Malnutrition and nonthyroidal illness syndrome after stroke

Thyroid hormones and stroke, the gap between clinical and experimental studies

Despite plenty of human studies on changes in thyroid hormones after stroke and some animal studies that assessed the effects of thyroid hormone administration on stroke, conclusive evidence for clinical application is lacking. This review aimed to determine the consistency of the results between clinical and preclinical studies. This article reviewed the PubMed, Embase, web of Knowledge, and Google Scholar databases up to June 2023 using the MeSH terms "stroke, cerebral ischemia, cerebral infarction, brain ischemia, brain infarction, triiodothyronine (T3), tetraiodothyronine (T4), thyroxine (T4), and thyroid hormone". The results of clinical and preclinical studies related to T3 substantially confirm each other. That is, in most human studies lower T3 was associated with poor outcomes, and in experimental studies, T3 administration also had therapeutic effects. However, the results of experimental studies related to T4 could not support those of clinical studies. There seem to be some conflicts between experimental and human studies, especially regarding changes and effects of T4 after stroke. The gap between experimental and clinical studies may lead to non-applicable results, wasting time and money, and unnecessary killing of animals.

Dysphagia screening post-stroke: systematic review

BACKGROUND/SCOPE

Stroke is one of the main causes of death, especially when associated with dysphagia. Hence, the assessment of nutritional status and aspiration risk is important to improve clinical outcomes. The aim of this systematic review is to identify which are the most suitable dysphagia screening tools in chronic post-stroke patients.

METHODOLOGY

A systematic literature search was conducted for articles published from 1 January 2000 to 30 November 2022 in the Cochrane Library, PubMed, Embase, CINAHL, Scopus and Web of Science databases, including primary studies providing quantitative or qualitative data. Additionally, a manual search was conducted scanning the reference lists of relevant articles and Google Scholar was searched to retrieve additional records. The process of screening, selection and inclusion of the articles, as well as the assessment of risk of bias and methodological quality, were conducted by two reviewers.

RESULTS

Out of the 3672 records identified, we included 10 studies, mostly (n=9) cross-sectional, evaluating screening for dysphagia in 1653 chronic post-stroke patients. Volume-Viscosity Swallow Test was the only test applied in multiple studies with adequate sample size, demonstrating high diagnostic accuracy (sensitivity=96.6%-88.2%; specificity=83.3%-71.4%) compared with the videofluoroscopic swallowing study.

CONCLUSIONS

Dysphagia is an important complication in chronic post-stroke patients. Early identification of this condition through screening tools with adequate diagnostic accuracy is of paramount importance. The limited number of studies available and their small sample sizes may be a limitation to this study.

PROSPERO REGISTRATION NUMBER

CRD42022372303.

Thyroid Function in Causal Relation to MRI Markers of Cerebral Small Vessel Disease: A Mendelian Randomization Analysis

CONTEXT

Observational studies have provided insufficient information on the association between thyroid function and the risk of cerebral small vessel disease (CSVD); moreover, the causality of this link is still unclear.

OBJECTIVE

This study aims to investigate whether genetically predicted variation within thyroid function is causally associated with the risk of CSVD using 2-sample Mendelian randomization (MR) analysis.

METHODS

In this 2-sample MR study with genome-wide association variants, we estimated the causal effects of genetically predicted thyrotropin (thyroid-stimulating hormone, TSH; n = 54 288), free thyroxine (FT4; n = 49 269), hypothyroidism (n = 51 823), and hyperthyroidism (n = 51 823) on 3 neuroimaging markers of CSVD, including white matter hyperintensity (WMH; n = 42 310), mean diffusivity (MD; n = 17 467), and fractional anisotropy (FA, n = 17 663). The primary analysis was conducted by the inverse variance-weighted MR method, followed by sensitivity analyses using MR-PRESSO, MR-Egger, weighted median, and weighted mode methods.

RESULTS

Genetically increased TSH was associated with increased MD (β = .311, 95% CI 0.0763, 0.548, P = .01). Genetically increased FT4 was associated with increased FA (β = .540, 95% CI 0.222, 0.858, P < .001). Sensitivity analyses using different MR methods showed similar directions but lower precision. No significant associations of hypothyroidism or hyperthyroidism with WMH, MD, or FA were found (all P > .05).

CONCLUSION

This study indicated that genetically predicted increased TSH was associated with increased MD, as well as increased FT4 with increased FA, implying the causal effect of thyroid dysfunction on white matter microstructural injury. There were no significant causal relationships of hypothyroidism or hyperthyroidism with CSVD. Further investigations should verify these findings and clarify the underlying pathophysiological mechanisms.

Investigating the Predictive Value of Thyroid Hormone Levels for Stroke Prognosis

Given the expansion of life expectancy, the aging of the population, and the anticipated rise in the number of stroke survivors in Europe with severe neurological consequences in the coming decades, stroke is becoming the most prevalent cause of functional disability. Therefore, the prognosis for a stroke must be timely and precise. Two databases (MEDLINE and Scopus) were searched to identify all relevant studies published between 1 January 2005 and 31 December 2022 that investigated the relationship between thyroid hormone levels and acute stroke severity, mortality, and post-hospital prognosis. Only full-text English-language articles were included. This review includes Thirty articles that were traced and incorporated into the present review. Emerging data regarding the potential predictive value of thyroid hormone levels suggests there may be a correlation between low T3 syndrome, subclinical hypothyroidism, and poor stroke outcome, especially in certain age groups. These findings may prove useful for rehabilitation and therapy planning in clinical practice. Serum thyroid hormone concentration measurement is a non-invasive, relatively harmless, and secure screening test that may be useful for this purpose.

Cardiovascular and Neuronal Consequences of Thyroid Hormones Alterations in the Ischemic Stroke

Ischemic stroke is one of the leading global causes of neurological morbidity and decease. Its etiology depends on multiple events such as cardiac embolism, brain capillaries occlusion and atherosclerosis, which ultimately culminate in blood flow interruption, incurring hypoxia and nutrient deprivation. Thyroid hormones (THs) are pleiotropic modulators of several metabolic pathways, and critically influence different aspects of tissues development. The brain is a key TH target tissue and both hypo- and hyperthyroidism, during embryonic and adult life, are associated with deranged neuronal formation and cognitive functions. Accordingly, increasing pieces of evidence are drawing attention on the consistent relationship between the THs status and the acute cerebral and cardiac diseases. However, the concrete contribution of THs systemic or local alteration to the pathology outcome still needs to be fully addressed. In this review, we aim to summarize the multiple influences that THs exert on the brain and heart patho-physiology, to deepen the reasons for the harmful effects of hypo- and hyperthyroidism on these organs and to provide insights on the intricate relationship between the THs variations and the pathological alterations that take place after the ischemic injury.

Investigation of the Effect of Nutritional Supplementation with Whey Protein and Vitamin D on Muscle Mass and Muscle Quality in Subacute Post-Stroke Rehabilitation Patients: A Randomized, Single-Blinded, Placebo-Controlled Trial

In post-stroke hemiparesis patients, the skeletal muscle mass decrease rapidly with the histological degradation. We investigated the effect of nutritional supplementation with whey protein and vitamin D on the muscle mass and muscle quality, in post-stroke convalescent rehabilitation patients in a randomized, single-blinded, placebo-controlled trial. Fifty patients were randomly assigned to two groups; HP group received supplemental jelly (100 kcal; whey protein 10 g; vitamin D 20 μg) twice a day throughout up to 16-week period, the control group received placebo jelly. Cross-sectional area (CSA) of thigh muscle, skeletal muscle index (SMI), muscle strength, activity of daily living (ADL), and some nutritional indicators in blood were measured. Although no significant difference was observed in CSA and SMI between the groups, fat infiltration into the thighs muscle was singnificantly lower in the HP group. There were no significant difference in muscle strength and ADL between the groups. Blood urea nitrogen and serum 25(OH)D at endpoint were significantly higher in the HP group but physiological normal ranges. Supplementation with whey protein and vitamin D in post-stroke patients led to suppression of fat infiltration into the muscle. Long-term follow-up studies are needed to verify whether this nutritional intervention provides substantial benefits for the prognosis of stroke survivors.

Impaired Nutritional Condition After Stroke From the Hyperacute to the Chronic Phase: A Systematic Review and Meta-Analysis

Background

Malnutrition is common after stroke and can affect rehabilitation and healthcare costs. A comprehensive overview of stroke patients' nutritional condition from the hyperacute to the chronic phase is lacking. This systematic review aimed to investigate the prevalence of impaired nutritional condition (INC) across the continuum of care in specific phases after stroke.

Methods

CAB ABSTRACTS, Embase, MEDLINE, were used to collect studies published between 01-01-1999 and 26-08-2020. Primary and secondary outcomes were prevalence of INC and prevalence of malnutrition, respectively. Exploratory outcomes were prevalence of INC at follow-up, nutritional examination methods, prevalence of dysphagia, stroke severity, adverse events, and continent-specific prevalence of INC. A random-effects meta-analysis model was used to estimate the phase-specific pooled prevalence of INC and malnutrition.

Results

The dataset consisted of 78 study groups selected over a total of 1,244 identified records. The pooled prevalence of INC and malnutrition were 19% (95%CI:7–31) (N = 4) and 19% (95%CI:9–29) (N = 3), 34% (95%CI:25–43) (N = 34) and 26% (95%CI:18–35) (N = 29), 52% (95%CI:43–61) (N = 34) and 37% (95%CI:28–45) (N = 31), 21% (95%CI:12–31) (N = 3) and 11% (95%CI:0–24) (N = 3) and 72% (95%CI:41–100) (N = 3) and 30% (95%CI:0–76) (N = 2) in the hyperacute, acute, early subacute, late subacute, and chronic phase, respectively.

Conclusion

INC and malnutrition are highly prevalent in all stages of stroke care. Since malnutrition has been shown to negatively affect clinical outcomes, mortality, and overall healthcare expenditure in stroke survivors, it is essential to examine and monitor the nutritional status of stroke patients throughout their care journey to guide and plan, timely nutritional support and dietary modification.

Nonthyroidal Illness Syndrome in Patients With Short-Bowel Syndrome

BACKGROUND

Nonthyroidal illness syndrome (NTIS) is prevalent in critical illness and is associated with poor outcomes. However, only few studies have focused on the relationship between NTIS and short-bowel syndrome (SBS). The aim of this study was to investigate the prevalence, etiology, and prognosis of NTIS and its correlation with clinical variables in adult patients with SBS.

METHODS

Sixty-one eligible adults diagnosed with SBS, from December 2016 to December 2018, were retrospectively identified from a prospectively maintained database. Demographic and clinical characteristics (including thyroid hormones and nutrition variables) were evaluated for each participant.

RESULTS

The prevalence of NTIS in adults with SBS was 52.5%. Patients with NTIS tended to have a longer duration of hospital stay and poor survival, but the results were not significant. A decreased, standard thyroid-stimulating hormone index and sum activity of deiodinases and an increased secretory capacity by the thyroid were observed in the NTIS group. Receiver operating characteristic curve analysis showed that insulin-like growth factor-1 (IGF-1) had better performance for distinguishing NTIS from patients with euthyroidism, with an area under the curve of 0.862 (cutoff, 101.0; sensitivity, 0.813; and specificity, 0.800).

CONCLUSIONS

NTIS is a common complication in adult patients with SBS. Patients with NTIS tend to have a worse nutrition status and poor prognosis. A potential pituitary thyrotroph dysfunction and hypodeiodination condition may play a role in the pathophysiology of NTIS in SBS. Furthermore, IGF-1 is a meaningful predictor for distinguishing NTIS from euthyroid.

Correlation analysis of serum thyroid stimulating hormone with acute cerebrovascular disease

Background

Acute cerebrovascular disease (ACVD) could cause abnormal metabolism of thyroid hormones (TH), mostly represented as a euthyroid sick syndrome or low T3 syndrome. However, the changes in serum thyroid-stimulating hormone (TSH) are controversial. The aim of this study is to investigate the clinical significance of TSH alteration in patients with ACVD.

Method

Patients with ACVD admitted in our hospitals between January 2013 and September 2017 were enrolled in this study (n = 245, including 176 cerebral infarctions and 69 cerebral hemorrhages). Their thyroid hormones were measured and compared with healthy individuals (n = 75). The correlation of TSH with severity and prognosis of ACVD were analyzed by receiver operating characteristic curve.

Results

Serum TSH in ACVD group was higher than the control group (1.64 ± 1.08 vs. 1.26 ± 0.36 μIU/mL, P < 0.05). The TSH levels in intermediate and severe patients with ACVD were higher than in mild patients (1.72 ± 1.18 vs. 2.71 ± 0.93 vs. 1.02 ± 0.47 μIU/mL, P < 0.05). Receiver Operating Characteristic curve (ROC) of TSH in determining the severity of patients were 0.863 (Area under the curve, AUC), 1.496 μIU/L (optimal threshold), 76.5% (sensitivity) and 87.3% (specificity). TSH levels in improved and unchanged groups were significantly higher than the primarily healing group (2.27 ± 1.11 vs. 2.88 ± 1.07 vs. 0.86 ± 0.46 μIU/mL, P < 0.05). ROC of TSH in determining the prognosis of patients was 0.910 (AUC), 1.681 mIU/L (optimal threshold), 79.8% (sensitivity) and 90.5% (specificity) correspondingly.

Conclusion

Since elevated TSH in ACVD patients affects the outcome of thyroid function evaluation, it is preferable to re-check after the acute period. A correlation between a high TSH level and the severity and prognosis of ACVD was detected, but the mechanism of this correlation needs to be further studied.

Thyroid Hormones in the Brain and Their Impact in Recovery Mechanisms After Stroke

Thyroid hormones are of fundamental importance for brain development and essential factors to warrant brain functions throughout life. Their actions are mediated by binding to specific intracellular and membranous receptors regulating genomic and non-genomic mechanisms in neurons and populations of glial cells, respectively. Among others, mechanisms include the regulation of neuronal plasticity processes, stimulation of angiogenesis and neurogenesis as well modulating the dynamics of cytoskeletal elements and intracellular transport processes. These mechanisms overlap with those that have been identified to enhance recovery of lost neurological functions during the first weeks and months after ischemic stroke. Stimulation of thyroid hormone signaling in the postischemic brain might be a promising therapeutic strategy to foster endogenous mechanisms of repair. Several studies have pointed to a significant association between thyroid hormones and outcome after stroke. With this review, we will provide an overview on functions of thyroid hormones in the healthy brain and summarize their mechanisms of action in the developing and adult brain. Also, we compile the major thyroid-modulated molecular pathways in the pathophysiology of ischemic stroke that can enhance recovery, highlighting thyroid hormones as a potential target for therapeutic intervention.

Nutrition, Energy Expenditure, Dysphagia, and Self-Efficacy in Stroke Rehabilitation: A Review of the Literature

While significant research has been performed regarding the use of thrombolytic agents and thrombectomy in the setting of acute stroke, other factors, such as nutritional status of stroke patients, is a less explored topic. The topic of nutrition is critical to the discussion of stroke, as up to half of stroke survivors may be considered malnourished at discharge. Dysphagia, old age, restricted upper limb movement, visuospatial impairment, and depression are all important risk factors for malnutrition in this cohort. The purpose of this review is to analyze current literature discussing neuroprotective diets, nutritional, vitamin, and mineral supplementation, dysphagia, and post-stroke coaching in stroke patients.

Ischemic Stroke and Impact of Thyroid Profile at Presentation: A Systematic Review and Meta-analysis of Observational Studies

BACKGROUND

Stroke is the fifth leading cause of mortality in the United States and a leading cause of disability. A complex relationship between thyroid hormone levels and severity of, and outcome after, stroke has been described.

AIM

Our objective is to identify the association between baseline thyroid function profile and outcome after acute ischemic stroke.

METHODS

Studies looking at the association between thyroid function and functional stroke outcomes were identified from available electronic databases from inception to December 16, 2016. Study-specific risk ratios were extracted and combined with a random effects model meta-analysis.

RESULTS

In the analysis of 12 studies with 5218 patients, we found that subclinical hypothyroidism was associated with better modified Rankin scale scores at 1 and 3 months (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.13-5.91, P = .03 and OR 2.28, 95% CI 1.13-3.91, P = .003, respectively) compared with the euthyroid cases. Likewise, patients with higher initial thyrotropin-releasing hormone (TSH) and fT3 or T3 levels had favorable outcomes at discharge (mean differences of TSH .12 [95% CI .03-.22, P = .009] and of fT3 .36 (CI .20-.53, P < .0001]) and at 3 months (mean differences of TSH .25 [95% CI .03-.47, P = .03] and of T3 8.60 [CI 4.58-12.61, P < .0001]).

CONCLUSIONS

Elevated initial TSH (clinical or subclinical hypothyroidism) may correspond to better functional outcomes, whereas low initial T3/fT3 might correlate with worse outcomes in acute ischemic stroke among clinically euthyroid patients. This complex relation merits further well-designed investigations. Whether correcting thyroid profile with hormone supplementation or antagonism may lead to improved outcomes will require large, prospective, interventional studies.

Oro-facial impairment in stroke patients

Stroke is considered one of the leading causes of death and acquired disability with a peak prevalence over the age of 80 years. Stroke may cause debilitating neurological deficiencies that frequently result in sensory deficits, motor impairment, muscular atrophy, cognitive deficits and psychosocial impairment. Oro-facial impairment may occur due to the frequent involvement of the cranial nerves' cortical representation areas, central nervous system pathways or motoneuron pools. The aim of this narrative, non-systematic review was to discuss the implications of stroke on oro-facial functions and oral health-related quality of life (OHRQoL). Stroke patients demonstrate an impaired masticatory performance, possibly due to reduced tongue forces and disturbed oral sensitivity. Furthermore, facial asymmetry is common, but mostly discrete and lip restraining forces are reduced. Bite force is not different between the ipsi- and contra-lesional side. In contrast, the contra-lesional handgrip strength and tongue-palate contact during swallowing are significantly impaired. OHRQoL is significantly reduced mainly because of the functional impairment. It can be concluded that impaired chewing efficiency, dysphagia, facial asymmetry, reduced lip force and OHRQoL are quantifiable symptoms of oro-facial impairment following a stroke. In the absence of functional rehabilitation, these symptoms seem not to improve. Furthermore, stroke affects the upper limb and the masseter muscle differently, both, at a functional and a morphological level. The rehabilitation of stroke survivors should, therefore, also seek to improve the strength and co-ordination of the oro-facial musculature. This would in turn help improve OHRQoL and the masticatory function, subsequently preventing weight loss and malnutrition.

Combination of Low Body Mass Index and Low Serum Albumin Level Leads to Poor Functional Recovery in Stroke Patients

BACKGROUND

Nutritional status is associated with the functional recovery of stroke patients. This study aimed to examine the influence of the combination of body mass index (BMI) and serum albumin level on functional recovery in subacute stroke patients.

METHODS

This retrospective cohort study included 259 subacute stroke patients (mean age 68.9 ± 12.3 years). Patients were categorized into 4 groups according to their BMI and serum albumin level: group 1, low BMI (<18.5 kg/m²) and low serum albumin level (<3.5 g/dL); group 2, low BMI and high serum albumin level (≥3.5 g/dL); group 3, normal weight (≥18.5 kg/m²) and low serum albumin level; and group 4, normal weight and high serum albumin level. The outcome variable was the motor subscale of the Functional Independence Measure (M-FIM) effectiveness. We defined the first quartile of M-FIM effectiveness as poor functional recovery. Multivariate logistic regression analysis was performed to examine the influence of the combination of BMI and serum albumin level on poor functional recovery.

RESULTS

Multivariate logistic regression analysis adjusted for baseline characteristics (reference, group 4) showed that group 1 was mostly associated with a significant risk of poor functional recovery (odds ratio, 4.13; 95% confidence interval, 1.53-11.15).

CONCLUSIONS

Our results suggested that the combination of low BMI and low serum albumin level was more significantly associated with poor functional recovery in subacute stroke patients than either factor alone. The combination of BMI and serum albumin level should be taken into account when predicting functional recovery in subacute stroke patients.

Role of enteral nutrition in nonthyroidal illness syndrome: a retrospective observational study

BACKGROUND

The nonthyroidal illness syndrome (NTIS) is prevalent among patients with enterocutaneous fistula and is associated with poor outcomes. The present study aimed to explore the role of enteral nutrition (EN) therapy on thyroid function among patients with enterocutaneous fistula and NTIS.

METHODS

We conducted a retrospective observational study among patients with enterocutaneous fistula between January 2013 and April 2014. All enrolled patients received EN therapy. Thyroid function and other parameters were measured.

RESULTS

After administration of 4 weeks of EN therapy, NTIS was resolved in 66 patients (Group A), while it persisted in 14 patients (Group B). The overall treatment success rate was 82.50 %. There were no significant differences between groups A and B at baseline for all parameters, except for the time from admission to start of EN therapy. The logistic analysis revealed that the time from admission to start of EN therapy was a significant independent indicator for achieving resolution of NTIS in our cohort.

CONCLUSIONS

This retrospective observational cohort study demonstrated that EN therapy can aid in the resolution of NTIS among patients with enterocutaneous fistula. These findings confirm the benefit of EN in the treatment of enterocutaneous fistula.

Impact of nutritional status and dietary quality on stroke: do we need specific recommendations?

Stroke, one of the most prevalent geriatric diseases, is a leading cause of death worldwide that often results in permanent physical disability and decreased quality of life, and can have a negative impact on families both financially and emotionally. Although many previous studies have shown relationships between the risk of stroke and nutritional factors, clear dietary recommendations for the prevention and reduction of stroke recurrence have not been established. Several factors should be considered to control and manage stroke. For example, a considerable number of patients with stroke are poorly nourished, have several comorbidities and undesirable health-related behaviors may be present. Stroke patients are less likely to consume beneficial foods, have poorer eating habits and have impoverished dietary quality. In addition, psychological factors such as depression must also be considered in stroke management. Given these factors, dietary recommendations for stroke patients should be established. In this article, we summarized the nutritional status and dietary quality of stroke patients. We also suggested some nutritional guidelines for stroke patients and for those who are at risk for stroke.

Body weight after stroke: lessons from the obesity paradox

BACKGROUND AND PURPOSE

Outcome after acute stroke is determined to a large extent by poststroke complications. Nutritional status and metabolic balance may substantially contribute to outcome after stroke. Key mechanisms of stroke pathophysiology can induce systemic catabolic imbalance with impaired metabolic efficiency and degradation of body tissues.

SUMMARY

Tissue wasting, sarcopenia, and cachexia may impair and delay poststroke rehabilitation and worsen the prognosis. Although current guidelines for secondary prevention after stroke recommend weight reduction, increasing evidence suggests that patients who are overweight and mildly obese may actually have a better outcome. An "obesity paradox" has been identified to describe the contrasting impact of being overweight in patients with chronic illness compared with healthy populations. We present an overview on the metabolic regulation in patients with stroke and evaluate current data on the impact of body weight and weight change after stroke. The emerging picture suggests that being overweight and obese may impact patients with stroke differently than it does healthy subjects.

CONCLUSIONS

We propose that current knowledge on obesity and its management in primary prevention cannot be transferred to patients with established stroke. Systematic studies on changes in body composition after stroke and on treatment options are warranted to establish the pathophysiology and evidence-driven management of nutritional status in these patients.

Clinical analysis on alteration of thyroid hormones in the serum of patients with acute ischemic stroke

Low T3 has been associated with increased short-term mortality in intensive care unit and long-term mortality in cardiovascular disease. The objective of this retrospective study is to investigate associations of thyroid hormone status with clinical severity and outcome in acute ischemic stroke, and whether there is association between the pituitary axis abnormality and the anterior/posterior circulation involvement. Patients with no history of thyroid abnormality who presented first ever stroke were studied. Total T3, T4, TSH levels, basic and clinical characteristics were collected and categorized. Neurological impairment was assessed using NIHSS and modified Rankin Scale. Twenty-nine patients (61%) had T3 ≤ 75 ng/dL. Low T3 group had significant higher NIHSS compared to normal T3 group. There was a significant negative correlation between T3 levels and NIHSS scores on admission. A significantly smaller percentage of patients with low T3 showed favorable neurological function improvement by both NIHSS and mRS measures compared to those with normal T3. There was no significant difference for anterior or posterior circulation involvement between low T3 and normal T3 groups. It is suggested that low T3 is associated with worse neurological outcome. The severity of low T3 may be a predictor of functional improvement in acute ischemic stroke.

Hypertension and white matter lesions are independently associated with apathetic behavior in healthy elderly subjects: the Sefuri brain MRI study

Apathy is defined as a syndrome of primary loss of motivation not attributable to emotional distress, intellectual impairment or consciousness disturbance. The aim of our study was to investigate the effects of vascular risk factors and silent ischemic brain lesions on apathetic behavior of community-dwelling elderly subjects. Brain MRI and other medical examinations were performed on 222 non-demented community-dwelling elderly subjects (96 men and 126 women, average age 70.1 years). The apathy group was defined as the most apathetic quintile determined by Starkstein's apathy scale. Silent infarction, deep white matter lesions (DWMLs) and periventricular hyperintensities were detected in 12.2, 39.2 and 22.5%, respectively. Linear regression analysis (Pearson) revealed that the scores on the apathy scale correlated slightly but significantly with logarithmically transformed scores of the Modified Stroop Test (r=0.135, P=0.045), but not with the Mini-Mental State Examination. The apathy group tended to have more high blood pressure (141.6/82.6 vs. 136.1/79.6 mm Hg), less prevalent hyperlipidemia (18 vs. 35%) and lower serum albumin. Multivariate analysis (the forward stepwise method of logistic analysis) revealed an independent correlation between the apathy and grade of DWMLs (odds ratio 1.826, 95% confidence interval (CI) 1.129-2.953 per grade) or diastolic blood pressure (DBP) (odds ratio 1.055, 95% CI 1.014-1.098 per mm Hg) after adjusting for possible confounders. The mean apathy scale score in the DBP>or=90 mm Hg group was significantly lower (more apathetic) than that in the DBP<80 group (P=0.011, analysis of covariance). This study showed that hypertension and DWMLs are independently associated with apathy in healthy elderly subjects.