Reduced daytime activity in patients with acquired brain damage and apathy: A study with ambulatory actigraphy

Detecting apathy in patients with cerebral small vessel disease

Background

Apathy is attracting more and more attention in clinical practice. As one of the most common features of cerebral small vessel disease (CSVD), the assessment of apathy still mainly relies on observers. With the development of Information and Communication Technologies (ICTs), new objective tools take part in the early detection of apathy.

Objectives

To detect apathy in patients with CSVD and find out the relationship between apathy and actigraphic data sampled from the diurnal and nocturnal periods.

Methods

A total of 56 patients with CSVD were recruited for a cross-sectional observational study. Apathy was diagnosed by the diagnostic criteria for apathy in neurocognitive disorders. The presence of lacunes, white matter hyperintensities, cerebral microbleeds (CMBs), and perivascular spaces (PVS) in magnetic resonance imaging (MRI) images were rated independently. Actigraph devices were worn in the non-dominant hands of each subject for 7 consecutive days to collect samples of raw data, and diurnal vector magnitude (VM) and a series of sleep quality variables were obtained.

Results

We found that the frequency of apathy in Chinese patients with CSVD reached 37.50%. Patients in the Apathy+ group showed more lacunes and CMBs, and higher Fazekas scores in comparison to apathy-group individuals. Diurnal VM, instead of other sleep quality variables, was lower in CSVD patients with apathy relative to those without apathy. Lastly, we discovered that diurnal VM and total time in bed (TTB) correlated negatively with apathy severity in patients with CSVD.

Conclusion

Actigraphy is a promising choice to evaluate apathy in patients with CSVD.

Examining the Use of a Rest-Activity Ratio in a Pediatric Rehabilitation Setting

OBJECTIVE

To examine the relationship between an estimate of sleep/wake regulation derived from actigraphy would be sensitive to neurocognitive dysfunction associated with acquired brain injury (ABI) in a pediatric rehabilitation sample.

DESIGN

cross-sectional design SETTING: Inpatient pediatric rehabilitation facility PARTICIPANTS: A sample of 31 males (72.1%) and 12 females (27.9%) admitted to a pediatric rehabilitation hospital wore an actigraph (wrist accelerometer) for one week. Ages ranged from 8 to 17 years (M=13.1, SD=2.7).

INTERVENTIONS

not applicable MAIN OUTCOME MEASURE(S): Raw actigraphy activity counts in 1-minute epochs were used to derive a rest-activity ratio over each 24-hour period and a 5-day average value was calculated covering Monday through Friday. Brain injury status was derived through medical record review and three groups were formed: traumatic brain injury (n=14), non-traumatic brain injury (n=16), and a non-ABI control group (n=13). Functional status was measured using WeeFIM Cognitive and Motor scores extracted from the medical records.

RESULTS

Unadjusted models showed a significant main group effect for brain injury status (p=0.012). Compared with controls, the rest-activity ratio was significantly lower in both the traumatic brain injury (p = 0.005), and non-traumatic brain injury (p = 0.023) groups. However, the main group effect was no longer significant in an adjusted model controlling for WeeFIM Cognitive and WeeFIM Motor scores at admission. In the context of the adjusted model, there was a significant relationship between the rest-activity ratio and WeeFIM Cognitive scores at admission.

CONCLUSIONS

Individuals with lower functional status at admission, especially in the cognitive domain, had lower rest-activity ratios, suggesting poorer sleep/wake regulation. Similar to findings in adults with acquired brain injury, this ratio may have utility in tracking sleep/wake regulation in the pediatric rehabilitation setting. Future studies should investigate sensitivity to change over the course of recovery and responsiveness to clinical interventions to improve sleep.

Modification of the Patient Competency Rating Scale to Measure Anosodiaphoria after Severe Acquired Brain Injury: Preliminary Findings

OBJECTIVE

Impaired self-awareness (ISA) of altered functional capacities is a common sequelae of severe acquired brain injury that can severely hamper neuro-rehabilitation in this clinical population. ISA is frequently associated with anosodiaphoria and/or apathy. Although several scales are available to measure apathy, no tools have been published to specifically assess anosodiaphoria after acquired brain injury. In this paper, we reported an initial effort to develop an anosodiaphoria subscale in a commonly used measure of ISA, that is, the Patient Competency Rating scale-neurorehabilitation form (PCRS-NR).

METHOD

A sample of 46 participants with severe acquired brain injury completed a functional, ISA, apathy, and anosodiaphoria assessment. One informal caregiver of each patient participated in the study. Thus, we were able to obtain external data on his/her level of functional competencies, and self-awareness, which allowed separating patients with low self-awareness (LSA) from those with high self-awareness (HSA). Finally, the patients were compared with 44 healthy age-gender-years of formal education matched control participants (HCs).

RESULTS

Compared to both patients with HSA and HCs, patients with LSA demonstrated greater anosodiapvhoria and lower levels of functioning than both HSA patients and HCs. A stronger relationship emerged between ISA and anosodiaphoria rather than with apathy.

CONCLUSIONS

These initial findings provide support that PCRS scale can be adapted to measure anosodiaphoria as well as ISA. The findings reveal a stronger correlation between this measure of anosodiaphoria and ISA compared with the correlation of apathy to ISA. The present method for measuring anosodiaphoria takes into account the actual levels of patients' functioning.

Predicting incident dementia and mild cognitive impairment in older women with nonparametric analysis of circadian activity rhythms in the Study of Osteoporotic Fractures

STUDY OBJECTIVES

Disrupted daily rhythms are associated with mild cognitive impairment (MCI) and dementia. The specific nature of how rhythms and cognition are related, however, is unknown. We hypothesized characteristics from a nonparametric estimate of circadian rest-activity rhythm patterns would be associated to the development of MCI or dementia.

METHODS

Wrist actigraphy from 1232 cognitively healthy, community-dwelling women (mean age 82.6 years) from the Study of Osteoporotic Fractures was used to estimate rest-activity patterns, including intradaily variability (IV), interdaily stability (IS), most active 10-hour period (M10), least active 5-hour period (L5), and relative amplitude (RA). Logistic regression examined associations of these predictors with 5-year incidence of MCI or dementia. Models were adjusted for potential confounders.

RESULTS

Women with earlier sleep/wake times had higher risk of dementia, but not MCI, (early vs. average L5 midpoint: OR, 1.66; 95% CI, 1.08-2.55) as did women with smaller day/night activity differentials (low vs. high RA: OR, 1.96; 95% CI, 1.14-3.35). IV, IS, and M10 were not associated with MCI or dementia.

CONCLUSION

The timing and difference in day/night amplitude, but not variability of activity, may be useful as predictors of dementia.

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

Neurobehavioral Initiation and Motivation Problems After Acquired Brain Injury

Motivation is a primary and permanent source of human behavior and adaptation. Motivational deficits, along with deficiencies in initiation, frequently occur in individuals with acquired brain injury (ABI). These neurobehavioral problems are associated with consequences at the participation level: patients are reluctant to engage in rehabilitation, and their subsequent social reintegration is often at risk. The same problems may also become a heavy burden for the families of individuals with ABI. In the present paper, we will critically review both the current definitions and the instruments used to measure motivational disorders following ABI. We will also describe the neural system underlying motivation and its impairments. What emerges is the need to develop specific rehabilitative treatments, still absent at the moment, with the ultimate aim of ensuring a better quality of life for both the patients and their proxies.

Exploration Deficits Under Ecological Conditions as a Marker of Apathy in Frontotemporal Dementia

Apathy is one of the six clinical criteria for the behavioral variant of frontotemporal dementia (bvFTD), and it is almost universal in this disease. Although its consequences in everyday life are debilitating, its underlying mechanisms are poorly known, its assessment is biased by subjectivity and its care management is very limited. In this context, we have developed "ECOCAPTURE," a method aimed at providing quantifiable and objective signature(s) of apathy in order to assess it and identify its precise underlying mechanisms. ECOCAPTURE consists of the observation and recording of the patient's behavior when the participant is being submitted to a multiple-phase scenario reproducing a brief real-life situation. It is performed in a functional exploration platform transformed into a fully furnished waiting room equipped with a video and sensor-based data acquisition system. This multimodal method allowed video-based behavior analyses according to predefined behavioral categories (exploration behavior, sustained activities or inactivity) and actigraphy analyses from a 3D accelerometer. The data obtained were also correlated with behavioral/cognitive tests and scales assessing global cognitive efficiency, apathy, cognitive disinhibition, frontal syndrome, depression and anxiety. Here, bvFTD patients (n = 14) were compared to healthy participants (n = 14) during the very first minutes of the scenario, when the participants discovered the room and were encouraged to explore it. We showed that, in the context of facing a new environment, healthy participants first explored it and then engaged in sustained activities. By contrast, bvFTD patients were mostly inactive and eventually explored this new place, but in a more irregular and less efficient mode than normal subjects. This exploration deficit was correlated with apathy, disinhibition and cognitive and behavioral dysexecutive syndromes. These findings led us to discuss the presumed underlying mechanisms responsible for the exploration deficit (an inability to self-initiate actions, to integrate reward valuation and to inhibit involuntary behavior). Altogether, these results pave the way for simple and objective assessment of behavioral changes that represents a critical step for the evaluation of disease progression and efficacy of treatment in bvFTD.

The Games for Older Adults Active Life (GOAL) Project for People With Mild Cognitive Impairment and Vascular Cognitive Impairment: A Study Protocol for a Randomized Controlled Trial

Background: People living with Mild Cognitive Impairment (MCI) and Vascular Cognitive Impairment (VCI) are persons who do not fulfill a diagnosis of dementia, but who have a high risk of progressing to a dementia disorder. The most recent guidelines to counteract cognitive decline in MCI/VCI subjects suggest a multidimensional and multi-domain interventions combining cognitive, physical, and social activities. The purpose of this study is to test an innovative service that provides a multi-dimensional tele-rehabilitation program through a user-friendly web application. The latter has been developed through a participatory design involving MCI specialists, patients, and their caregivers. Particularly, the proposed tele-rehabilitation program includes cognitive, physical, and caregiver-supported social activities. The goal is to promote and preserve an active life style and counteract cognitive decline in people living with MCI/VCI. Methods:The study is a randomized controlled trial. Sixty subjects will be randomly assigned to the experimental group, who will receive the tele-rehabilitation program, or the control group, who will not receive any treatment. The trial protocol comprises three steps of assessment for the experimental group: at the baseline (T_0), after tele-rehabilitation program (T_1) and at follow-up after 12-months (T_2). Differently, the control group will be assessed twice: at the baseline and at 12-months follow-up. Both the experimental and the control group will be assessed with a multidimensional evaluation battery, including cognitive functioning, behavioral, functional, and quality of life measures. The tele-rehabilitation program lasts 8 weeks and includes cognitive exercises 3 days a week, physical activities 2 days a week, and social activities once a week. In addition, group will be given an actigraph (GENEActiv, Activisinghts Ltd., Cambridgshire, UK) to track physical and sleep activity. Discussion:Results of this study will inform on the efficacy of the proposed tele-rehabilitation to prevent or delay further cognitive decline in MCI/VCI subjects. The expected outcome is to counteract cognitive decline and improve both physical functioning and quality of life. Ethics and Dissemination:The study is approved by the Local Ethics Committee and registered in https://clinicaltrials.gov (NCT03383549). Dissemination will include submission to a peer-reviewed journal, patients, and healthcare magazines and congress presentations. Trial Registration: ClinicalTrials.gov ID: NCT03383549 (registration date: 26/dec/2017) Trial Funding: Bando FAS Salute 2014 Regione Toscana Version Identifier: ver 5-16/11/2018.

Longitudinal Course and Predictors of Apathetic Symptoms after Severe Traumatic Brain Injury

Objectives

Apathy is one of the most common behavioral symptoms encountered after traumatic brain injury (TBI). However, very little is known about the longitudinal course and predictors of apathetic manifestations. The aims of the present study were to examine how apathy changes and the predictive value of cognitive factors (memory, attention/executive mechanisms, and multitasking) and personal identity factors (self-esteem and self-efficacy beliefs) for apathy over a period of 10 months.

Method

To this end, 68 participants (32 patients with severe TBI matched with 36 control participants) living in the community were enrolled. At Time 1, participants were given three questionnaires to assess self-esteem, self-efficacy beliefs, anxiety and depression symptoms, and five tasks to assess cognitive processes. Simultaneously, a close relative of each participant completed a questionnaire that assessed lack of initiative/initiative. At Time 2, all questionnaires were re-administered to each patient and their relatives.

Results

Patients displayed a significant lack of initiative/interest at all post-injury assessments. At the individual level, the results revealed that a majority of patients had no change in their apathetic symptoms over the 10-month follow-up, whereas in the others, apathetic symptoms mostly increased. Furthermore, impaired memory was the only mechanism that significantly predicted later apathetic manifestations. Complementary profile analyses indicated that patients with worsening symptoms over the follow-up period showed higher inaccurate memory at Time 1 than patients with stable symptoms.

Conclusions

These results provide valuable insight into the longitudinal evolution and predictors of apathy after TBI, which opens interesting prospects for psychological interventions.

[Neuropsychiatric disorders and technological solutions]

Innovative new tools today allow better clinical evaluation. Indeed, new information and communication technology is particularly interesting for the screening, monitoring and management of neuropsychiatric disorders of the elderly. A personalised approach to patients can further enhance their adherence and involvement.

Wrist Actigraphy Validation of Exercise Movement in COPD

A wrist actigraph is a device used in sleep research studies to measure whole body movements. The purpose of this study was to evaluate the feasibility, sensitivity, and validity of wrist actigraphy during pulmonary rehabilitation (PR) upper-extremity exercise in chronic obstructive pulmonary disease (COPD) patients. In this study, 20 patients wore Octagonal Basic Motionlogger® actigraphs during two 90-minute PR sessions while the investigator recorded details of the subject's upper-extremity movements. Concurrent validity with supervised exercise records was supported for upper-extremity endurance (UEE) intensity at baseline ( r = .885, p < .001) and 1 week ( r = .935, p < .001). Criterion validity was supported for UEE ( r = .56, p = .01) and combined lower- and upper-extremity resistance ( r = .72, p < .01) compared with rank-ordered type of exercise. Wrist actigraphy is shown to be a feasible, sensitive, and valid instrument to measure upper-extremity movement during PR in COPD patients.

Quantifying Poststroke Apathy With Actimeters

The authors tested the hypothesis that wrist-worn actimeters can quantify the severity of poststroke apathy. The authors studied 57 patients admitted to an acute rehabilitation unit for ischemic or hemorrhagic stroke. After accounting for motor deficit of the affected arm and accounting for age, each increment of the Apathy Inventory score correlated with 5.6 fewer minutes of moving per hour. The overall statistical model had an R(2) of only 0.34, suggesting unexplained factors for total movement time. Wrist-worn actimeters may serve as an objective, quantifiable measure of poststroke apathy in patients with an intact upper extremity but cannot be used alone to diagnose apathy.

Wrist Actigraphy: A Simple Way to Record Motor Activity in Elderly Patients with Dementia and Apathy or Aberrant Motor Behavior

INTRODUCTION

In dementia, behavioral psychological symptoms are frequent and variable.

OBJECTIVE

To assess the value of wrist actigraphy as a measure of disorder in motor behavior especially apathy, aberrant motor behavior, agitation and anxiety.

METHODS

Cross sectional observational study of consecutive patients older than 75 years admitted to an intermediate care unit of a geriatric hospital ward during a two-year period. Psycho behavioral symptoms and cognitive status were assessed using the NPI scale and MMSE and diagnosis of dementia was done using DSMIV criteria. A wrist actigraph was worn for 10 days to record motor activity, sleep time and number of periods of sleep.

RESULTS

183 patients were included. Among patients with dementia, a significant decrease in motor activity was recorded in those with apathy from 9h to 12h and 18h to 21h (p <0.05) and in those with anxiety from 21h to 24h (p <0.05). Aberrant motor behavior in dementia was associated with a significant increase in motor activity from 21h to 24h (p <0.01). Agitation was not associated with a significant differences in motor activity.

CONCLUSIONS

Wrist actigraphy can be used to record motor activity in elderly patients with dementia especially in those with apathy and aberrant motor behavior.

Apathy: who cares? A concept analysis

Apathy has been identified as an independent clinical syndrome. As prevalent and problematic as it is in the field of neuropsychiatry, there is no fully accepted definition of apathy. In this study, a concept analysis utilizing Rodgers' evolutionary approach was performed. CINAHL Plus with Full Text was searched, and altogether 36 publications were identified for the concept analysis. Our study shows that psychometric scales may have resulted in an inappropriate diagnosis of depression instead of apathy. As a whole, the literature showed that apathy was defined in comparison to depression as well as altered motivation, emotionality, activity, interest, and initiative. We discuss the advances in the development of apathy as an evolutionary concept. Consistent with Rodgers' evolutionary method, these findings are not an endpoint.

Quantitative electroencephalography and behavioural correlates of daytime sleepiness in chronic stroke

Sleepiness is common after stroke, but in contrast to its importance for rehabilitation, existing studies focus primarily on the acute state and often use subjective sleepiness measures only. We used quantitative electroencephalography (qEEG) to extract physiological sleepiness, as well as subjective reports, in response to motor-cognitive demand in stroke patients and controls. We hypothesised that (a) slowing of the EEG is chronically sustained after stroke; (b) increased power in lower frequencies and increased sleepiness are associated; and (c) sleepiness is modulated by motor-cognitive demand. QEEGs were recorded in 32 chronic stroke patients and 20 controls using a Karolinska Drowsiness Test protocol administered before and after a motor priming task. Subjective sleepiness was measured using the Karolinska Sleepiness Scale. The findings showed that power density was significantly increased in delta and theta frequency bands over both hemispheres in patients which were not associated with subjective sleepiness ratings. This effect was not observed in controls. The motor priming task induced differential hemispheric effects with greater increase in low-frequency bands and presumably compensatory increases in higher frequency bands. The results indicate sustained slowing in the qEEG in chronic stroke, but in contrast to healthy controls, these changes are not related to perceived sleepiness.

A review of current information and communication technologies: can they be used to assess apathy?

BACKGROUND

Neuropsychiatric symptoms, such as apathy, have an important impact on the quality of life of both patients diagnosed with dementia and their caregivers and represent a strong predictor of progression of the illness. Current clinical assessment methods risk bias resulting from the assessor's subjectivity, pointing to a need for additional objective and systematic assessment tools. Therefore, the use of information and communication technologies (ICT) such as actigraphy and automatized video monitoring are of interest in addition to current assessment methods.

AIM

The goal of this study is to give an overview of current assessment tools for apathy in clinical practice and new approaches to assessment methods with the help ICT.

METHODS

This study was conducted with the use of narrative literature overview.

RESULTS

There is evidence that apart from the currently used assessment methods for apathy, new ICT approaches could provide clinicians with valuable additional information for an earlier detection and therefore more accurate diagnosis of apathy.

CONCLUSIONS

There are no ICT techniques specifically designed for the assessment of apathy, but nevertheless several techniques seem to be promising and deserve more study.

Apathy following traumatic brain injury

Traumatic brain injury (TBI) may result in significant emotional and behavioral changes, such as depression, impulsivity, anxiety, aggressive behavior, and posttraumatic stress disorder. Apathy has been increasingly recognized as a relevant sequela of TBI, with a negative impact on the patients' quality of life as well as their participation in rehabilitation activities. This article reviews the nosologic and phenomenological aspects of apathy in TBI, diagnostic issues, frequency and prevalence, relevant comorbid conditions, potential mechanisms, and treatment.

Characterization of apathy in persons with frontotemporal dementia and the impact on family caregivers

This study characterized daytime activity and apathy in patients with behavioral variant frontotemporal dementia (bvFTD) and semantic dementia (SD) and their family caregivers. Twenty-two patient-caregiver dyads were enrolled: 13 bvFTD and 9 SD. Data were collected on behavior and movement. Patients and caregivers wore Actiwatches for 2 weeks to record activity. We predicted that bvFTD patients would show greater caregiver report of apathy and less daytime activity compared with patients diagnosed with SD. Patients with bvFTD spent 25% of their day immobile, whereas patients with SD spent 16% of their day inactive. BvFTD caregivers spent 11% of their day immobile and SD caregivers were immobile 9% of their day. Apathy was present in all of the patients with bvFTD and in all but one patient with SD; the severity of apathy was greater in bvFTD compared with SD. Apathy correlated with caregiver emotional distress in both groups. In conclusion, apathy has been defined as a condition of diminished motivation that is difficult to operationalize. Among patients with frontotemporal dementia, apathy was associated with lower levels of activity, greater number of bouts of immobility, and longer immobility bout duration. Apathy and diminished daytime activity appeared to have an impact on the caregiver. Objective measures of behavioral output may help in formulation of a more precise definition of apathy.

Recommendations for ICT use in Alzheimer's disease assessment: Monaco CTAD Expert Meeting

Alzheimer disease (AD) and other related dementia represent a major challenge for health care systems within the aging population. It is therefore important to develop better instruments for assessing disease severity and disease progression to optimize patient's care and support to care providers, and also provide better tools for clinical research. In this area, Information and Communication Technologies (ICT) are of particular interest. Such techniques enable accurate and standardized assessments of patients' performance and actions in real time and real life situations. The aim of this article is to provide basic recommendation concerning the development and the use of ICT for Alzheimer's disease and related disorders. During he ICT and Mental Health workshop (CTAD meeting held in Monaco on the 30th October 2012) an expert panel was set up to prepare the first recommendations for the use of ICT in dementia research. The expert panel included geriatrician, epidemiologist, neurologist, psychiatrist, psychologist, ICT engineers, representatives from the industry and patient association. The recommendations are divided into three sections corresponding to 1/ the clinical targets of interest for the use of ICT, 2/ the conditions, the type of sensors and the outputs (scores) that could be used and obtained, 3/ finally the last section concerns specifically the use of ICT within clinical trials.

Neurological and psychiatric aspects of emotion

Neurological and psychiatric aspects of emotions have been the focus of intense research for the past 30 years. Studies in both acute (e.g., stroke, traumatic brain injury (TBI)) and chronic (e.g., dementia, Parkinson's disease) neurological disorders demonstrated a high frequency of both depression and apathy. Studies in stroke and TBI reported a significant association between lesion location and depression. Both depression and apathy are significant predictors of poor recovery among patients with brain injuries, and of steeper cognitive and functional decline among patients with neurodegenerative disorders. Poor insight and judgment are frequently found among patients with brain injury or degeneration. There is increasing evidence that damage to specific brain regions, such as the ventromedial prefrontal cortex, is associated with inappropriate emotional reactions in social contexts and diminished anxiety and concern for the future. In severe cases, behavioural changes may also include poor decision-making in the social realm, deficits in goal-directed behavior, and lack of insight into these changes. Future studies will validate specific diagnostic criteria for the various cognitive, emotional, and behavioral problems reported among patients with neurological disorders, which may result in more specific and effective treatments.

Decreased daytime motor activity associated with apathy in Alzheimer disease: an actigraphic study

OBJECTIVE

Across all stages of Alzheimer disease (AD), apathy is the most common neuropsychiatric symptom. Studies using the Neuropsychiatric Inventory (NPI) have found that apathy is present in up to 70% of individuals with Alzheimer disease. One of the main difficulties in assessing apathy and other neuropsychiatric symptoms is the absence of reliable, objective measures. Motor activity assessment using ambulatory actigraphy could provide an indirect, objective evaluation of apathy. The aim of our study was to assess the relationship between apathy and daytime motor activity in AD, using ambulatory actigraphy.

METHODS

One hundred seven AD outpatients wore a wrist actigraph (Motionlogger) during seven consecutive 24-hour periods to evaluate motor activity. Participants were divided into two subgroups according to their apathy subscores on the NPI: individuals with apathy (NPI-apathy subscores >4) and those without. Daytime mean motor activity scores were compared between the two subgroups.

RESULTS

Individuals with AD who had symptoms of apathy (n = 43; age = 79 ± 4.7 years; Mini-Mental State Examination = 20.9 ± 4.8) had significantly lower daytime mean motor activity than AD patients without apathy (n = 64; age = 76.3 ± 7.7; Mini-Mental State Examination = 21.5 ± 4.7), while nighttime mean motor activity did not significantly differ between the two subgroups.

CONCLUSIONS

Ambulatory actigraphy could be added to currently used questionnaires as a simple, objective technique for assessing apathy in the routine assessment of AD patients.

Facial expression in Alzheimer's disease: impact of cognitive deficits and neuropsychiatric symptoms

In Alzheimer's disease (AD), nonverbal aspects of communication become increasingly important in caregiver-patient interactions when the ability to communicate verbally is fading with progression of the disease. We therefore investigated the impact of cognitive deficits and neuropsychiatric symptoms, particularly apathy, on facial expression in AD. While overall neuropsychiatric symptoms were not associated with facial expression, apathy exhibited substantial correlations, even after controlling for cognitive deficits. Moreover, apathy appeared to moderate the influence of cognitive deficits: without considering apathy, cognitive deficits were associated with less specific facial expressions. After controlling for apathy, cognitive decline was related to increased facial expressiveness. In conclusion, apathetic symptoms appear to be specifically associated with facial expression in AD and thus could contribute to a disregard for patients' needs in everyday life.

Circadian activity rhythms and risk of incident dementia and mild cognitive impairment in older women

OBJECTIVE

Previous cross-sectional studies have observed alterations in activity rhythms in dementia patients but the direction of causation is unclear. We determined whether circadian activity rhythms measured in community-dwelling older women are prospectively associated with incident dementia or mild cognitive impairment (MCI).

METHODS

Activity rhythm data were collected from 1,282 healthy community-dwelling women from the Study of Osteoporotic Fractures (SOF) cohort (mean age 83 years) with wrist actigraphy for a minimum of three 24-hour periods. Each participant completed a neuropsychological test battery and had clinical cognitive status (dementia, MCI, normal) adjudicated by an expert panel approximately 5 years later. All analyses were adjusted for demographics, body mass index (BMI), functional status, depression, medications, alcohol, caffeine, smoking, health status, and comorbidities.

RESULTS

After 4.9 years of follow-up, 195 (15%) women had developed dementia and 302 (24%) had developed MCI. Older women with decreased activity rhythms had a higher likelihood of developing dementia or MCI when comparing those in the lowest quartiles of amplitude (odds ratio [OR] = 1.57; 95% CI, 1.09-2.25) or rhythm robustness (OR = 1.57; 95% CI, 1.10-2.26) to women in the highest quartiles. An increased risk of dementia or MCI (OR = 1.83; 95% CI, 1.29-2.61) was found for women whose timing of peak activity occurred later in the day (after 3:51 PM) when compared to those with average timing (1:34 PM-3:51 PM).

INTERPRETATION

Older, healthy women with decreased circadian activity rhythm amplitude and robustness, and delayed rhythms have increased odds of developing dementia and MCI. If confirmed, future studies should examine whether interventions (physical activity, bright light exposure) that influence activity rhythms will reduce the risk of cognitive deterioration in the elderly.

Actigraphic Daytime Activity is Reduced in Patients With Cognitive Impairment and Apathy

Objectives

Apathy is a neuropsychiatric symptom in mild cognitive impairment (MCI) and dementia. This study examines correlations between Apathy Evaluation Scale (AES) ratings and actigraphic measures of daytime activity. The aim of this study is to determine the value of ambulatory actigraphy in the assessment of locomotor deficits as a correlate of apathy in geriatric patients with cognitive impairment.

Patients and methods

In this cross-sectional study a total of 82 participants were recruited, 32 patients with dementia, 21 patients with MCI and 23 elderly controls. Rating scales for apathy (AES) and depression (Beck Depression Inventory, BDI) were completed. To measure daytime activity a wrist-worn actigraph and an established protocol were used. A single measure of mean daytime activity per participant was calculated for further statistical analysis.

Results

In the two groups of patients with MCI and dementia, apathy is associated with reduced daytime activity, independent of diagnosis (no group by apathy interaction). AES scores correlate significantly with daytime activity. Cognitive impairment reduces daytime activity (effect greater in dementia than in MCI). Daytime activity is negatively correlated with memory deficits.

Conclusion

Ambulatory actigraphy is a promising method to evaluate self-initiated action as a correlate of apathy in patients with cognitive impairment.

Ambulatory actigraphy correlates with apathy in mild Alzheimer’s disease

Aim: Apathy is one of the most common behavioral symptoms in Alzheimer’s disease (AD). The aim of our study was to assess the relationship between apathy and locomotor activity in mild Alzheimer’s disease (AD).

Methods: Thirty AD subjects and fifteen healthy controls were recruited from the Nice Memory Center. Apathy was assessed with the Apathy Inventory (AI). Patients with a score greater than three on the AI caregiver version are considered in this report as having apathy. Locomotor activity was assessed using a wrist-worn actigraph for 75 minutes, during which a neuropsychological and behavioral examination were performed (60 minutes) followed by 15 minutes of free activity. Results: AD patients shown lower motor activity than healthy subjects. AD patients with apathy had lower motor activity than AD patients without apathy. Apathy total score correlated negatively with mean motor activity. Most of the total score correlation was accounted for by correlations between the apathy dimensions lack of initiative and lack of interest, with mean motor activity.

Conclusion: Ambulatory actigraphy could be a simple technique to assess apathy objectively as part of routine assessment of AD patients.

Measurement of Neuropsychiatric Symptoms in Clinical Trials Targeting Alzheimer's Disease and Related Disorders

Behavioral and psychological symptoms (BPSD) are now known to be frequently associated to cognitive and functional decline in Alzheimer's disease and related disorders. They are present since the early stages of the disease and have negative impact on the disease process. BPSD assessment is crucial in clinical practice and also in future clinical trials targeting disease-modifying therapies for dementia. In this article, we will first review current assessment tools for BPSD, mainly global and domain-specific scales, and new assessment methods, currently available or in development, including new scales, diagnostic criteria and new technologies such as ambulatory actigraphy.

Approaches to measuring the effects of wake-promoting drugs: a focus on cognitive function

OBJECTIVES

In clinical drug development, wakefulness and wake-promotion may be assessed by a large number of scales and questionnaires. Objective assessment of wakefulness is most commonly made using sleep latency/maintenance of wakefulness tests, polysomnography and/or behavioral measures. The purpose of the present review is to highlight the degree of overlap in the assessment of wakefulness and cognition, with consideration of assessment techniques and the underlying neurobiology of both concepts.

DESIGN

Reviews of four key areas were conducted: commonly used techniques in the assessment of wakefulness; neurobiology of sleep/wake and cognition; targets of wake promoting and/or cognition enhancing drugs; and ongoing clinical trials investigating wake promoting effects.

RESULTS

There is clear overlap between the assessment of wakefulness and cognition. There are common techniques which may be used to assess both concepts; aspects of the neurobiology of both concepts may be closely related; and wake-promoting drugs may have nootropic properties (and vice versa). Clinical trials of wake-promoting drugs often, though not routinely, assess aspects of cognition.

CONCLUSIONS

Routine and broad assessment of cognition in the development of wake-promoting drugs may reveal important nootropic effects, which are not secondary to alertness/wakefulness, whilst existing cognitive enhancers may have underexplored or unknown wake promoting properties.

[Severe apathy following head injury: improvement with Selegiline treatment]

Apathy is defined as reduced goal-directed behavior due to lack of motivation. Traumatic brain injury is a frequent cause. Drugs activating the dopaminergic system provide variable benefit. A 30-year-old patient was the victim of a severe head injury with frontal bruise at the age of 15. At the request of his family, he consulted for a 7-year history that included a lack of initiative and the inability to generate behavior spontaneously, contrasting with the ability to execute behaviors on command. He also presented indifference, major emotional disruption without sadness, pessimism, and other depressive signs. The examination found a severe apathetic syndrome confirmed by specific scales with a mild impairment of executive functions and without depressive syndrome. Encephalic MRI showed atrophy of the whole prefrontal cerebral cortex. The patient was treated with bromocriptine, which he did not tolerate, then with Selegiline at 15 mg per day, which dramatically improved his symptoms. Apathy occurs frequently after traumatic brain injury, in 23-71% of patients according to the authors. The pathophysiology of apathy has been described in anatomical terms as related to disruption of frontal-subcortical pathways. The biochemical hypothesis postulates a disruption in dopaminergic activity. The use of dopaminergic agents usually improves cases similar to our patient. Apathy is frequent following head injury, warranting a search for systematic causes. Since it increases dopaminergic activity, Selegiline is well worth trying in these patients.

Cognition in older women: the importance of daytime movement

OBJECTIVES

To determine whether an objective measure of daytime movement is associated with better cognitive function in women in their 80s.

DESIGN

Cross-sectional.

SETTING

A study of health and aging.

PARTICIPANTS

Two thousand seven hundred thirty-six older women without evidence of dementia.

MEASUREMENTS

Daytime movement was assessed using actigraphy, which involved wearing a watch-like device that objectively quantified accelerometer motion over a mean of 3.0+/-0.8 days. Cognitive function was measured using the Trail-Making Test, Part B (Trails B) and the Mini-Mental State Examination (MMSE). Cognitive impairment was defined as performing 1.5 standard deviations (SDs) worse than the mean on a given test.

RESULTS

Participants had a mean age of 83+/-4; 10% were African American. After adjustment for age, race, and education, women in the highest movement quartiles had better mean cognitive test scores (20+/-0.3 seconds faster on Trails B and 0.3+/-0.2 points higher on MMSE, both P<.001) than those in the lowest quartile and were less likely to be cognitively impaired (odds ratio (OR)=0.61, 95% confidence interval (CI)=0.41-0.92 for Trails B; OR=0.68, 95% CI=0.44-1.07 for MMSE). Associations were similar in different subgroups and were independent of self-reported walking, medical comorbidities, physical function, and other health-related behaviors.

CONCLUSION

Daytime movement as measured objectively using actigraphy was associated with better cognitive function and lower odds of cognitive impairment in women in their 80s. Additional studies are needed to clarify the direction of the association and to explore potential mechanisms.