Anosognosia

Patients with hemispatial inattention may frequently deny that they have a problem. In the examination room, patients tell us they have no problem to the left and never run into things, but their spouse or caregiver may quickly report that the patient is constantly running into things, tripping and being startled.

The most famous case of anosognosia was President Woodrow Wilson. After suffering two strokes in the right posterior hemisphere, he developed left hemispatial inattention and a left homonymous hemianopsia. When colleagues came to visit him, he failed to respond to them until they were escorted to his right side. He denied he had a problem and planned to run for a third term as president until his wife finally intervened.

Frequently, we see patients who by the report of their spouse are doing much better since the field expander trial with a press-on was initiated, but the patient insists the field expander is making no difference. In one case in particular the patient said he had no problems in his vision and demanded the press-on field expander be removed immediately. After failing to convince him to continue with it for a longer period of time, I removed it. He started to walk out of the examination room and crashed to the left door-frame.  Fortunately, he returned, sat down and said, “Put it back on!”

Our experience tells us to discuss the functioning of these patients with both the patient and the caregiver. Do not rely entirely on what the patients report if your observation and the caregiver observations differ. Try to get the patient to stay with the system long enough for real behavioral patterns to be observed.