Philip D. Harvey, PhD

Technology is pervasive, and for many people, it is central to their daily activities. Younger people who have been exposed to technology for their entire lives take this for granted, but older individuals often have had much less experience with it. Many technological developments that are now a part of most people’s daily life, such as personal computers, cell phones, and automated teller machines (ATMs), have occurred in the past 4 decades, with the pace accelerating in the last 15 to 20 years.

Such changes have had a substantial impact on older adults who were never exposed to these technologies during their working life. For example, an 85-year-old person who retired at age 65 would probably have not been exposed to wireless internet prior to retirement. Therefore, all of the tasks that they are now required to complete online would have been performed in other ways. Banking, accessing instruction manuals for new devices, and even scheduling and confirming health care appointments and accessing medical records all now require individuals to have a level of technological skills that many older individuals find challenging. At times, this can limit their ability to complete routine daily activities, and also can have clinical implications (Table).

Fortunately, there are strategies clinicians can use to help their older patients face these challenges. In this article, we describe the cognitive domains associated with learning technological skills, how aging affects these domains, and what can be done to help older adults improve their technological skills.

Limited training on how to use new technology

Technological skills are similar to any other skills in one critical way: they need to be learned. At the same time, technological skills also differ from many other skills, such as playing a musical instrument, because of the constant updating of devices, programs, and applications. When smartphones or computers update their operating systems, the visual appearance of the screen and the way that tasks are performed also can change. Buttons can move and sequences of commands can be altered. Updates often happen with little or no notice, and users may need to navigate a completely different device landscape in order to perform tasks that they had previously mastered.

In addition, the creators/distributors of technology typically provide little training or documentation. Further, institutions such as banks or health care systems frequently do not provide any specific training for using their systems. For example, when patients are required to use technology to refill prescriptions, typically there is no training available on how the system operates.

Cognitive domains associated with technological skills

Because there are minimal opportunities to receive training in how to use most aspects of technology, users have to be able to learn by exposure and experience. This requires several different cognitive abilities to work together. In a recent review, Harvey¹ described cognition and cognitive assessment in the general population, with a focus on cognitive domains. Here we discuss several of these domains in terms of the relationship to real-world functional tasks and discuss their importance for mastering technology.

Reasoning and problem solving. Because most technological devices and applications are designed to be “intuitive,” the user needs to be able to adopt a sequential approach to learning the task. For example, using the internet to refill a prescription requires several steps:

• accessing the internet
• finding the pharmacy web site
• establishing a user ID and password
• navigating the web site to the prescriptions section
• identifying the correct prescription
• requesting the refill
• selecting the pickup date and time.

Continue to: After navigating these steps...

After navigating these steps, an individual still needs other cognitive abilities to refill other prescriptions later. However, executive functioning is also critical for maintaining organization across different technological demands. For example, web sites have different password rules and require frequent changes without re-using old passwords, so it becomes critical to maintain an organized list of web site addresses and their passwords.

Refilling a prescription with a telephone voice menu also requires a series of steps. Typically, this process is simpler than an internet refill, because no log-in information is necessary. However, it still requires a structured series of tasks.

Working memory refers to the ability to hold information in consciousness long enough to operate on it. At each step of the navigation process, the user needs to remember which steps he/she has already completed, because repeating steps can slow down the process or lead to error messages. Thus, remembering which steps have been completed is as critical for performing tasks as is correctly understanding the anticipated sequence of steps. Further, when a password is forgotten, the user needs to remember the newly provided password.

Working memory can be spatial as well. For example, most web sites do not display a password while it is being entered, which eliminates spatial working memory from the equation. Thus, the ability to remember which characters have been entered and which still need to be entered is necessary.

Episodic memory is the process of learning and retaining newly presented verbal or spatial information as well as recalling it later for adaptive use. After successfully using a new technology, it is critical to be able to remember what to do the next time it is used. This includes both recalling how to access the technology (including the web address, user ID, and password), recalling the steps needed to be performed and their sequence, and recognizing the buttons and instructions presented onscreen.

Continue to: Procedural memory

Procedural memory is memory for motor acts and sequences. For instance, remembering how to ride a bicycle is a procedural memory, as is the ability to perform motor acts in sequence, such as peeling, cutting, and cooking vegetables. Interestingly, procedural memory can be spared in individuals with major challenges in episodic memory, such as those with amnestic conditions or cortical dementia. Thus, it may be possible for people to continue to perform technology-based skills despite declines in episodic memory. Many current technological functional tasks have fixed sequences of events that, if remembered, can lead to increased efficiency and higher chances of success in performance of functional tasks.

Prospective memory is the ability to remember to perform tasks in the future. This can include event-related tasks (eg, enter your password before trying to make a hotel reservation on a web site) or time-related tasks (eg, refill your prescriptions next Friday). Technology can actually facilitate prospective memory by providing reminders to individuals, such as alarms for appointments. However, prospective memory is required to initially set up such alarms, and setting up confusing or incorrect alarms can impede task performance.

Processing speed is the ability to perform cognitively demanding tasks under time constraints. Traditional processing speed tasks include coding and sorting tasks, which require processing new information and effort for relatively short periods of time. In our research, we discovered that processing speed measured with traditional tests was strongly correlated with the time required to perform functional tasks such as an ATM banking task.^2,3 This correlation makes sense in terms of the fact that many real-world functional tasks with technology often have a series of sequential demands that must be accomplished before progression to the next task.

Manual dexterity is also important for using technology. Many electronic devices have small, touch screen-based keyboards. Being able to touch the correct key requires dexterity and can be made more difficult by age-related vision changes, a tremor, or reduced sensation in extremities.

Cognitive changes and aging

It is normal for certain cognitive abilities to change with aging. There are a set of cognitive skills that are generally stable from early adulthood until the early “senescent” period. Some of these skills decline normatively after age 60 to 65, or earlier in some individuals. These include processing new information, solving new problems, and learning and remembering information. Referred to as “fluid intelligence,” these abilities show age-related decline during healthy aging, and even greater decline in individuals with age-related cognitive conditions.

Continue to: On the other hand...

On the other hand, some cognitive abilities do not decline with aging. These include previously acquired knowledge, such as vocabulary and mathematics skills, as well as factual information, such as academic information and the faces of familiar people. These are referred to as “crystallized intelligence,” and there is limited evidence that they decline with age. In fact, these abilities do not decline until the moderately severe stage of cortical dementias, and are commonly used to index premorbid cognitive functioning and cognitive reserve.

Why is this distinction between fluid intelligence and crystallized intelligence important? As noted above, many older people do not have early-life experience with technology. Thus, their crystallized intelligence, which is not as vulnerable to decline with aging, does not include information about how to perform many technological tasks. In contrast to today’s adolescents and young adults, older adults’ academic history typically does not include using smartphones, doing homework via Google Docs, or having homework and classwork assigned via the internet.

Learning how to use new technology requires fluid intelligence, and these abilities are less efficient in older adults. So for many older people, technological tasks can be complex and unfamiliar, and the skills needed to learn how to perform them are also more limited, even in comparison to older adults’ own ability when younger. Because many technology-based activities require concurrent performance of multiple tasks, older adults are at a disadvantage.⁴ It is not surprising, therefore, that a subset of older adults rate their technology skills as weak, and technology-based tasks as challenging or anxiety-provoking.

However, studies show most older adults’ attitudes toward technology remain largely positive, and that they are capable of attaining the necessary skills to use information and communication technology.^4,5 An individual’s perception of his/her age, age-related beliefs, and self-efficacy are associated not only with attitudes toward technology, but possibly with cognition itself.⁶

Education level and socioeconomic factors also influence a person’s ability to become proficient in using technology.^7-9 In fact, socioeconomic factors are more strongly related to access to the internet than age. Many older adults have internet access, but this access does not always translate into full use of its services.

Continue to: The Box...

The Box^10-22 describes some of the effects of aging on the brain, and how these changes are reflected in cognitive abilities.

Box

The role of cognitive training

Existing interventions for helping older adults improve their technology proficiency generally focus on improving cognition, and not necessarily on addressing skills learning. Skills learning and cognition are related; however, the brain depends on neural plasticity for skills learning, whereas cognitive declines are a result of gradual and functional worsening of memory, processing speed, executive functioning, and attention.²³ Interventions such as cognitive strategy training are capable of altering brain neurocircuitry to improve attention and memory.^10,11 Other interventions known to improve cognition include exercise¹⁰ and processing speed training.²⁴ On the other hand, skills learning is more effectively targeted by interventions that focus on stimulating realistic environments to mimic activities of daily living that involve technology.

Studies have consistently demonstrated cognitive improvements associated with computerized cognitive training (CCT). The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study was designed to evaluate the efficacy of cognitive training in 2,832 healthy adults age >65 across 6 recruitment sites in the United States.²⁵ Participants were randomized to a control group (no treatment) or to 1 of 3 treatment groups:

• memory strategy training (instructor-led, not computerized)
• reasoning training (instructor-led, not computerized)
• speed training (no instructor, adaptive computerized training).

Each treatment group received 10 sessions of classroom-based training (1 hour each, twice per week for 5 weeks). Following the intervention, participants who had completed ≥8 sessions were randomized to receive 4 booster sessions at 11 and 35 months after the initial training, or no booster sessions.

Each cognitive training program significantly improved performance on within-domain cognitive tests relative to the control group. Effect sizes were large immediately following training; they declined over time, but were still significant at 10-year follow-up. As hypothesized, training effects did not generalize to neuropsychological tests in other training domains. The booster subgroup of speed training showed improved performance on a separate functional speed measure at 2-year²⁶ and 5-year follow-up.²⁷ Each condition showed slower decline in instrumental activities of daily living relative to the control group.

Continue to: The Figure...

The Figure shows the type of stimuli presented in the speed training, a procedure where individuals are taught high-speed multitasking by having to identify and locate visual information quickly in a divided-attention format. A stimulus appears in the center of the screen—either a car or a truck—and at the same time, a “Route 66” sign appears in the periphery. For every successful response, the next stimulus is presented at a shorter duration after every successful response, and more slowly after errors.

Secondary outcome analyses demonstrated that for older adults, speed training reduced rates of driving cessation,²⁷ improved driving habits, and lowered the incidence of at-fault crashes²⁸ (based on motor vehicle records). Speed training also resulted in improvements in health-related quality of life,^29,30 depression,³¹ locus of control,³² and medical expenditures.³³ An analysis of 10-year outcomes³⁴ found that speed training was associated with a 29% reduction in risk of developing of dementia, while the other 2 interventions were not. However, despite these multiple areas of benefit, there was no evidence that new functional skills were acquired as a result of the training.^26-34

Functional skills training

While there is a long history of using functional skills training to help patients with schizophrenia, for healthy older people, there are considerably more challenges. First, aging is not a disease. Consequently, functional skills training is typically not covered by health insurance. Second, functional skills training delivered by a human trainer can be expensive and is not readily available. Finally, there are no real curricula for training functional skills, particularly those that are device-based (phone, tablet, or computer).

Recently, researchers have developed a functional skills assessment and training program that was originally piloted as a fixed difficulty simulation as described in 2 studies by Czaja et al.^2,3 The original assessment was used to compare healthy control individuals with people with mild cognitive impairment (MCI) or schizophrenia. Most recently, training modules for 6 different technology-based functional tasks have been developed and piloted in samples of healthy controls and patients with MCI in a randomized trial.³⁵ Half of the participants in each of the 2 groups were randomized to receive speed training similar to the ACTIVE study, and the other half received skills training alone. All participants were trained for 24 sessions over 12 weeks or until they mastered all 6 simulations.

Both patients with MCI and healthy controls improved in all 6 simulations. Although patients with MCI were considerably less efficient at baseline, their training gains per session were equivalent to that of healthy controls. Finally, concurrent cognitive training increased the efficiency of skills training. At the end of the study, functional gains were the same for people in both groups randomized to either condition, even though individuals in the combined cognitive and skills training interventions received only half as much skills training time.

Continue to: What to tell patients

What to tell patients

Older patients might ask their clinicians what they can do to “exercise their brain.” Let them know that CCT has been shown to improve cognitive performance in healthy older people, and that there are several evidence-based, commercially available products for this purpose. Two such self-administrable systems with supportive data are BrainHQ (www.brainhq.com) and Happy Neuron (www.happy-neuron.com). Explain that it is likely that the best strategy is a combination of cognitive and functional skills training. One commercially available functional skills training program with supportive data is i-Function (www.i-Function.com). (Editor’s note: One of the authors, PDH, is an employee of i-Function, Inc.)

Bottom Line

Clinicians should ensure older patients that they have the cognitive capacity to learn new technology-related functional skills, and that such patients have the opportunity to learn these skills. Clinicians need to be able to identify people who are at high risk of not being able to adhere to instructions and suggestions that require interactions with technology. Treatment options include computerized cognitive training and functional skills training.

Related Resources

• Hill NT, Mowszowski L, Naismith SL, et al. Computerized cognitive training in older adults with mild cognitive impairment or dementia: a systematic review and metaanalysis. Am J Psychiatry. 2017;174(4):329-340.
• Harvey PD, McGurk SR, Mahncke H, et al. Controversies in computerized cognitive training. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3(11):907-915.

Technology is pervasive, and for many people, it is central to their daily activities. Younger people who have been exposed to technology for their entire lives take this for granted, but older individuals often have had much less experience with it. Many technological developments that are now a part of most people’s daily life, such as personal computers, cell phones, and automated teller machines (ATMs), have occurred in the past 4 decades, with the pace accelerating in the last 15 to 20 years.

Such changes have had a substantial impact on older adults who were never exposed to these technologies during their working life. For example, an 85-year-old person who retired at age 65 would probably have not been exposed to wireless internet prior to retirement. Therefore, all of the tasks that they are now required to complete online would have been performed in other ways. Banking, accessing instruction manuals for new devices, and even scheduling and confirming health care appointments and accessing medical records all now require individuals to have a level of technological skills that many older individuals find challenging. At times, this can limit their ability to complete routine daily activities, and also can have clinical implications (Table).

Fortunately, there are strategies clinicians can use to help their older patients face these challenges. In this article, we describe the cognitive domains associated with learning technological skills, how aging affects these domains, and what can be done to help older adults improve their technological skills.

Limited training on how to use new technology

Technological skills are similar to any other skills in one critical way: they need to be learned. At the same time, technological skills also differ from many other skills, such as playing a musical instrument, because of the constant updating of devices, programs, and applications. When smartphones or computers update their operating systems, the visual appearance of the screen and the way that tasks are performed also can change. Buttons can move and sequences of commands can be altered. Updates often happen with little or no notice, and users may need to navigate a completely different device landscape in order to perform tasks that they had previously mastered.

In addition, the creators/distributors of technology typically provide little training or documentation. Further, institutions such as banks or health care systems frequently do not provide any specific training for using their systems. For example, when patients are required to use technology to refill prescriptions, typically there is no training available on how the system operates.

Cognitive domains associated with technological skills

Because there are minimal opportunities to receive training in how to use most aspects of technology, users have to be able to learn by exposure and experience. This requires several different cognitive abilities to work together. In a recent review, Harvey¹ described cognition and cognitive assessment in the general population, with a focus on cognitive domains. Here we discuss several of these domains in terms of the relationship to real-world functional tasks and discuss their importance for mastering technology.

Reasoning and problem solving. Because most technological devices and applications are designed to be “intuitive,” the user needs to be able to adopt a sequential approach to learning the task. For example, using the internet to refill a prescription requires several steps:

• accessing the internet
• finding the pharmacy web site
• establishing a user ID and password
• navigating the web site to the prescriptions section
• identifying the correct prescription
• requesting the refill
• selecting the pickup date and time.

Continue to: After navigating these steps...

After navigating these steps, an individual still needs other cognitive abilities to refill other prescriptions later. However, executive functioning is also critical for maintaining organization across different technological demands. For example, web sites have different password rules and require frequent changes without re-using old passwords, so it becomes critical to maintain an organized list of web site addresses and their passwords.

Refilling a prescription with a telephone voice menu also requires a series of steps. Typically, this process is simpler than an internet refill, because no log-in information is necessary. However, it still requires a structured series of tasks.

Working memory refers to the ability to hold information in consciousness long enough to operate on it. At each step of the navigation process, the user needs to remember which steps he/she has already completed, because repeating steps can slow down the process or lead to error messages. Thus, remembering which steps have been completed is as critical for performing tasks as is correctly understanding the anticipated sequence of steps. Further, when a password is forgotten, the user needs to remember the newly provided password.

Working memory can be spatial as well. For example, most web sites do not display a password while it is being entered, which eliminates spatial working memory from the equation. Thus, the ability to remember which characters have been entered and which still need to be entered is necessary.

Episodic memory is the process of learning and retaining newly presented verbal or spatial information as well as recalling it later for adaptive use. After successfully using a new technology, it is critical to be able to remember what to do the next time it is used. This includes both recalling how to access the technology (including the web address, user ID, and password), recalling the steps needed to be performed and their sequence, and recognizing the buttons and instructions presented onscreen.

Continue to: Procedural memory

Procedural memory is memory for motor acts and sequences. For instance, remembering how to ride a bicycle is a procedural memory, as is the ability to perform motor acts in sequence, such as peeling, cutting, and cooking vegetables. Interestingly, procedural memory can be spared in individuals with major challenges in episodic memory, such as those with amnestic conditions or cortical dementia. Thus, it may be possible for people to continue to perform technology-based skills despite declines in episodic memory. Many current technological functional tasks have fixed sequences of events that, if remembered, can lead to increased efficiency and higher chances of success in performance of functional tasks.

Prospective memory is the ability to remember to perform tasks in the future. This can include event-related tasks (eg, enter your password before trying to make a hotel reservation on a web site) or time-related tasks (eg, refill your prescriptions next Friday). Technology can actually facilitate prospective memory by providing reminders to individuals, such as alarms for appointments. However, prospective memory is required to initially set up such alarms, and setting up confusing or incorrect alarms can impede task performance.

Processing speed is the ability to perform cognitively demanding tasks under time constraints. Traditional processing speed tasks include coding and sorting tasks, which require processing new information and effort for relatively short periods of time. In our research, we discovered that processing speed measured with traditional tests was strongly correlated with the time required to perform functional tasks such as an ATM banking task.^2,3 This correlation makes sense in terms of the fact that many real-world functional tasks with technology often have a series of sequential demands that must be accomplished before progression to the next task.

Manual dexterity is also important for using technology. Many electronic devices have small, touch screen-based keyboards. Being able to touch the correct key requires dexterity and can be made more difficult by age-related vision changes, a tremor, or reduced sensation in extremities.

Cognitive changes and aging

It is normal for certain cognitive abilities to change with aging. There are a set of cognitive skills that are generally stable from early adulthood until the early “senescent” period. Some of these skills decline normatively after age 60 to 65, or earlier in some individuals. These include processing new information, solving new problems, and learning and remembering information. Referred to as “fluid intelligence,” these abilities show age-related decline during healthy aging, and even greater decline in individuals with age-related cognitive conditions.

Continue to: On the other hand...

On the other hand, some cognitive abilities do not decline with aging. These include previously acquired knowledge, such as vocabulary and mathematics skills, as well as factual information, such as academic information and the faces of familiar people. These are referred to as “crystallized intelligence,” and there is limited evidence that they decline with age. In fact, these abilities do not decline until the moderately severe stage of cortical dementias, and are commonly used to index premorbid cognitive functioning and cognitive reserve.

Why is this distinction between fluid intelligence and crystallized intelligence important? As noted above, many older people do not have early-life experience with technology. Thus, their crystallized intelligence, which is not as vulnerable to decline with aging, does not include information about how to perform many technological tasks. In contrast to today’s adolescents and young adults, older adults’ academic history typically does not include using smartphones, doing homework via Google Docs, or having homework and classwork assigned via the internet.

Learning how to use new technology requires fluid intelligence, and these abilities are less efficient in older adults. So for many older people, technological tasks can be complex and unfamiliar, and the skills needed to learn how to perform them are also more limited, even in comparison to older adults’ own ability when younger. Because many technology-based activities require concurrent performance of multiple tasks, older adults are at a disadvantage.⁴ It is not surprising, therefore, that a subset of older adults rate their technology skills as weak, and technology-based tasks as challenging or anxiety-provoking.

However, studies show most older adults’ attitudes toward technology remain largely positive, and that they are capable of attaining the necessary skills to use information and communication technology.^4,5 An individual’s perception of his/her age, age-related beliefs, and self-efficacy are associated not only with attitudes toward technology, but possibly with cognition itself.⁶

Education level and socioeconomic factors also influence a person’s ability to become proficient in using technology.^7-9 In fact, socioeconomic factors are more strongly related to access to the internet than age. Many older adults have internet access, but this access does not always translate into full use of its services.

Continue to: The Box...

The Box^10-22 describes some of the effects of aging on the brain, and how these changes are reflected in cognitive abilities.

Box

The role of cognitive training

Existing interventions for helping older adults improve their technology proficiency generally focus on improving cognition, and not necessarily on addressing skills learning. Skills learning and cognition are related; however, the brain depends on neural plasticity for skills learning, whereas cognitive declines are a result of gradual and functional worsening of memory, processing speed, executive functioning, and attention.²³ Interventions such as cognitive strategy training are capable of altering brain neurocircuitry to improve attention and memory.^10,11 Other interventions known to improve cognition include exercise¹⁰ and processing speed training.²⁴ On the other hand, skills learning is more effectively targeted by interventions that focus on stimulating realistic environments to mimic activities of daily living that involve technology.

Studies have consistently demonstrated cognitive improvements associated with computerized cognitive training (CCT). The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study was designed to evaluate the efficacy of cognitive training in 2,832 healthy adults age >65 across 6 recruitment sites in the United States.²⁵ Participants were randomized to a control group (no treatment) or to 1 of 3 treatment groups:

• memory strategy training (instructor-led, not computerized)
• reasoning training (instructor-led, not computerized)
• speed training (no instructor, adaptive computerized training).

Each treatment group received 10 sessions of classroom-based training (1 hour each, twice per week for 5 weeks). Following the intervention, participants who had completed ≥8 sessions were randomized to receive 4 booster sessions at 11 and 35 months after the initial training, or no booster sessions.

Each cognitive training program significantly improved performance on within-domain cognitive tests relative to the control group. Effect sizes were large immediately following training; they declined over time, but were still significant at 10-year follow-up. As hypothesized, training effects did not generalize to neuropsychological tests in other training domains. The booster subgroup of speed training showed improved performance on a separate functional speed measure at 2-year²⁶ and 5-year follow-up.²⁷ Each condition showed slower decline in instrumental activities of daily living relative to the control group.

Continue to: The Figure...

The Figure shows the type of stimuli presented in the speed training, a procedure where individuals are taught high-speed multitasking by having to identify and locate visual information quickly in a divided-attention format. A stimulus appears in the center of the screen—either a car or a truck—and at the same time, a “Route 66” sign appears in the periphery. For every successful response, the next stimulus is presented at a shorter duration after every successful response, and more slowly after errors.

Secondary outcome analyses demonstrated that for older adults, speed training reduced rates of driving cessation,²⁷ improved driving habits, and lowered the incidence of at-fault crashes²⁸ (based on motor vehicle records). Speed training also resulted in improvements in health-related quality of life,^29,30 depression,³¹ locus of control,³² and medical expenditures.³³ An analysis of 10-year outcomes³⁴ found that speed training was associated with a 29% reduction in risk of developing of dementia, while the other 2 interventions were not. However, despite these multiple areas of benefit, there was no evidence that new functional skills were acquired as a result of the training.^26-34

Functional skills training

While there is a long history of using functional skills training to help patients with schizophrenia, for healthy older people, there are considerably more challenges. First, aging is not a disease. Consequently, functional skills training is typically not covered by health insurance. Second, functional skills training delivered by a human trainer can be expensive and is not readily available. Finally, there are no real curricula for training functional skills, particularly those that are device-based (phone, tablet, or computer).

Recently, researchers have developed a functional skills assessment and training program that was originally piloted as a fixed difficulty simulation as described in 2 studies by Czaja et al.^2,3 The original assessment was used to compare healthy control individuals with people with mild cognitive impairment (MCI) or schizophrenia. Most recently, training modules for 6 different technology-based functional tasks have been developed and piloted in samples of healthy controls and patients with MCI in a randomized trial.³⁵ Half of the participants in each of the 2 groups were randomized to receive speed training similar to the ACTIVE study, and the other half received skills training alone. All participants were trained for 24 sessions over 12 weeks or until they mastered all 6 simulations.

Both patients with MCI and healthy controls improved in all 6 simulations. Although patients with MCI were considerably less efficient at baseline, their training gains per session were equivalent to that of healthy controls. Finally, concurrent cognitive training increased the efficiency of skills training. At the end of the study, functional gains were the same for people in both groups randomized to either condition, even though individuals in the combined cognitive and skills training interventions received only half as much skills training time.

Continue to: What to tell patients

What to tell patients

Older patients might ask their clinicians what they can do to “exercise their brain.” Let them know that CCT has been shown to improve cognitive performance in healthy older people, and that there are several evidence-based, commercially available products for this purpose. Two such self-administrable systems with supportive data are BrainHQ (www.brainhq.com) and Happy Neuron (www.happy-neuron.com). Explain that it is likely that the best strategy is a combination of cognitive and functional skills training. One commercially available functional skills training program with supportive data is i-Function (www.i-Function.com). (Editor’s note: One of the authors, PDH, is an employee of i-Function, Inc.)

Bottom Line

Clinicians should ensure older patients that they have the cognitive capacity to learn new technology-related functional skills, and that such patients have the opportunity to learn these skills. Clinicians need to be able to identify people who are at high risk of not being able to adhere to instructions and suggestions that require interactions with technology. Treatment options include computerized cognitive training and functional skills training.

Related Resources

• Hill NT, Mowszowski L, Naismith SL, et al. Computerized cognitive training in older adults with mild cognitive impairment or dementia: a systematic review and metaanalysis. Am J Psychiatry. 2017;174(4):329-340.
• Harvey PD, McGurk SR, Mahncke H, et al. Controversies in computerized cognitive training. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3(11):907-915.

Technology is pervasive, and for many people, it is central to their daily activities. Younger people who have been exposed to technology for their entire lives take this for granted, but older individuals often have had much less experience with it. Many technological developments that are now a part of most people’s daily life, such as personal computers, cell phones, and automated teller machines (ATMs), have occurred in the past 4 decades, with the pace accelerating in the last 15 to 20 years.

Such changes have had a substantial impact on older adults who were never exposed to these technologies during their working life. For example, an 85-year-old person who retired at age 65 would probably have not been exposed to wireless internet prior to retirement. Therefore, all of the tasks that they are now required to complete online would have been performed in other ways. Banking, accessing instruction manuals for new devices, and even scheduling and confirming health care appointments and accessing medical records all now require individuals to have a level of technological skills that many older individuals find challenging. At times, this can limit their ability to complete routine daily activities, and also can have clinical implications (Table).

Fortunately, there are strategies clinicians can use to help their older patients face these challenges. In this article, we describe the cognitive domains associated with learning technological skills, how aging affects these domains, and what can be done to help older adults improve their technological skills.

Limited training on how to use new technology

Technological skills are similar to any other skills in one critical way: they need to be learned. At the same time, technological skills also differ from many other skills, such as playing a musical instrument, because of the constant updating of devices, programs, and applications. When smartphones or computers update their operating systems, the visual appearance of the screen and the way that tasks are performed also can change. Buttons can move and sequences of commands can be altered. Updates often happen with little or no notice, and users may need to navigate a completely different device landscape in order to perform tasks that they had previously mastered.

In addition, the creators/distributors of technology typically provide little training or documentation. Further, institutions such as banks or health care systems frequently do not provide any specific training for using their systems. For example, when patients are required to use technology to refill prescriptions, typically there is no training available on how the system operates.

Cognitive domains associated with technological skills

Because there are minimal opportunities to receive training in how to use most aspects of technology, users have to be able to learn by exposure and experience. This requires several different cognitive abilities to work together. In a recent review, Harvey¹ described cognition and cognitive assessment in the general population, with a focus on cognitive domains. Here we discuss several of these domains in terms of the relationship to real-world functional tasks and discuss their importance for mastering technology.

Reasoning and problem solving. Because most technological devices and applications are designed to be “intuitive,” the user needs to be able to adopt a sequential approach to learning the task. For example, using the internet to refill a prescription requires several steps:

• accessing the internet
• finding the pharmacy web site
• establishing a user ID and password
• navigating the web site to the prescriptions section
• identifying the correct prescription
• requesting the refill
• selecting the pickup date and time.

Continue to: After navigating these steps...

After navigating these steps, an individual still needs other cognitive abilities to refill other prescriptions later. However, executive functioning is also critical for maintaining organization across different technological demands. For example, web sites have different password rules and require frequent changes without re-using old passwords, so it becomes critical to maintain an organized list of web site addresses and their passwords.

Refilling a prescription with a telephone voice menu also requires a series of steps. Typically, this process is simpler than an internet refill, because no log-in information is necessary. However, it still requires a structured series of tasks.

Working memory refers to the ability to hold information in consciousness long enough to operate on it. At each step of the navigation process, the user needs to remember which steps he/she has already completed, because repeating steps can slow down the process or lead to error messages. Thus, remembering which steps have been completed is as critical for performing tasks as is correctly understanding the anticipated sequence of steps. Further, when a password is forgotten, the user needs to remember the newly provided password.

Working memory can be spatial as well. For example, most web sites do not display a password while it is being entered, which eliminates spatial working memory from the equation. Thus, the ability to remember which characters have been entered and which still need to be entered is necessary.

Episodic memory is the process of learning and retaining newly presented verbal or spatial information as well as recalling it later for adaptive use. After successfully using a new technology, it is critical to be able to remember what to do the next time it is used. This includes both recalling how to access the technology (including the web address, user ID, and password), recalling the steps needed to be performed and their sequence, and recognizing the buttons and instructions presented onscreen.

Continue to: Procedural memory

Procedural memory is memory for motor acts and sequences. For instance, remembering how to ride a bicycle is a procedural memory, as is the ability to perform motor acts in sequence, such as peeling, cutting, and cooking vegetables. Interestingly, procedural memory can be spared in individuals with major challenges in episodic memory, such as those with amnestic conditions or cortical dementia. Thus, it may be possible for people to continue to perform technology-based skills despite declines in episodic memory. Many current technological functional tasks have fixed sequences of events that, if remembered, can lead to increased efficiency and higher chances of success in performance of functional tasks.

Prospective memory is the ability to remember to perform tasks in the future. This can include event-related tasks (eg, enter your password before trying to make a hotel reservation on a web site) or time-related tasks (eg, refill your prescriptions next Friday). Technology can actually facilitate prospective memory by providing reminders to individuals, such as alarms for appointments. However, prospective memory is required to initially set up such alarms, and setting up confusing or incorrect alarms can impede task performance.

Processing speed is the ability to perform cognitively demanding tasks under time constraints. Traditional processing speed tasks include coding and sorting tasks, which require processing new information and effort for relatively short periods of time. In our research, we discovered that processing speed measured with traditional tests was strongly correlated with the time required to perform functional tasks such as an ATM banking task.^2,3 This correlation makes sense in terms of the fact that many real-world functional tasks with technology often have a series of sequential demands that must be accomplished before progression to the next task.

Manual dexterity is also important for using technology. Many electronic devices have small, touch screen-based keyboards. Being able to touch the correct key requires dexterity and can be made more difficult by age-related vision changes, a tremor, or reduced sensation in extremities.

Cognitive changes and aging

It is normal for certain cognitive abilities to change with aging. There are a set of cognitive skills that are generally stable from early adulthood until the early “senescent” period. Some of these skills decline normatively after age 60 to 65, or earlier in some individuals. These include processing new information, solving new problems, and learning and remembering information. Referred to as “fluid intelligence,” these abilities show age-related decline during healthy aging, and even greater decline in individuals with age-related cognitive conditions.

Continue to: On the other hand...

On the other hand, some cognitive abilities do not decline with aging. These include previously acquired knowledge, such as vocabulary and mathematics skills, as well as factual information, such as academic information and the faces of familiar people. These are referred to as “crystallized intelligence,” and there is limited evidence that they decline with age. In fact, these abilities do not decline until the moderately severe stage of cortical dementias, and are commonly used to index premorbid cognitive functioning and cognitive reserve.

Why is this distinction between fluid intelligence and crystallized intelligence important? As noted above, many older people do not have early-life experience with technology. Thus, their crystallized intelligence, which is not as vulnerable to decline with aging, does not include information about how to perform many technological tasks. In contrast to today’s adolescents and young adults, older adults’ academic history typically does not include using smartphones, doing homework via Google Docs, or having homework and classwork assigned via the internet.

Learning how to use new technology requires fluid intelligence, and these abilities are less efficient in older adults. So for many older people, technological tasks can be complex and unfamiliar, and the skills needed to learn how to perform them are also more limited, even in comparison to older adults’ own ability when younger. Because many technology-based activities require concurrent performance of multiple tasks, older adults are at a disadvantage.⁴ It is not surprising, therefore, that a subset of older adults rate their technology skills as weak, and technology-based tasks as challenging or anxiety-provoking.

However, studies show most older adults’ attitudes toward technology remain largely positive, and that they are capable of attaining the necessary skills to use information and communication technology.^4,5 An individual’s perception of his/her age, age-related beliefs, and self-efficacy are associated not only with attitudes toward technology, but possibly with cognition itself.⁶

Education level and socioeconomic factors also influence a person’s ability to become proficient in using technology.^7-9 In fact, socioeconomic factors are more strongly related to access to the internet than age. Many older adults have internet access, but this access does not always translate into full use of its services.

Continue to: The Box...

The Box^10-22 describes some of the effects of aging on the brain, and how these changes are reflected in cognitive abilities.

Box

The role of cognitive training

Existing interventions for helping older adults improve their technology proficiency generally focus on improving cognition, and not necessarily on addressing skills learning. Skills learning and cognition are related; however, the brain depends on neural plasticity for skills learning, whereas cognitive declines are a result of gradual and functional worsening of memory, processing speed, executive functioning, and attention.²³ Interventions such as cognitive strategy training are capable of altering brain neurocircuitry to improve attention and memory.^10,11 Other interventions known to improve cognition include exercise¹⁰ and processing speed training.²⁴ On the other hand, skills learning is more effectively targeted by interventions that focus on stimulating realistic environments to mimic activities of daily living that involve technology.

Studies have consistently demonstrated cognitive improvements associated with computerized cognitive training (CCT). The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study was designed to evaluate the efficacy of cognitive training in 2,832 healthy adults age >65 across 6 recruitment sites in the United States.²⁵ Participants were randomized to a control group (no treatment) or to 1 of 3 treatment groups:

• memory strategy training (instructor-led, not computerized)
• reasoning training (instructor-led, not computerized)
• speed training (no instructor, adaptive computerized training).

Each treatment group received 10 sessions of classroom-based training (1 hour each, twice per week for 5 weeks). Following the intervention, participants who had completed ≥8 sessions were randomized to receive 4 booster sessions at 11 and 35 months after the initial training, or no booster sessions.

Each cognitive training program significantly improved performance on within-domain cognitive tests relative to the control group. Effect sizes were large immediately following training; they declined over time, but were still significant at 10-year follow-up. As hypothesized, training effects did not generalize to neuropsychological tests in other training domains. The booster subgroup of speed training showed improved performance on a separate functional speed measure at 2-year²⁶ and 5-year follow-up.²⁷ Each condition showed slower decline in instrumental activities of daily living relative to the control group.

Continue to: The Figure...

The Figure shows the type of stimuli presented in the speed training, a procedure where individuals are taught high-speed multitasking by having to identify and locate visual information quickly in a divided-attention format. A stimulus appears in the center of the screen—either a car or a truck—and at the same time, a “Route 66” sign appears in the periphery. For every successful response, the next stimulus is presented at a shorter duration after every successful response, and more slowly after errors.

Secondary outcome analyses demonstrated that for older adults, speed training reduced rates of driving cessation,²⁷ improved driving habits, and lowered the incidence of at-fault crashes²⁸ (based on motor vehicle records). Speed training also resulted in improvements in health-related quality of life,^29,30 depression,³¹ locus of control,³² and medical expenditures.³³ An analysis of 10-year outcomes³⁴ found that speed training was associated with a 29% reduction in risk of developing of dementia, while the other 2 interventions were not. However, despite these multiple areas of benefit, there was no evidence that new functional skills were acquired as a result of the training.^26-34

Functional skills training

While there is a long history of using functional skills training to help patients with schizophrenia, for healthy older people, there are considerably more challenges. First, aging is not a disease. Consequently, functional skills training is typically not covered by health insurance. Second, functional skills training delivered by a human trainer can be expensive and is not readily available. Finally, there are no real curricula for training functional skills, particularly those that are device-based (phone, tablet, or computer).

Recently, researchers have developed a functional skills assessment and training program that was originally piloted as a fixed difficulty simulation as described in 2 studies by Czaja et al.^2,3 The original assessment was used to compare healthy control individuals with people with mild cognitive impairment (MCI) or schizophrenia. Most recently, training modules for 6 different technology-based functional tasks have been developed and piloted in samples of healthy controls and patients with MCI in a randomized trial.³⁵ Half of the participants in each of the 2 groups were randomized to receive speed training similar to the ACTIVE study, and the other half received skills training alone. All participants were trained for 24 sessions over 12 weeks or until they mastered all 6 simulations.

Both patients with MCI and healthy controls improved in all 6 simulations. Although patients with MCI were considerably less efficient at baseline, their training gains per session were equivalent to that of healthy controls. Finally, concurrent cognitive training increased the efficiency of skills training. At the end of the study, functional gains were the same for people in both groups randomized to either condition, even though individuals in the combined cognitive and skills training interventions received only half as much skills training time.

Continue to: What to tell patients

What to tell patients

Older patients might ask their clinicians what they can do to “exercise their brain.” Let them know that CCT has been shown to improve cognitive performance in healthy older people, and that there are several evidence-based, commercially available products for this purpose. Two such self-administrable systems with supportive data are BrainHQ (www.brainhq.com) and Happy Neuron (www.happy-neuron.com). Explain that it is likely that the best strategy is a combination of cognitive and functional skills training. One commercially available functional skills training program with supportive data is i-Function (www.i-Function.com). (Editor’s note: One of the authors, PDH, is an employee of i-Function, Inc.)

Bottom Line

Clinicians should ensure older patients that they have the cognitive capacity to learn new technology-related functional skills, and that such patients have the opportunity to learn these skills. Clinicians need to be able to identify people who are at high risk of not being able to adhere to instructions and suggestions that require interactions with technology. Treatment options include computerized cognitive training and functional skills training.

Related Resources

• Hill NT, Mowszowski L, Naismith SL, et al. Computerized cognitive training in older adults with mild cognitive impairment or dementia: a systematic review and metaanalysis. Am J Psychiatry. 2017;174(4):329-340.
• Harvey PD, McGurk SR, Mahncke H, et al. Controversies in computerized cognitive training. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3(11):907-915.

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.

Lack of insight or “unawareness of illness” occurs within a set of self-assessment problems commonly seen in schizophrenia.¹ In the clinical domain, people who do not realize they are ill typically are unwilling to accept treatment, including medication, with potential for worsened illness. They also may have difficulty self-assess­ing everyday function and functional potential, cognition, social cognition, and attitude, often to a variable degree across these domains (Table 1).^1-3

Self-assessment of performance can be clinically help­ful whether performance is objectively good or bad. Those with poor performance could be helped to attempt to match their aspirations to accomplishments and improve over time. Good performers could have their functioning bolstered by recognizing their competence. Thus, even a population whose performance often is poor could ben­efit from accurate self-assessment or experience additional challenges from inaccurate self-evaluation.

This article discusses patient characteristics associated with impairments in self-assessment and the most accu­rate sources of information for clinicians about patient functioning. Our research shows that an experienced psy­chiatrist is well positioned to make accurate judgments of functional potential and cognitive abilities for people with schizophrenia.

Patterns in patients with impaired self-assessment
Healthy individuals routinely overestimate their abilities and their attractiveness to others.⁴ Feedback that deflates these exag­gerated estimates increases the accuracy of their self-assessments. Mildly depressed individuals typically are the most accurate judges of their true functioning; those with more severe levels of depression tend to underestimate their competence. Thus, sim­ply being an inaccurate self-assessor is not “abnormal.” These response biases are con­sistent and predictable in healthy people.

People with severe mental illness pose a different challenge. As in the following cases, their reports manifest minimal cor­relation with other sources of information, including objective information about performance.

CASE 1
JR, age 28, is referred for occupational therapy because he has never worked since graduat­ing from high school. He tells the therapist his cognitive abilities are average and intact, although his scores on a comprehensive cog­nitive assessment suggest performance at the first percentile of normal distribution or less. His self-reported Beck Depression Inventory (BDI) score is 4. He says he would like to work as a certified public accountant, because he believes he has an aptitude for math. He admits he has no idea what the job entails, but he is quite motivated to set up an interview as soon as possible.

CASE 2
LM, age 48, says his “best job” was managing an auto parts store for 18 months after he earned an associate’s degree and until his second psychotic episode. His most recent work was approximately 12 years ago at an oil-change facility. He agrees to discuss employment but feels his vocational skills are too deteriorated for him to succeed and requests an assessment for Alzheimer’s disease. His cognitive perfor­mance averages in the 10th percentile of the overall population, and his BDI score is 18. Tests of his ability to perform vocational skills sug­gest he is qualified for multiple jobs, including his previous technician position.

Individuals with schizophrenia who report no depression and no work history routinely overestimate their functional potential, whereas those with a history of unsuccessful vocational attempts often underestimate their functional potential. Inaccurate self-assessment can contrib­ute to reduced functioning—in JR’s case because of unrealistic assessment of the match between skills and vocational poten­tial, and in LM’s case because of overly  pessimistic self-evaluation. For people with schizophrenia, inability to self-evaluate can have a bidirectional adverse impact on func­tioning: overestimation may lead to trying tasks that are too challenging, and under­estimation may lead to reduced effort and motivation to take on functional tasks.

Metacognition and introspective accuracy
“Metacognition” refers to self-assessment of the quality and accuracy of performance on cognitive tests.^5-7 Problem-solving tests— such as the Wisconsin Card Sorting test (WCST), in which the person being assessed needs to solve the test through performance feedback—are metacognition tests. When errors are made, the strategy in use needs to be discarded; when responses are correct, the strategy is retained. People with schizo­phrenia have disproportionate difficulties with the WCST, and deficits are especially salient when the test is modified to measure self-assessment of performance and ability to use feedback to change strategies.

“Introspective accuracy” is used to describe the wide-ranging self-assessment impairments in severe mental illness. Theories of metacognition implicate a broad spectrum, of which self-assessment is 1 component, whereas introspective accuracy more specifically indicates judg­ments of accuracy. Because self-assessment is focused on the self, and hence is intro­spective, this conceptualization can be applied to self-evaluations of:
   • achievement in everyday functioning (“Did I complete that task well?”)
   • potential for achievement in everyday functioning (“I could do that job”)
   • cognitive performance (“Yes, I remembered all of those words”)
   • social cognition (“He really is angry”).

Domains of impaired introspective accuracy
Everyday functioning. The 3 global domains of everyday functioning are social outcomes, productive/vocational out­comes, and everyday activities, including residential independence/support for peo­ple with severe mental illness. Two areas of inquiry are used in self-assessing everyday functioning: (1) what are you doing now and (2) what could you do in the future? For people with schizophrenia, a related question is how perceived impairments in everyday functioning are associated with subjective illness burden.

People with schizophrenia report illness burden consistent with their self-reported disability, suggesting their reports in these domains are not random.⁸ Studies have consistently found, however, that these patients report:
   • less impairment on average in their everyday functioning than observed by clinicians
   • less subjective illness burden com­pared with individuals with much less severe illnesses.

Their reports also fail to correlate with cli­nicians’ observations.9 Patients with schizo­phrenia who have never been employed may report greater vocational potential than those employed full-time. Interestingly, patients who were previously—but not currently—employed reported the least vocational potential.¹⁰ These data suggest that experience may be a factor: individuals who have never worked have no context for their self-assessments, whereas people who are persistently unemployed may have a perspective on the challenges associated with employment.

In our research,⁹ high-contact clinicians (ie, case manager, psychiatrist, therapist, or residential facility manager) were bet­ter able than family or friends to generate ratings from an assessment questionnaire that correlated with performance-based measures of patients’ ability to perform everyday functional skills. The ratings were generated across multiple functional status scales, suggesting that the rater was more important than the specific scale. We concluded that high-contact clinicians can generate ratings of everyday functioning that are convergent with patients’ abilities, even when they have no information about actual performance scores.

Cognitive performance. When self-reported cognitive abilities are correlated with the results of performance on neuro­psychological assessments, the results are quite consistent. Patients provide reports that do not correlate with their objective performance.¹¹ Interestingly, when clini­cians were asked to use the same strategies as patients to generate ratings of cognitive impairment, clinician ratings had consider­ably greater evidence of validity. In several studies, patients’ ratings of their cognitive performance did not correlate with their neuropsychological test performance, even though they had just been tested on the assessment battery. Ratings by clinicians or other high-contact informants (who were unaware of patients’ test performance) were much more strongly related to patients’ objective test performance, compared with patient self-reports.¹²

The convergence of clinician ratings of cognitive performance with objective test data has been impressive. Correlation coef­ficients of at least r = 0.5, reflecting a moder­ate to large relationships between clinician ratings and objective performance, have been detected. Individual cognitive test domains, such as working memory and processing speed, often do not correlate with each other or with aspects of everyday functioning to that extent.¹³ These data sug­gest that a clinician assessment of cognitive performance, when focused on the correct aspects of cognitive functioning, can be a highly useful proxy for extensive neuropsy­chological testing.

Social cognitive performance. Introspective accuracy for social cognitive judg­ments can be assessed similarly to the strategies used to assess the domains of everyday functioning and cognitive perfor­mance. Patients are asked to complete a typi­cal social cognitive task, such as determining emotions from facial stimuli or examin­ing the eye region of the face, to determine the mental state of the depicted person. Immediately after responding to each stimu­lus, participants rate their confidence in the correctness of that response.

Consistent with the pattern of introspec­tive accuracy for everyday functioning, patients with schizophrenia tend to make more high-confidence errors than healthy individuals on social cognitive tasks. That is, the patients are less likely to realize when they are wrong in their judgments of social stimuli. A similar pattern has been found for mental state attribution,¹⁴ rec­ognition of facial emotion from the self,¹⁵ and recognition of facial emotion from others.¹⁶ These high-confidence errors also are more likely to occur for more difficult stimuli, such as faces that display only mildly emotional expressions. These dif­ficulties appear to be specific to judgments in an immediate evaluation situation. When asked to determine if the behavior of another individual is socially appropri­ate, individuals with schizophrenia are as able as healthy individuals to recognize social mistakes.¹⁷ This work suggests that, at least within the domain of social cogni­tion, introspective accuracy impairment is not caused by generalized poor judgment, just as self-assessments of disability and illness burden are generated at random.

Choosing a reliable informant
If a clinician has not had adequate time or exposure to a patient to make a cogni­tive or functional judgment, what should the strategy be? If asking the patient is uninformative, who should be asked? Our group has gathered information that may help clinicians identify informants who can provide ratings of cognitive perfor­mance and everyday functioning that are convergent with objective evidence.

In a systematic study of validity of reports of various informants, we com­pared correlations between reports of competence of everyday functioning with objective measures of cognitive test per­formance and ability to perform everyday functional skills. Our findings:
   • Patient reports of everyday function­ing were not correlated with performance-based measures for any of 6 rating scales.⁹
   • Clinician reports of everyday func­tioning were correlated with objective per­formance across 4 of 6 rating scales.
   • Correlations between ratings gener­ated by friend or relative informants and other information were almost shocking in their lack of validity (Table 2).⁹

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.

Acknowledgment
This paper was supported by Grants MH078775 to Dr. Harvey and MH093432 to Drs. Harvey and Pinkham from the National Institute of Mental Health.

Disclosures
Dr. Harvey has received consulting fees from AbbVie, Boehringer Ingelheim, Forum Pharmaceuticals, Genentech, Otsuka America Pharmaceuticals, Roche, Sanofi, Sunovion Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Pinkham has served as a consultant for Otsuka America Pharmaceuticals.