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Clinical Manifestations.

Chin Yee Cheong1,2, Li Cheng Heng3, Chong Jin Ng4

  • 1Khoo Teck Puat Hospital, Singapore, United Kingdom.

Alzheimer'S & Dementia : the Journal of the Alzheimer'S Association
|December 24, 2025
PubMed
Summary

Deep white matter disease (DWMH) impairs insight in cognitive impairment indirectly by affecting judgment. Clinicians should monitor for judgment and insight challenges in patients with DWMH.

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Area of Science:

  • Neurology
  • Cognitive Neuroscience
  • Geriatrics

Background:

  • Impaired insight is a significant challenge in cognitive impairment, affecting diagnosis and care.
  • White matter disease (WMD) is linked to cognitive decline, but its specific impact on insight is unclear.
  • Understanding the cognitive pathways mediating WMD's effect on insight is crucial.

Purpose of the Study:

  • To investigate if white matter disease (WMD) impacts insight in individuals with cognitive impairment.
  • To explore the mediating role of cognitive domains in the relationship between WMD and insight.

Main Methods:

  • 133 participants with mild cognitive impairment or dementia underwent assessment of white matter hyperintensities (WMH) using the Fazekas scale and insight using the Clinical Insight Rating Scale.
  • Structural equation modeling (SEM) was used to analyze direct and indirect pathways between WMH subtypes, cognitive domains, and insight.
  • Analyses adjusted for relevant covariates.

Main Results:

  • Deep white matter hyperintensities (DWMH), but not periventricular WMH, were associated with poor insight.
  • Impaired judgment was strongly linked to poor insight.
  • SEM revealed DWMH indirectly affected insight via impaired judgment, with this pathway remaining significant after adjustment.

Conclusions:

  • Deep white matter hyperintensities (DWMH) impair insight primarily through their effect on judgment.
  • While dementia severity is a strong predictor of insight, the DWMH-judgment link suggests structural changes drive these deficits.
  • Disruption of frontal-subcortical circuits by DWM lesions may underlie these findings, necessitating clinical attention to judgment and insight in affected individuals.