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  • Writer's pictureValerie Brooke, MD

Poor Insight

One of my favorite words in stroke recovery is anosognosia (a-no-sag-no-zhea). This is the bizarre symptom a patient often has after an injury to the right side of their brain. It manifests as the inability to recognize they have any physical or cognitive problems. In medical documentation, because the word anosognosia is not easy to type or say for that matter, we often call this symptom “poor insight into deficits.”

I recall once many years ago when I was asked to consult on a patient who’d had a severe stroke, to see if she was ready to be admitted to the rehabilitation hospital. I walked into her hospital room and found her lying on her back on the hospital bed at an odd angle, her left leg dangling over the side and her left arm twisted under her back like it was paralyzed. I introduced myself and asked her why she was in the hospital. She replied she didn’t know why but she knew she didn’t belong there. She was barely able to move her left arm and leg, and that she also had difficulty noticing anything on the left side of the room, including myself where I stood next to her bed. I told her she had a stroke causing her to have trouble moving her body as well as difficulty with her thinking. She looked at me like I was crazy and told me she was fine and that she was just getting ready to get up and walk right out of the hospital. I smiled and told her that she needed to do some therapy at the rehab hospital before going home. Despite her obvious inability to stand up, she still did not understand.

Of course, not all patients with anosognosia are that extreme; the symptom can be much more subtle. There are the countless number of elderly patients I see at the rehabilitation hospital that assure me they are still safe for driving. They have not had a stroke, but rather seem to have reverted to the teenage brain that feels invincible and overly competent. They are evaluated by our speech and language pathologists, found to have mild to moderate cognitive impairments, almost always in memory, but also deficits in problem solving, attention, and vision. All the things one needs to drive safely.

When I tell these elderly patients that they cannot return to driving until they are cleared by a physician or the department of motor vehicles (DMV), they always retort with seeming logical reasons they are okay to drive. “I only drive around town and I never get on the freeway.” They obviously don’t know that most accidents happen within 5 miles of a person’s home. “I never drive over the speed limit.” Again, most accidents happen at low speeds. “I always take my spouse with me,” as if having a mate in the cockpit will keep the car from crashing.

At this point I often must tell them if they won’t give up their keys, then I will have to report them to the DMV. “Well Doctor, I know that I didn’t do well on that silly test of yours, but I know, I know, I am safe to drive.” I understand how important driving is to the elderly as it keeps them independent and autonomous; I’m sure I’m going to resist giving up my keys when I get to that age as well. But trying to explain the rationale of why they are no longer safe to drive is like trying to explain to a child why a red colored object is not blue, no matter how much they insist it is so.

Anosognosia or poor insight can even occur with patients that aren’t elderly or that haven’t had an injury to the brain. I’m not sure how to explain why someone with a normally functioning brain, having passed the speech therapy cognitive assessment, still can have poor insight into their deficits. Stubbornness? Ignorance? Foolishness? Several years ago, I had a young patient in his 20s who did not take care of his type 1 diabetes very effectively. He stopped using his insulin, letting his sugars run dangerously high, causing several hospital admissions for something called DKA – diabetic ketoacidosis. Eventually over time, his high blood sugars caused peripheral neuropathy, severe damage to the sensory nerves in his feet and lower legs.

This is dangerous for both type 1 and type 2 diabetics, as they can get an injury to the bottom of their feet or toes, and not feel it at all. This is what happened to this young patient. He likely stepped onto something that cut his skin, that very important barrier keeping bacteria from entering the body. Because he was not in the habit of checking his feet and toes daily for wounds, this cut slowly developed into an infection. When he eventually developed a fever and was hospitalized yet again for DKA, the infection had spread to the bones of his foot. He required a lower leg amputation.

He came to the rehabilitation hospital after having had his right leg cut off below the knee, a transtibial amputation. The infection was gone, and yet he was still at very high risk of poor healing due to his uncontrolled blood sugars, in addition to having a high risk of eventually having the other leg amputated at some point in the future. While he finally understood the importance of remaining compliant with his insulin regimen, he had zero insight into how he was going to be able to return to his previous life. He lived in a house with roommates, friends that had their own lives to manage and would not be able to physically assist him. “I’ll be fine,” he told me. “How are you going to be able to get up the 3 steps to your house?” the therapists asked him. “I’ll hop!” “How are you going to be able to get into your bathroom – with doorways to narrow for your wheelchair?” “I’ll figure it out!” he replied. “How are you going to go back to work in construction before you get your prosthesis?” “No problem!”

His poor insight may have been due to his young age and immature brain. It may have been denial about how serious this complication was and how long he was going to take to heal. It would take many months and possibly a year to get his prosthetic leg, depending upon his healing process. It may have been his naivete, his belief he was invincible, or even his fear of facing the truth. Slowly he came to understand that he would not be able to return to his previous home and fortunately for him, he had a sister that lived in a wheelchair accessible home and was willing to take him in. When he was discharged from the hospital many weeks later, being wheeled out by his sister to her car, he smiled at me. “Doc! I’ll be back next week with my new leg!” I just smiled back, giving up on explaining to him one last time the long process of recovering from an amputation and getting a prosthesis. His anosognosia and poor insight was not something I was going to fix. Maybe this time red really was blue.

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