Innovations In Clinical Neuroscience

JAN-FEB 2017

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 4 , N U M B E R 1 – 2 , J A N U A R Y – F E B R U A R Y 2 0 1 7 ] 36 SOCIAL COGNITION AND METACOGNITION The assessment of social cognition and metacognition—the cognitive domains infrequently measured as part of standard cognitive evaluations—may offer another m eans of detecting and tracking change across the AD spectrum. Social cognition has been referred to as the means by which individuals make sense of themselves in relation to others and the world around them 58 and the processes they engage to understand or interpret the self in relation to others. 59 Metacognition, in comparison, is one's knowledge about his or her own cognitive functioning and immediately proximal performance. While theoretically different constructs, metacognition can be considered to contribute to social cognition to the extent that preserved awareness of oneself and one's behavior promotes social interactions. Both elements of higher-level cognition are dissociable from general cognitive abilities and contribute to important functional outcomes, such as dependence in the case of social cognition 60 and decision making capacity in the case of metacognition, 61,62 and healthcare use. 6 3 Historically, both social cognition and metacognition in dementia have been evaluated based on information gathered from an informant or through clinical observation. Assessment of these areas has largely entailed evaluating elements of personality and behavior (social cognition), and symptom awareness (metacognition). In recent years, however, a number of performance-based measures have been applied, mostly in the context of research, to more precisely measure and understand the specific cognitive changes that underlie clinically observable changes in these areas. Such measures offer a promising means of identifying early signs of disease in high functioning individuals who may not yet evidence easily observable impairment, as well as more objective means of quantifying and tracking impairment. Indeed, changes in social cognition and metacognition have been reported as early as MCI, 64–67 but it is likely that subtle changes may be detectable even earlier. Social cognition is a multi-faceted, complex construct, a characteristic that both challenges and facilitates its m easurement. In one respect, the fact that many elements of cognition are considered to fall under its umbrella (e.g., perspective taking [theory of mind], emotion perception, knowledge of social norms, m oral reasoning, self-monitoring, and empathy), social cognition is difficult to quickly or comprehensively measure. 68 Viewed differently, such complexity offers many opportunities to examine the integrity of social cognition. A number of studies have examined elements of social cognition in AD using performance-based measures, revealing impairments in abilities such as processing facial emotions, 69 making moral judgments, 70 and comprehending social situations. 71 Thus while elements of social cognition are generally found to be preserved in AD as compared with frontotemporal dementia, 72 they are not fully preserved nor do they appear to be fully explained by general cognitive deficits. One of the most frequently applied performance-based measures of social cognition, the "theory of mind" (TOM) task, examines the degree to which individuals can attribute independent mental and emotional states to another— that is, to take another's perspective. 73 Aspects of TOM performance in both AD 74,75 and MCI 64–66 have been reported to be impaired in comparison with healthy older adults. Verdon et al 7 6 conducted a study to more closely examine the basis of TOM deficits in AD and to determine whether there was a specific deficit in reasoning about psychological intention as opposed to causality more generally. Results suggested that patients had selective impairment understanding when an individual's deliberate actions lead to an intended goal (i.e., the factors that cause individuals to behave). Moreover, this impairment was worse in individuals with more advanced disease, and preceded impaired reasoning regarding causes of physical events. Recent work has also attempted to look at TOM in a more natural context using a referential communication task. 65 Such a task enables examination of how speakers take into account experiences and perspectives shared with others through conversation. Individuals with MCI were found to rely less on mutually shared experiences than did healthy older adults, a nd this was not a reflection of impaired memory for such information. Accumulating evidence, therefore, suggests that a variety of performance- based tasks assessing social cognitive p rocesses, only a few of which were reviewed here, may offer an important means of detecting disease and tracking disease progress from its earliest stages. The use of performance-based tasks of metacognition is another area of potential utility. Several groups have shown that individuals with AD as a whole have greater difficulty monitoring their memory performance than healthy older adults. 76–78 That is, individuals with AD are less likely to make accurate estimations regarding episodic memory performance when queried in the context of metacognitive tasks such as "feeling of knowing" (FOK) or "judgment of learning" (JOL). Such tasks generate objective metrics of memory awareness, reflecting the degree to which individuals adjust their expectations for performance in accord with actual memory performance (e.g., resolution, relative accuracy) as well as the extent to which individuals are generally under or overconfident in their estimations (e.g., calibration, absolute accuracy). Objective metacognitive tasks also enable examination of the factors that influence self-assessment and the conditions under which it is best preserved. One compelling reason to further explore the utility of metacognitive tasks for measuring and tracking disease is that impaired performance on such tasks has been shown to relate to clinically observed deficits in self-awareness, 60 a disease symptom with important implications for patient decision making, safety, and independence. SUMMARY AND CONCLUSION It is apparent that the continued development of novel methods of cognitive and performance-based assessment is needed as the focus moves toward earlier and more reliable identification and treatment of earlier stages of AD. It is possible that the most viable strategies for both early detection and sensitivity to treatment of early-stage AD will be novel tasks that have shown sensitivity to pre- MCI states and have been validated against

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