing). Scores for each item range from 0 (no neglect) to 3 (severe neglect). The anosognosia questionnaire asks participants to rate their level of difficulty performing each item using the 0–3 scale (no difficulty, neglect to severe difficulty, neglect). We conducted interrater reliability analyses using Cohen’s kappa to examine the level of agreement between assessor and participant ratings. A paired t test was conducted to determine if there were significant differences between assessor and participant total scores.

RESULTS: Participants were primarily men (58.6%) who had experienced a right (72.4%) ischemic (75%) stroke. There were no significant differences, t(28) = 1.66, p = .11, between total CBS assessor-rated (M = 8.2, SD = 5.5) and participant-rated (M = 6.4, SD = 4.4) scores. However, the level of agreement between assessor and participant scores on the CBS items were all nonsignificant (p > .05) and ranged from κ = –0.05 (clean mouth) to κ = 0.20 (gaze).

CONCLUSION: Findings suggest that individuals with neglect have some awareness of their impairments and rate their overall neglect severity similarly to assessors. However, discrepancies exist at the item level, and there is only slight agreement for CBS items. Individuals often lack insight into the neglect they demonstrate when performing specific tasks and perceive the level of difficulty they experience differently than assessors.

IMPACT STATEMENT: This study addresses a research priority (functional cognition) identified by the American Occupational Therapy Foundation. This research highlights how important it is for practitioners to assess for anosognosia of neglect and to plan treatment to address anosognosia. Given the prevalence of poststroke neglect (Vossel et al., 2013), these findings have widespread implications for practitioners.

References

Azouvi, P., Olivier, S., de Montety, G., Samuel, C., Louis-Dreyfus, A., & Tesio, L. (2003). Behavioral assessment of unilateral neglect: Study of the psychometric properties of the Catherine Bergego Scale. Archives of Physical Medicine and Rehabilitation, 84, 51–57. https://doi.org/10.1053/apmr.2003.50062

Buxbaum, L. J., Dawson, A. M., & Linsley, D. (2012). Reliability and validity of the Virtual Reality Lateralized Attention Test in assessing hemispatial neglect in right-hemisphere stroke. Neuropsychology, 26, 430–441. doi: 10.1037/a0028674

Vossel, S., Weiss, P. H., Eschenbeck, P., & Fink, G. R. (2013). Anosognosia, neglect, extinction and lesion site predict impairment of daily living after right-hemispheric stroke. Cortex, 49, 1782–1789. https://doi.org/10.1016/j.cortex.2012.12.011

Wilson, B., Cockburn, J., & Halligan, P. (1987). Development of a behavioral test of visuospatial neglect. Archives of Physical Medicine and Rehabilitation, 68, 98–102.