Insight into illness in late-life schizophrenia: A function of illness severity and premorbid intellectual function Philip Gerretsen a , Benoit H. Mulsant a , Angela Y. Liu a , Eric Granholm b , Mahesh Menon a,c , Ariel Graff-Guerrero a , Bruce G. Pollock a , David C. Mamo a , Tarek K. Rajji a, ⁎ a University of Toronto and Centre for Addiction and Mental Health, Toronto, ON, Canada b University of California, San Diego, CA, United States c University of British Columbia, Vancouver, BC, Canada abstract article info Article history: Received 7 May 2013 Received in revised form 8 July 2013 Accepted 11 July 2013 Available online 21 August 2013 Keywords: Insight Cognition Schizophrenia Aging Illness awareness Impaired insight into illness is a common but poorly understood phenomenon in schizophrenia. Several studies in midlife adults with schizophrenia have reported an association between impaired insight and illness severity, executive dysfunction, premorbid intellectual function, and to a lesser degree attention. Aging is associated with a decline in attention and executive function. Thus, the relationship between cognition and insight is expected to differ between younger and older adults with schizophrenia. This study assessed this relationship among 50 pa- tients with schizophrenia 60 years and older. Insight was explained by illness severity (16.2% of the variance) and premorbid intellectual function (23.9% of the variance), but not by attention or executive function. Our findings suggest that the predictors of insight in schizophrenia differ early and later in life. In particular, insight's associ- ation with attention and executive function observed in younger patients is attenuated by age-related changes in cognition. In contrast, premorbid intellectual function continues to be a strong predictor of insight in late life, which highlights the need to better understand and enhance cognitive function early in the course of schizophrenia. © 2013 Elsevier B.V. All rights reserved. 1. Introduction Impaired insight into illness is a common but poorly understood phenomenon in schizophrenia (Jablensky et al., 1992). It is associated with illness severity, medication non-adherence and poor treatment outcomes (Amador et al., 1994; Buckley et al., 2007). Several studies in midlife adults with schizophrenia have shown that impaired insight is associated with executive dysfunction [assessed using the Wisconsin Card Sorting Test (WCST) and Trails Making Test B (TMT-B)], lower premorbid intellectual function [i.e., estimated premorbid Intelligence Quotient (IQ)], and, to a lesser degree, impaired attention (as assessed by the Continuous Performance Task) (Aleman et al., 2006; Shad et al., 2006a,b; Orfei et al., 2008; Trevisi et al., 2012). Aging is associated with a decline in attention and executive function; however, intellectual function remains stable (Hedden and Gabrieli, 2004; Dickinson and Hiscock, 2010). Thus, the relationship between cog- nition and insight in late-life schizophrenia could differ from that in mid- life. Specifically, two possible scenarios are conceivable to understand the effects of aging on the relationship between insight and cognition in late-life schizophrenia. If the relationship between cognitive deficits and insight is independent of the pathological processes underlying cog- nitive impairment in schizophrenia, one would expect to observe a sim- ilar relationship in late life between insight and cognition as what is observed in mid-life. In other words, the relationship between cognitive deficits (e.g., attention and executive dysfunction) and insight persists in late life despite the effect of aging on cognition. Alternatively, if the impairment in insight is mediated by schizophrenia-specific (and not age-related) cognitive deficits, aging is expected to attenuate the relationship between insight and attention or executive function in late life, while its relationship with premorbid intellectual function would be preserved. Hence, in late-life schizophre- nia, the relationship between insight and attention or executive function is expected to be weaker than that between insight and premorbid intel- lectual function. To date, few studies have explored insight in older adults with schizophrenia. In one study of middle-aged and older adult persons with schizophrenia (≥40 years, mean ~50 years), lower insight was associated with negative symptom severity and poorer quality of life (Roseman et al., 2008). Another study investigated the relationship be- tween insight and treatment outcomes with Cognitive Behavioral and Social Skills Training (CBSST) in older persons with schizophrenia (mean 53 years, range 42–72 years). In this study, higher insight was associated with hopelessness and worse every day functioning, but not depression (Emmerson et al., 2009). Neither of these analyses in- cluded measures of cognition or premorbid intellectual function to Schizophrenia Research 150 (2013) 217–222 ⁎ Corresponding author at: University of Toronto, Chief, Geriatric Psychiatry Division, Centre for Addiction and Mental Health, 80 Workman Way, Room 6312, Toronto, Ontario M6J 1H4, Canada. Tel.: +1 4165358501. E-mail address: tarek.rajji@camh.ca (T.K. Rajji). 0920-9964/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.schres.2013.07.025 Contents lists available at ScienceDirect Schizophrenia Research journal homepage: www.elsevier.com/locate/schres