Impaired Novelty Processing in Apathy After Subcortical Stroke

Specific mechanisms underlying executive and emotional apathy: A phenotyping study

Apathy is a behavioral symptom prevalent both in neuropsychiatric pathologies and in the healthy population. However, the knowledge of the cognitive and neural mechanisms underlying apathy is still very limited, even if clinical and fMRI data support the existence of three forms of apathy (executive, emotional, initiative). These forms could be explained by the alteration of specific mechanisms. This present study's aim is to specify the cognitive and neuronal mechanisms of executive and emotional apathy. We used an EEG study conducted on 68 subjects comprising two groups of young people with specific executive or emotional phenotypes of apathy and one group with no apathy. Despite having symptom of apathy, participants were free of any neurological, metabolic, or psychiatric diagnoses and with high education. Two tasks were used: the DPX for cognitive control and the MID for motivation. Our results showed that distinct mechanisms underlie these two forms of apathy, and, for the first time, we specified these mechanisms. A deficit of the proactive control mode, reflected by a reduced probe-N2 amplitude in AY trials, underlies the executive form of apathy (p < .03), whereas liking motivational blunting, highlighted by a reduced LPP amplitude for financial loss, characterizes the emotional form (p < .04). The main limit of the results is that generalizability to the general population may be reduced since the apathetic samples were chosen for having a specific form of apathy. To conclude, better knowledge of these mechanisms informs new, more targeted treatments, both pharmacological and non-pharmacological, necessary for reducing the debilitating consequences of apathy.

Auditory attention measured by EEG in neurological populations: systematic review of literature and meta-analysis

Sensorimotor synchronization strategies have been frequently used for gait rehabilitation in different neurological populations. Despite these positive effects on gait, attentional processes required to dynamically attend to the auditory stimuli needs elaboration. Here, we investigate auditory attention in neurological populations compared to healthy controls quantified by EEG recordings. Literature was systematically searched in databases PubMed and Web of Science. Inclusion criteria were investigation of auditory attention quantified by EEG recordings in neurological populations in cross-sectional studies. In total, 35 studies were included, including participants with Parkinson's disease (PD), stroke, Traumatic Brain Injury (TBI), Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS). A meta-analysis was performed on P3 amplitude and latency separately to look at the differences between neurological populations and healthy controls in terms of P3 amplitude and latency. Overall, neurological populations showed impairments in auditory processing in terms of magnitude and delay compared to healthy controls. Consideration of individual auditory processes and thereafter selecting and/or designing the auditory structure during sensorimotor synchronization paradigms in neurological physical rehabilitation is recommended.

Motor-cognitive functions required for driving in post-stroke individuals identified via machine-learning analysis

BACKGROUND

People who were previously hospitalised with stroke may have difficulty operating a motor vehicle, and their driving aptitude needs to be evaluated to prevent traffic accidents in today's car-based society. Although the association between motor-cognitive functions and driving aptitude has been extensively studied, motor-cognitive functions required for driving have not been elucidated.

METHODS

In this paper, we propose a machine-learning algorithm that introduces sparse regularization to automatically select driving aptitude-related indices from 65 input indices obtained from 10 tests of motor-cognitive function conducted on 55 participants with stroke. Indices related to driving aptitude and their required tests can be identified based on the output probability of the presence or absence of driving aptitude to provide evidence for identifying subjects who must undergo the on-road driving test. We also analyzed the importance of the indices of motor-cognitive function tests in evaluating driving aptitude to further clarify the relationship between motor-cognitive function and driving aptitude.

RESULTS

The experimental results showed that the proposed method achieved predictive evaluation of the presence or absence of driving aptitude with high accuracy (area under curve 0.946) and identified a group of indices of motor-cognitive function tests that are strongly related to driving aptitude.

CONCLUSIONS

The proposed method is able to effectively and accurately unravel driving-related motor-cognitive functions from a panoply of test results, allowing for autonomous evaluation of driving aptitude in post-stroke individuals. This has the potential to reduce the number of screening tests required and the corresponding clinical workload, further improving personal and public safety and the quality of life of individuals with stroke.

Psychiatric sequelae of stroke affecting the non-dominant cerebral hemisphere

There are a plethora of cognitive sequelae in addition to neglect and extinction that arise with unilateral right hemispheric stroke (RHS). Cognitive deficits following non-dominant (right) hemisphere stroke are common with unilateral neglect and extinction being the most recognized examples. The severity of RHS is usually underestimated by the National Institutes of Health Stroke Scale (NIHSS), which in terms of lateralized right hemisphere cognitive deficits, tests only for visual inattention/extinction. They account for 2 out of 42 total possible points. Additional neuropsychiatric sequelae include but are not limited to deficiencies in affective prosody comprehension and production (aprosodias), understanding and expressing facial emotions, empathy, recognition of familiar faces, anxiety, mania, apathy, and psychosis. These sequelae have a profound impact on patients' quality of life; affecting communication, interpersonal relationships, and the ability to fulfill social roles. They also pose additional challenges to recovery. There is presently a gap in the literature regarding a cohesive overview of the significant cognitive sequelae following RHS. This paper serves as a narrative survey of the current understanding of the subject, with particular emphasis on neuropsychiatric poststroke syndromes not predominantly associated with left hemisphere lesions (LHL), bilateral lesions, hemiplegia, or paralysis. A more comprehensive understanding of the neuropsychological consequences of RHS extending beyond the typical associations of unilateral neglect and extinction may have important implications for clinical practice, including the ways in which clinicians approach diagnostics, treatment, and rehabilitation.

Changes in Physical and Psychological States with Respect to the Gender of Outpatients Receiving Rehabilitation at Geriatric Health Services Facilities during the COVID-19 State of Emergency

This study was a sub-analysis of 20 consecutive elderly participants who underwent outpatient rehabilitation at a geriatric health services facility from January 2020 to the end of May 2020, based on our previous report. This study aimed to evaluate the longitudinal changes in their physical and psychological states with respect to gender in rehabilitation outpatients between the pre-nationwide (T1) and post-nationwide state of emergency (T2) caused by the Coronavirus disease 2019 (COVID-19). Gait speed (GS), timed up and go (TUG), handgrip strength (HG), and maximum phonation time (MPT) were measured as indices of physical status. The Japanese version of the Apathy Scale and five-level EuroQoL five-dimensional questionnaire (EQ-5D-5L) were used to assess the psychological state. Both states were measured in the male and female groups at T1 and T2 and then were compared. The final analysis was comprised of 13 outpatients. In males, the physical (GS, p = 0.463; TUG, p = 0.600; HG, p = 0.753; and MPT, p = 0.249) and psychological (Apathy Scale, p = 0.891 and EQ-5D-5L, p = 0.249) states did not change significantly between T1 and T2. In the females, the physical (GS, p = 0.600; TUG, p = 0.735; HG, p = 1.000; and MPT, p = 0.310) and psychological (Apathy Scale, p = 0.588 and EQ-5D-5L, p = 0.176) states also did not show significant change between T1 and T2. In both sexes, the continuance of outpatient rehabilitation might be recommended as one activity that can maintain physical and psychological states during a COVID-19-related state of emergency.

Lesions in the right Rolandic operculum are associated with self-rating affective and apathetic depressive symptoms for post-stroke patients

Stroke survivors majorly suffered from post-stroke depression (PSD). The PSD diagnosis is commonly performed based on the clinical cut-off for psychometric inventories. However, we hypothesized that PSD involves spectrum symptoms (e.g., apathy, depression, anxiety, and stress domains) and severity levels. Therefore, instead of using the clinical cut-off, we suggested a data-driven analysis to interpret patient spectrum conditions. The patients’ psychological conditions were categorized in an unsupervised manner using the k-means clustering method, and the relationships between psychological conditions and quantitative lesion degrees were evaluated. This study involved one hundred sixty-five patient data; all patients were able to understand and perform self-rating psychological conditions (i.e., no aphasia). Four severity levels—low, low-to-moderate, moderate-to-high, and high—were observed for each combination of two psychological domains. Patients with worse conditions showed the significantly greater lesion degree at the right Rolandic operculum (part of Brodmann area 43). The dissimilarities between stress and other domains were also suggested. Patients with high stress were specifically associated with lesions in the left thalamus. Impaired emotion processing and stress-affected functions have been frequently related to those lesion regions. Those lesions were also robust and localized, suggesting the possibility of an objective for predicting psychological conditions from brain lesions.

Relationships between motor and cognitive functions and subsequent post-stroke mood disorders revealed by machine learning analysis

Mood disorders (e.g. depression, apathy, and anxiety) are often observed in stroke patients, exhibiting a negative impact on functional recovery associated with various physical disorders and cognitive dysfunction. Consequently, post-stroke symptoms are complex and difficult to understand. In this study, we aimed to clarify the cross-sectional relationship between mood disorders and motor/cognitive functions in stroke patients. An artificial neural network architecture was devised to predict three types of mood disorders from 36 evaluation indices obtained from functional, physical, and cognitive tests on 274 patients. The relationship between mood disorders and motor/cognitive functions were comprehensively analysed by performing input dimensionality reduction for the neural network. The receiver operating characteristic curve from the prediction exhibited a moderate to high area under the curve above 0.85. Moreover, the input dimensionality reduction retrieved the evaluation indices that are more strongly related to mood disorders. The analysis results suggest a stress threshold hypothesis, in which stroke-induced lesions promote stress vulnerability and may trigger mood disorders.

Vitality index is a predictor of the improvement in the functional independence measure score in subacute stroke patients with cognitive impairment

OBJECTIVES

To investigate the effect of motivation on improvements in the Functional Independence Measure (FIM) scores in subacute stroke patients with cognitive impairment.

METHODS

This retrospective cohort study included 358 consecutive subacute stroke patients with first-ever stroke and Mini-Mental State Examination score ≤23 at admission. We determined motivation and rehabilitation outcome using the vitality index and FIM-motor gain, respectively. Stepwise multiple regression analysis was performed to identify the factors at admission related to FIM-motor gain.

RESULTS

Of 80 participants enrolled in this study (mean age: 74.2 ± 11.3 years). The median (interquartile range) vitality index at admission and FIM-motor gain were 7 (4) and 23 (22) points, respectively. Stepwise multiple regression analysis revealed that age (B, -0.43; 95% confidence interval [CI], -0.65-(-0.21); β, -0.31; P <.001), duration from stroke onset to admission (B, -0.18; 95% CI, -0.33-(-0.04); β, -0.20; P =.014) and Stroke Impairment Assessment Set-motor function (B, 1.27; 95% CI, 0.92-1.61; β, 0.78; P <.001), FIM-motor (B, -0.80; 95% CI, -1.01-(-0.60); β, -0.95; P <.001), and vitality index (B, 3.79; 95% CI, 2.37-5.21; β, 0.50; P <.001) scores at admission were significantly associated with the FIM-motor gain.

DISCUSSION

The vitality index was significantly associated with FIM improvement in subacute stroke patients with cognitive impairment.

Apathy and depression during the recovery stage after stroke

Background/Aims

Both apathy and depression occur during the recovery period following stroke; however, the relationship between post-stroke apathy and depression is still unclear. The present study investigated the clinical course of apathy and its association with depression, cognitive function and daily function during the recovery period after stroke.

Methods

A total of 42 patients (29 male and 13 female, aged 69.1 ± 12.4 years) who had experienced stroke participated in this study. Each participant was assessed using the Apathy Scale, Self-rating Depression Scale, Mini-Mental State Examination, Clinical Assessment of Attention and Trail-Making-Test parts A and B. Quality of life was evaluated using the Stroke Specific Quality of Life Scale. Physical function and functional status were assessed using the Brunnstrom Stages of Stroke Recovery and Functional Independence Measure respectively.

Results

The incidence of apathy did not change from the time of admission to discharge. Apathy Scale score did not correlate with Self-rating Depression Scale score at admission, but it did correlate at the time of discharge. Patients with apathy after stroke suffered from greater cognitive disturbance and attention and executive dysfunctions than those without apathy. Total Functional Independence Measure score did not correlate with Apathy Scale or Self-rating Depression Scale score, but there was an association between Self-rating Depression Scale score and the Functional Independence Measure motor and Brunnstrom scores at discharge.

Conclusions

Apathy and depression had different relationships with cognitive and physical function during the recovery stage after stroke. The prevalence of apathy and depression changed, with the interrelationship between apathy and depression altering during the recovery period. Symptoms of apathy and depression should be distinguished from each other and appropriately evaluated to provide effective intervention to support physical and mental recovery after stroke.

Network neuroscience of apathy in cerebrovascular disease

Apathy is a reduction in motivated goal-directed behavior (GDB) that is prevalent in cerebrovascular disease, providing an important opportunity to study the mechanistic underpinnings of motivation in humans. Focal lesions, such as those seen in stroke, have been crucial in developing models of brain regions underlying motivated behavior, while studies of cerebral small vessel disease (SVD) have helped define the connections between brain regions supporting such behavior. However, current lesion-based models cannot fully explain the neurobiology of apathy in stroke and SVD. To address this, we propose a network-based model which conceptualizes apathy as the result of damage to GDB-related networks. A review of the current evidence suggests that cerebrovascular disease-related pathology can lead to network changes outside of initially damaged territories, which may propagate to regions that share structural or functional connections. The presentation and longitudinal trajectory of apathy in stroke and SVD may be the result of these network changes. Distinct subnetworks might support cognitive components of GDB, the disruption of which results in specific symptoms of apathy. This network-based model of apathy may open new approaches for investigating its underlying neurobiology, and presents novel opportunities for its diagnosis and treatment.

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.

Do Event-Related Evoked Potentials Reflect Apathy Tendency and Motivation?

Apathy is a mental state of diminished motivation. Although the reward system as the foundation of the motivation in the human brain has been studied extensively with neuroimaging techniques, the electrophysiological correlates of motivation and apathy have not been fully explored. Thus, in 14 healthy volunteers, we examined whether event-related evoked potentials (ERP) obtained during a simple number discrimination task with/without rewards reflected apathy tendency and a reward-dependent tendency, which were assessed separately using the apathy scale and the temperament and character inventory (TCI). Participants were asked to judge the size of a number, and received feedback based on their performance in each trial. The P3 amplitudes related to the feedback stimuli increased only in the reward condition. Furthermore, the P2 amplitudes related to the negative feedback stimuli in the reward condition had a positive correlation with the reward-dependent tendency in TCI, whereas the P3 amplitudes related to the positive feedback stimuli had a negative correlation with the apathy score. Our result suggests that the P2 and P3 ERPs to reward-related feedback stimuli are modulated in a distinctive manner by the motivational reward dependence and apathy tendency, and thus the current paradigm may be useful for investigating the brain activity associated with motivation.

Right Fronto-Temporal EEG can Differentiate the Affective Responses to Award-Winning Advertisements

Affective engineering aims to improve service/product design by translating the customer's psychological feelings. Award-winning advertisements (AAs) were selected on the basis of the professional standards that consider creativity as a prerequisite. However, it is unknown if AA is related to satisfactory advertising performance among customers or only to the experts' viewpoints towards the advertisements. This issue in the field of affective engineering and design merits in-depth evaluation. We recruited 30 subjects and performed an electroencephalography (EEG) experiment while watching AAs and non-AAs (NAAs). The event-related potential (ERP) data showed that AAs evoked larger positive potentials 250-1400 [Formula: see text]ms after stimulus onset, particularly in the right fronto-temporal regions. The behavioral results were consistent with the professional recognition given to AAs by experts. The perceived levels of creativity and "product-like" quality were higher for the AAs than for the NAAs. Event-related spectral perturbation (ERSP) analysis further revealed statistically significant differences in the theta, alpha, beta, and gamma band activity in the right fronto-temporal regions between the AAs and NAAs. Our results confirm that EEG features from the time/frequency domains can differentiate affective responses to AAs at a neural circuit level, and provide scientific evidence to support the identification of AAs.

Cognitive and Neurophysiological Effects of Non-invasive Brain Stimulation in Stroke Patients after Motor Rehabilitation

The primary aim of this study was to evaluate and compare the effectiveness of two specific Non-Invasive Brain Stimulation (NIBS) paradigms, the repetitive Transcranial Magnetic Stimulation (rTMS), and transcranial Direct Current Stimulation (tDCS), in the upper limb rehabilitation of patients with stroke. Short and long term outcomes (after 3 and 6 months, respectively) were evaluated. We measured, at multiple time points, the manual dexterity using a validated clinical scale (ARAT), electroencephalography auditory event related potentials, and neuropsychological performances in patients with chronic stroke of middle severity. Thirty four patients were enrolled and randomized. The intervention group was treated with a NIBS protocol longer than usual, applying a second cycle of stimulation, after a washout period, using different techniques in the two cycles (rTMS/tDCS). We compared the results with a control group treated with sham stimulation. We split the data analysis into three studies. In this first study we examined if a cumulative effect was clinically visible. In the second study we compared the effects of the two techniques. In the third study we explored if patients with minor cognitive impairment have most benefit from the treatment and if cognitive and motor outcomes were correlated. We found that the impairment in some cognitive domains cannot be considered an exclusion criterion for rehabilitation with NIBS. ERP improved, related to cognitive and attentional processes after stimulation on the motor cortex, but transitorily. This effect could be linked to the restoration of hemispheric balance or by the effects of distant connections. In our study the effects of the two NIBS were comparable, with some advantages using tDCS vs. rTMS in stroke rehabilitation. Finally we found that more than one cycle (2-4 weeks), spaced out by washout periods, should be used, only in responder patients, to obtain clinical relevant results.

Apathy, Novelty Processing, and the P3 Potential in Parkinson's Disease

Parkinson's disease (PD) is characterized by deficits in goal-directed behavior as well as mood and motivational symptoms, including apathy, depression, and anxiety. The present study investigated novelty processing in PD, using event-related potentials (ERPs) to characterize electrophysiological reflections of visual novelty processing. Since apathy has been associated with decreased novelty processing (P3 potentials) in highly apathetic PD patients, we were particularly interested to see if this relationship exists in a sample of PD patients with heterogeneous levels of apathy. Non-demented patients with PD receiving dopaminergic treatment (n = 14) and healthy control participants (n = 12) completed a three-stimulus oddball task while EEG was recorded. Relative to controls, the PD patients exhibited reductions in centrofrontally distributed P3 potentials when viewing novel distracters during this task. Distracter-related P3 amplitudes evoked by novel distracters were strongly associated with apathy symptoms, even after controlling for the effects of depression, anxiety, and executive function. Executive dysfunction was also predictive of novelty-related P3 processing, yet this relationship was independent from that of apathy. These findings suggest that the brain's electrophysiological response to novelty is closely related to both motivational and cognitive symptoms in PD, even for patients whose apathy symptoms are not excessive. These results have significant implications for our understanding of non-motor symptoms in this clinical population.

Cognitive impairments and mood disruptions negatively impact instrumental activities of daily living performance in the first three months after a first stroke

BACKGROUND

Cognition and mood play crucial roles in post-stroke recovery; however, the stroke literature is unclear as to how impairments in both domains influence performance of instrumental activities of daily living (IADL).

OBJECTIVE

(1) Evaluate the extent to which mood and cognition at two weeks post-stroke predict performance three months post-stroke. (2) Assess performance differences in patients with impairments in both cognition and mood to patients with impairments in either cognition or mood.

METHODS

Inpatients with a first-ever ischemic or hemorrhagic stroke were assessed at 2 weeks (n = 52) and at 3 months (n = 41) post-stroke. Patients completed a battery of neuropsychological tests, self-report measures and performance-based tests. Cognitive impairments and mood disruptions were assessed at 2 weeks and three months and IADL performance, as assessed by the Executive Function Performance Test, was evaluated at three months.

RESULTS

Complete data from the 41 patients assessed at both time points were analyzed. Regression analysis showed that composite cognition and composite mood variables at two weeks post-stroke predicted 48% of the variance in IADL performance at three months (F3,37 = 12.04; adjusted R(2) = 0.48, P < 0.001). Statistically significant differences were found in performance scores for patients with a single impairment (M = 7.86, SD = 7.81) and for those with impairments in both mood and cognition (M = 19.2, SD = 13.2) (t(39) = - 3.41, P = 0.008).

CONCLUSION

The results of this study suggest that cognitive and mood impairments at two weeks post-stroke are important predictors of performance in complex activities required for full independence at home and should be routinely assessed in stroke rehabilitation.

Social adaptive functioning, apathy, and nondysphoric depression among nursing home-dwelling very old adults

BACKGROUND

Apathetic and subsyndromal depressive conditions are common in the oldest old. This study examined whether nondysphoric depression (NDD), a clinical condition characterized by ideational and vegetative but no emotional symptoms of depression, belongs to the apathetic presentations of late-life depression. Rates of NDD, dysphoric depression (DD), apathy, and social functional impairment were examined in a sample of nondemented very old (mean age 87.5 years, SD = 7.7) nursing home residents. It was hypothesized that individuals with NDD show greater apathy and greater social functional impairment relative to DD and nondepressed individuals.

METHODS

Social functioning was measured using the Social-Adaptive Functioning Evaluation (SAFE) and apathy was measured using the global apathy rating on the Scale for the Assessment of Negative Symptoms (SANS).

RESULTS

The rates of DD (50.0%) and NDD (27.4%) were quite high. Participants with DD reported greater apathy than those with NDD (and nondepressed individuals). NDD and DD subjects showed greater social functional impairment relative to the comparison group. There was no difference in social functioning between DD and NDD individuals.

CONCLUSIONS

The present data are inconsistent with the view that NDD among the oldest old is an apathetic form of depression. NDD involves social functional impairment. Limitations include rather selected population of nursing home residents that may have included individuals with early dementia, lack of data on prior depressive episodes, and apathy assessment not validated on the specific population.

Neuroanatomic pathways associated with poststroke affective and apathetic depression

OBJECTIVES

Our goal was to localize lesions in poststroke depression patients using magnetic resonance imaging, based on the statistical parametric maps image analysis technique that can be used to combine image data from multiple participants and correlate these images with other data sets.

METHODS

Magnetic resonance imaging acquisitions were obtained from 149 poststroke patients, who were assessed for affective and apathetic symptoms using the Hospital Anxiety and Depression Scale and the Apathy Scale, respectively. We created a statistical parametric map that displayed an association between lesion location and affective and apathetic symptoms.

RESULTS

Among the patients with higher depressive scores, the lesion overlap centered on the brainstem, left basal ganglia, and left frontal cortex. Among the patients with higher apathy scores, the lesion overlap centered on the brainstem and bilateral striatum. The overlap lesion for both affective and apathetic depression centered mainly on the brainstem; however, the two types of depression often did not overlap.

CONCLUSIONS

Two core symptoms that can occur after stroke, affective and apathetic symptoms, appear to be associated with different monoaminergic neuroanatomic pathways (serotonergic and dopaminergic).

Functional brain networks associated with cognitive control, cocaine dependence, and treatment outcome

Individuals with cocaine dependence often evidence poor cognitive control. The purpose of this exploratory study was to investigate networks of functional connectivity underlying cognitive control in cocaine dependence and examine the relationship of the networks to the disorder and its treatment. Independent component analysis (ICA) was applied to fMRI data to investigate if regional activations underlying cognitive control processes operate in functional networks, and whether these networks relate to performance and treatment outcome measures in cocaine dependence. Twenty patients completed a Stroop task during fMRI prior to entering outpatient treatment and were compared to 20 control participants. ICA identified five distinct functional networks related to cognitive control interference events. Cocaine-dependent patients displayed differences in performance-related recruitment of three networks. Reduced involvement of a "top-down" fronto-cingular network contributing to conflict monitoring correlated with better treatment retention. Greater engagement of two "bottom-up" subcortical and ventral prefrontal networks related to cue-elicited motivational processing correlated with abstinence during treatment. The identification of subcortical networks linked to cocaine abstinence and cortical networks to treatment retention suggests that specific circuits may represent important, complementary targets in treatment development for cocaine dependence.

Hearing impairment and cognitive function among a community-dwelling population in Japan

BACKGROUND

Hearing impairment is a prevalent and chronic condition in older people. This study investigated the relationship between cognitive function and hearing impairment in a Japanese population.

METHODS

A pure-tone average (0.5-2.0 kHz) was used to evaluate hearing impairment in 846 participants of the Iwaki Health Promotion Project who were aged at least 50 years old (310 men and 536 women). We also administered the Mini-Mental State Examination (MMSE), the Center for Epidemiologic Studies for Depression (CES-D) scale, Starkstein's apathy scale (AS) and the Short Form Health Survey Version 2 (SF-36v2). A multiple linear regression analysis assessed the association between hearing impairment and mental correlates.

RESULTS

The overall prevalence of hearing impairment in this study population was 37.7%. The participants with hearing impairment were older and less educated compared to those with no hearing problems. We observed significant differences in the MMSE and AS scores between the mild/moderate to severe groups versus the non-impaired group. After adjusting for age, gender and amount of education, hearing impairment was significantly associated with MMSE and AS scores, but not with CES-D scores. Hearing impairment was significantly related to the social functioning (SF) and role emotional (RE) scores of the SF-36v2.

CONCLUSIONS

Hearing impairment is common among older people and is associated with cognitive impairment, apathy and a poor health-related quality of life. Screening for and correcting hearing impairments might improve the quality of life and functional status of older patients.

Ankle brachial pressure index as a marker of apathy in a community-dwelling population

BACKGROUND

Apathy is defined as a lack of interest or emotion. Several studies have shown the relationship between apathy and atherosclerotic change in poststroke patients. Although apathy is confused with depression, it might be a specific neuropsychiatric syndrome separate from depression.

OBJECTIVE

To clarify the relationship between atherosclerotic change and apathy in a community-dwelling population, which does not include the psychologic factors associated with stroke events.

METHODS

The ankle brachial pressure index (ABI) was measured using a volume-plethymographic apparatus in 860 volunteers (315 males and 545 females) who participated in the Iwaki Health Promotion Project 2008. Starkstein's apathy score and the Center for Epidemiologic Studies Depression Scale (CES-D) were used to assess the psychologic status. The association between the ABI and apathy was assessed by a multiple linear regression analysis.

RESULTS

Gender and low-density lipoprotein (LDL)-cholesterol were independently and significantly associated with the CES-D score. We did not find any association between CES-D score and the ABI. In addition, the extent of education and the ABI were independently and significantly associated with the apathy scale (AS).

CONCLUSION

In a community-dwelling population, a lower ABI score was an independent risk factor for a higher AS score, but not for a higher CES-D score. Apathy and depression may have different etiologies in vascular factors.

Post-stroke depression and apathy: Interactions between functional recovery, lesion location, and emotional response

Depression and apathy are often observed after stroke and are often confused with one another. In the present review, we argue that the current concept of 'post-stroke depression' (PSD) in fact consists of two core symptoms or syndromes: (i) affective (depressive) PSD; and (ii) apathetic PSD. We argue that these two core symptoms are each associated with a different underlying neuroanatomical mechanism, a pattern that influences functional recovery. Post-stroke disabilities can provoke several distinct emotional responses, some of which are associated with severe depression. We examined one of these emotional responses previously, namely 'insistence on recovery', which was believed to be a negative indicator of functional improvement in disabled stroke patients. However, an appropriate level of insistence on recovery may, in fact, be associated with reduced depression and apathy, resulting in enhanced recovery from stroke-related disabilities. Improvements in physical disabilities (trunk stability or activities of daily living, such as walking) also reduce depression and apathy. Therefore, the experience of PSD/apathy may be intertwined with various initial emotional responses and improvements in physical functioning. Effective treatment of PSD/apathy requires a multidisciplinary approach, such that neuroanatomical/neurobiological, emotional, and physical (rehabilitation) domains are all addressed.

Apathy following stroke

OBJECTIVE

We will review the available evidence on the frequency, clinical correlates, mechanism, and treatment of apathy following stroke.

METHODS

We have explored relevant databases (that is, PubMed, MEDLINE, and PsycINFO) using the following key words and their combinations: apathy, motivation, abulia, stroke, cerebrovascular disease, basal ganglia, prefrontal cortex, anterior cerebral infarction, and thalamus.

RESULTS

The frequency of apathy following stroke has been consistently estimated between 20% and 25%. It appears to be associated with the presence of cognitive impairment, a chronic course characterized by progressive functional decline, and with disruption of neural networks connecting the anterior cingulate gyrus, the dorsomedial frontal cortex, and the frontal pole with the ventral aspects of the caudate nucleus, the anterior and ventral globus pallidus, and the dorsomedian and intralaminar thalamic nuclei. Published treatment studies have been mostly limited to anecdotal case reports, generally using dopamine agonists or stimulant medications. Cholinesterase inhibitors and nefiracetam may significantly reduce apathetic symptoms. However, their efficacy was examined in relatively small clinical trials that require replication.

CONCLUSION

Apathy is a frequent neuropsychiatric complication of stroke that, although often associated with depression and cognitive impairment, may occur independently of both. Its presence has been consistently associated with greater functional decline. However, there is no conclusive evidence about which is the best treatment for this condition.

Do people become more apathetic as they grow older? A longitudinal study in healthy individuals

BACKGROUND

The aim of this study was to determine levels, rates and progression of apathy in healthy older persons and to investigate factors associated with its progression.

METHODS

Seventy-six healthy elderly subjects, aged 58-85 years (mean 69.9), who were recruited by general advertisement and through local community groups, participated as a control group for a longitudinal study of stroke patients. Data were collected on demographic, psychological, neuropsychological and neuroimaging (MRI) variables and apathy was rated by informants on the Apathy Evaluation Scale (AES).

RESULTS

Apathy scores and rates increased over 5 years, especially in men. Change of apathy was associated with informant ratings of cognitive decline in the years prior to baseline assessment but not to subsequent neuropsychological, neuroimaging or functional changes.

CONCLUSIONS

Apathy increases with age in otherwise healthy community-dwelling individuals, particularly in men.

A longitudinal view of apathy and its impact after stroke

BACKGROUND AND PURPOSE

Stroke survivors are often described as apathetic. Because apathy may be a barrier to participation in promising therapies, more needs to be learned about apathy symptoms after stroke. The specific objective was to estimate the extent to which apathy changes with time over the first year after stroke and the impact of apathy on recovery.

METHODS

The Apathy Assessed cohort was formed from stroke survivors participating in a longitudinal study of health-related quality of life after stroke. A family caregiver completed an apathy questionnaire by telephone at 1, 3, 6, and 12 months after stroke (n=408). Group-based trajectory modeling and ordinal regression were used to identify distinctive groups of individuals with similar trajectories of apathy over the first year after stroke and predictors of apathy trajectory.

RESULTS

Both 3- and 5-group trajectory models fit the data. We used the 5-group model because of the potential to further explore the apathy construct. The largest group (50%) had low apathy and 33% had minor apathy that remained stable throughout the first year after stroke. A small proportion (3%) of the study sample had high apathy that remained high. Two other groups of almost equal size (7%) showed worsening and improving apathy. Poor cognitive status, low functional status, and high comorbidity predicted higher apathy. High apathy had a significant negative effect on physical function, participation, health perception, and physical health over the first 12 months after stroke.

CONCLUSION

Some degree of apathy was prevalent and persistent after stroke and was predicted by older age, poor cognitive status, and low functional status after stroke. Even a minor level of apathy had an important and statistically significant impact on stroke outcomes.

Apathy and functional recovery following first-ever stroke

Apathy is defined as lack of feeling, emotion, or concern. The objective of this study was to examine the frequency of apathy after a first-ever stroke and to prospectively study the impact of apathy on functional recovery. The patients enrolled in this study had the following characteristics: (i) they had experienced a first ischemic or hemorrhagic stroke; (ii) they ranged from 45 to 90 years of age; (iii) the interval from onset to admission ranged from 21 to 90 days; and (iv) they did not demonstrate either marked dementia or aphasia. The functional status was assessed by the Barthel index and the functional independence measures on admission and after a 3-month rehabilitation period. On the basis of the apathy scale, the patients were grouped into those experiencing apathy and those who did not. Next, the scores of the functional measures in the two groups were compared. A total of 67 patients--38 males and 29 females--were analyzed. Fourteen patients (21%) were diagnosed as being apathetic. The apathetic patients tended to be older and more cognitively impaired than the nonapathetic patients. The severity of neurological deficits, the frequency of depression, and the functional status on admission did not differ substantially in the patients with or without apathy. Although the difference was marginal, apathetic patients showed less improvement in the Barthel index or the subscore of functional independence measures than nonapathetic patients after rehabilitation. Thus, we concluded that apathy is not a rare condition after first-ever stroke and it may impair stroke recovery.

Cognitive consequences of multiple lacunes and leukoaraiosis as vascular cognitive impairment in community-dwelling elderly individuals

The aim of our study was to investigate the effects of silent brain lesions on cognitive function of community-dwelling elderly individuals. Brain magnetic resonance imaging and other medical examinations were performed on 350 nondemented elderly individuals (121 male and 229 female, average age 72.4 years) who resided in the rural community of Sefuri Village, Saga, Japan. The mini mental state examination and modified Stroop test (MST) were used to identify cognitive impairment. White matter lesions (WMLs) and cerebral atrophy on magnetic resonance imaging were measured quantitatively. Multivariate analyses were done using a logistic regression model with a software package. Cognitive impairment defined by mini mental state examination score less than 24 was present in 55 individuals (15.7%). They had a lower educational level, significantly larger quantity of WMLs, and more remarkable cerebral atrophy. Frontal lobe dysfunction was detected in 52 individuals (14.9%) through prolonged MST score (>36 seconds). Impaired frontal lobe function was related to number of silent lacunar infarcts, larger WMLs, and more prominent cerebral atrophy. MST score in individuals with two or more infarcts was significantly more prolonged compared with MST score in those without infarction. These results suggest that WMLs may cause rather diffuse cognitive decline, whereas multiple lacunar infarcts are specifically involved in frontal lobe dysfunction. Silent ischemic lesions in apparently healthy elderly individuals seem to form a distinctive group of people with vascular cognitive impairment without dementia. This group should be the primary target of prevention of vascular dementia.

The MRI brain correlates of depressed mood, anhedonia, apathy, and anergia in older adults with and without cognitive impairment or dementia

OBJECTIVES

We examined the magnetic resonance imaging (MRI) correlates of depressed mood, apathy, anhedonia, and anergia in older adults with and without cognitive impairment or dementia.

METHODS

This analysis included 270 community-dwelling older adults (59% male; 79% Caucasian; mean age 74.4 years) who were recruited into a multi-center longitudinal observational study of subcortical ischemic vascular disease (SIVD).The distribution of cognitive status included: cognitively intact (38%), cognitively impaired (27%), or demented (35%). All subjects underwent MRI and 41% were classified as having subcortical lacunes. MRI measures included cortical gray and white matter volumes, lacunar volumes in subcortical white and gray matter structures, volume of white matter hyperintensities, and total hippocampal volume. Depressed mood, anhedonia, anergia, and apathy apparent at the time of assessment were assessed using a behavioral assessment Associations between neuropsychiatric symptoms and MRI variables were evaluated using logistic regression.

RESULTS

Subjects with neuropsychiatric symptoms were more likely to be cognitively impaired or demented than those without neuropsychiatric symptoms. In multivariate models controlling for cognitive status, age, gender, and education, higher lacunar volume in white matter was independently associated with the presence of all four neuropsychiatric symptoms.

CONCLUSIONS

We report an association between the lacunar volumes in the white matter and depressed mood, anhedonia, apathy, and anergia, thus supporting the role of subcortical ischemic vascular disease in the pathogenesis of late-life neuropsychiatric disorders.

'Insistence on recovery' as a positive prognostic factor in Japanese stroke patients

AIM

The present study used two-step analyses to examine the effect of acceptance of disability or 'insistence on recovery' in Japanese stroke patients: first on their functional improvement and second, on their psychological symptoms.

METHODS

Disability was assessed using functional independence measurements (FIM), examining the stage of acceptance of disability by observation using Fink's theory (from shock to defensive retreat, acknowledgement, and acceptance/change stage), and estimation of insistence on recovery (on a scale of 1-4) by observation. The differences over time and the effects on the improvement in their FIM were then assessed. Depression was measured using the Zung Self-rating Depression Scale (SDS); apathy was measured using the Apathy Scale (AS), and the correlation with the acceptance stage or insistence on recovery was analyzed.

RESULTS

The acceptance stage and functional improvement progressed significantly, but insistence on recovery did not change significantly during hospitalization. Multiple regression indicated that the insistence on recovery score (but not the acceptance stage) was a good predictor of the degree of improvement in FIM (FIM gain per week) in the elderly group. Post-hoc testing showed that the SDS or AS score decreased from the first stage to the fourth stage (but increased at the third stage) of acceptance; whereas for insistence on recovery score, the SDS and AS scores decreased as insistence on recovery score changed from 1 to 3, and then increased as insistence on recovery score changed from 3 to 4.

CONCLUSIONS

The appropriate level of insistence on recovery reduced depression and apathy, resulting in enhanced improvement of disability after a stroke in elderly stroke patients.

Depression or apathy and functional recovery after stroke

OBJECTIVES

While depression and apathy are common after stroke, past studies have done little to examine the influence of these two symptoms on functional outcome respectively. This study was designed to examine the effect of depression or apathy on functional recovery after stroke in 237 Japanese stroke patients.

METHODS

We assessed the psychological status using self-rating scales [the Zung Self-Rating Depression Scale (SDS) for depression and the Apathy Scale (AS) for apathy] and an observer-rating scale [the Neuropsychiatric Inventory (NPI)]. We assessed physical disability using the Functional Independence Measurement (FIM). Post-hoc test and multiple regression analysis were used to determine the independent effects of post-stroke depression and apathy on functional outcome.

RESULTS

Depression was observed in 75 (31.6%) using SDS and 88 (40.2%) using NPI, and apathy in 95 (40.1%) using AS and 42 (19.2%) using NPI, respectively. Post-hoc test and multiple regression analysis indicated that the cognitive variable (Mini-Mental State Examination: MMSE score) and AS score, but not SDS score, correlated negatively with improvement in FIM.

CONCLUSIONS

Apathy might be more frequently associated with functional abilities and likely interact with the recovery process as compared with depression after stroke.

Sitting balance as an early predictor of functional improvement in association with depressive symptoms in stroke patients

The aim of the present study was to assess the relationship between sitting balance at an early stage and activities of daily living (ADL) function in 452 stroke patients. The effect of sitting balance on the two core elements of depression (apathy and depressive mood) was also examined. The ability to maintain a sitting position for 10 min (10-min sitting balance) was assessed, along with ADL using the Functional Independence Measurement, and psychological status using the Zung Self-rating Depression Scale (depressive mood), Apathy Scale (apathy) and Neuropsychiatric Inventory. Proportional-hazards analysis was used to determine the independent effect of post-stroke depression on functional outcome. Comparisons between sitting balance and psychological status were performed using logistic multiple regression analysis. Cox multiple regression analysis showed that significant differences were obtained for the sitting balance (P < 0.0002) and Mini-Mental State Examination scores (P < 0.02) in all six ADL subscales, and for age in four of the six ADL subscales (Dressing-Upper Body and Dressing-Lower Body, Toileting, Walking). Kaplan-Meier survival curves for reaching independence in ADL subscales showed highly significantly differences in achievement rate and time to reach goal for each subgroup on 10-min sitting balance (with or without assistance) and on age (young, <65; elderly, >/=65 years). Ten-minute sitting balance correlated with depressive mood and apathy. A rapid and simple screening method, 10-min sitting balance was related to scores for two core depressive symptoms, lowered mood and apathy, and was predictive of post-stroke ADL outcomes in the rehabilitation unit along with age.

Post-stroke affective or apathetic depression and lesion location: left frontal lobe and bilateral basal ganglia

This study was designed to examine the correlation between damage to the basal ganglia or frontal lobe and depression status (both affective and apathetic dimensions) in 243 stroke patients. We assessed the affective dimension in post-stroke depression (PSD) using the Zung Self-rating Depression Scale (SDS) and the apathetic dimension in PSD using the apathy scale (AS). We classified basal ganglia or frontal lobe damage into four groups: no damage, damage to the left side only, damage to the right side only, and damage to both sides. Affective and/or apathetic PSD was found in 126 patients (51.9%). The severity of affective depression (SDS score) was associated with left frontal lobe (but not basal ganglia) damage, and that of apathetic depression (AS score) was related to damage to the bilateral basal ganglia (but not to the frontal lobe). The anatomical correlates of PSD differ depending on the PSD dimension (affective or apathetic) and may explain interstudy differences regarding the association between lesion location and type of PSD.

Early cognitive impairment predicts long-term depressive symptoms and quality of life after stroke

OBJECTIVE

The aim of the present study was to examine the predictive value of cognitive impairment in the acute phase after stroke as a risk factor for long-term (six to ten months after stroke) depressive symptoms (DS) and a reduced quality of life (QOL), independent of demographic and neurological predictors.

METHODS

We evaluated 143 patients within the first 3 weeks post-stroke. Predictor variables included domain-specific cognitive function, demographic data, vascular risk factors, lesion characteristics, and clinical factors. Predictor variables associated with long-term DS (Montgomery Asberg Depression Rating Scale >or=7) and QOL (Stroke-Specific Quality of Life Scale) were identified with multiple logistic and linear regression.

RESULTS

Long-term DS were independently predicted by cognitive impairment at baseline, DS at baseline, female sex, diabetes mellitus, and previous TIA(s). Cognitive impairment, increasing age, and functional dependence predicted a reduced QOL, whereas hypercholesterolaemia predicted a better QOL. Among all cognitive disorders, unilateral neglect was the greatest risk factor for DS after 6 months, whereas a disorder in visual perception and construction affected QOL the most.

CONCLUSIONS

Cognitive impairment and vascular risk factors are important predictors of long-term DS and QOL after stroke. The prognostic value of cognition suggests a reactive component in the development or continuation of long-term DS.