A longitudinal view of apathy and its impact after stroke

Apathy in subarachnoid hemorrhage: study protocol for a 1-year follow-up study

Introduction

Apathy is a frequent and debilitating condition among subarachnoid hemorrhage (SAH) survivors. Few studies have evaluated apathy in SAH, and none have examined the course of the condition, predictors of persistent apathy, or its impact on functional outcomes. The proposed study will examine, for the first time, the 12-month course of apathy and its impact on functional outcomes in the largest cohort of SAH survivors to date.

Methods and analysis

The current study is designed as a prospective cohort study with a duration of 36 months. We will recruit 240 participants. A trained research assistant will assess apathy using the Apathy Evaluation Scale 3 months after SAH. Patients' level of functioning, comorbidity, global cognitive functioning, and depressive symptoms will be assessed. All SAH patients will participate in follow-up assessments of apathy and functioning at 9 (T2) and 15 months (T3) post-SAH or at 6 and 12 months after the first assessment. Predictors of persistent apathy and the impact of apathy on functional outcomes will be examined.

Discussion

This will be the first large-scale 1-year follow-up study of apathy in SAH survivors. The findings will provide valuable data to advance our understanding of the clinical course of apathy in this population. Moreover, the results will have clinical relevance by providing essential information to patients, caregivers, and clinicians; promoting the evaluation of apathy; and facilitating the development of prevention strategies, rehabilitation programs, and therapeutic options.

Ethics and dissemination

Ethical approval for this study was obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (CREC Ref. No.: 2023.339) on 3 October 2023. The findings of this study will be shared through publication in a peer-reviewed journal, presentations at relevant conferences, and dissemination through social media platforms.

Effort-based decision making and motivational deficits in stroke patients

Motivational deficits in patients recovering from stroke are common and can reduce active participation in rehabilitation and thereby impede functional recovery. We investigated whether stroke patients with clinically reduced drive, initiation, and endurance during functional rehabilitative training (n = 30) display systematic alterations in effort-based decision making compared to age, sex, and severity-matched stroke patients (n = 30) whose drive appeared unaffected. Notably, the two groups did not differ in self-reported ratings of apathy and depression. However, on an effort-based decision-making task, stroke patients with clinically apparent drive impairment showed intact willingness to accept effort for reward, but were more likely to fail to execute the required effort compared to patients without apparent drive impairments. In other words, the decision behavioural assessment revealed that stroke patients that displayed reduced drive, initiation, and endurance during inpatient neurorehabilitation failed to persist in goal-directed effort production, even over very short periods. These findings indicate that reduced drive during rehabilitative therapy in post-stroke patients is not due to a diminished motivation to invest physical effort, but instead is related to a reduced persistence with effortful behaviour.

Apathy After Stroke: Incidence, Symptom Trajectory, and Impact on Quality of Life and Disability

BACKGROUND AND OBJECTIVES

Apathy is one of the most common symptoms following stroke and is often associated with worse functional outcome and poor quality of life (QoL). The trajectory of apathy symptoms has been previously described, and different trajectories have been identified. We determined group and individual changes in apathy symptomatology from the acute phase until 1 year after stroke. We also examined the association of apathy and depression with disability and QoL 1 year after stroke.

METHODS

We measured apathy in a cohort of ischemic stroke survivors at 4 time points from 0 to 12 months after stroke. The Apathy Evaluation Scale (AES) and Dimensional Apathy Scale (DAS) were administered at each time point. Where possible we obtained apathy measured from carers. Depression was assessed with the Geriatric Depression Scale (GDS). Disability and QoL were assessed with the modified Rankin Scale (mRS) and 36-Item Short Form Survey (SF-36). We examined the cross-sectional and individual trajectory of apathy symptoms in each dimension and looked at associations of apathy and depression soon after stroke with mRS and SF-36 at 1 year.

RESULTS

Of 200 participants enrolled, 165 completed apathy measures at 12 months. Patient-rated apathy scores increased in both tests at the group level (AES: χ2(3) = 9.86, p = 0.019; DAS: χ2(3) = 8.49, p = 0.037) and individual level (AES: β = 0.13, p = 0.002; DAS β = 0.13, p = 0.005; DAS: executive β = 0.08, p < 0.001). By contrast, carer-rated apathy did not significantly increase (AES: χ2(3) = 0.75, p = 0.862; DAS: χ2(3) = 2.45, p = 0.484). Apathy scores were associated with worse mRS and SF-36, although most associations were no longer significant when controlling for depression. GDS was associated with worse mRS and SF-36 after controlling for covariates and apathy (mRS: β = 0.08, p = 0.006; SF-36 Mental Component Summary: β = -1.53, p < 0.001; SF-36 Physical Component Summary: β = -0.57, p = 0.016).

DISCUSSION

Self-reported apathy progressively increases after stroke, especially in the executive dimension. Apathy is associated with worse QoL and greater disability, although some of these associations might be mediated by depression.

Pre-stroke and early post-stroke apathy is associated with increased risk of dementia 3 months after stroke

OBJECTIVES

Apathy is a frequent neuropsychiatric syndrome after stroke. We determined whether pre-morbid and early post-stroke apathy predicts dementia 3 months after stroke.

METHODS

We included ischemic stroke patients without dementia who participated in the Prospective Observational Polish Study on post-stroke delirium. We used the Neuropsychiatric Inventory and clinician-reported version of Apathy Evaluation Scale to score apathy symptoms before stroke and on day 8 after stroke. Patients underwent neuropsychological examination 3 months after stroke.

RESULTS

Of 422 patients with ischemic stroke and without pre-stroke dementia, 194 patients (mean age: 67.5 ± 12.3; 45.9% female) underwent neuropsychological examination. Dementia was diagnosed in 21.6% of them. Patients with dementia had higher apathy scores before stroke (mean: 0.9 ± 1.7 vs. 0.2 ± 0.9, p < 0.01) and on day 8 (mean: 37.2 ± 9.3 vs. 29.0 ± 9.6, p < 0.01). Depressive symptoms did not differ between groups. In multivariate analysis adjusted for age, diabetes mellitus, stroke severity and in-hospital delirium, apathy symptoms before stroke and on day 8 after stroke predicted post-stroke dementia (adjusted OR: 1.59, 95%CI: 1.13-2.26, p = 0.01 and OR: 1.06, 95%CI: 1.01-1.11, p = 0.03, respectively).

CONCLUSIONS

Pre-stroke and early post-stroke apathy independently from age, stroke severity and delirium predicted dementia 3 months after stroke. Apathy might be useful in identifying at-risk patients.

Post-Stroke Neuropsychiatric Complications: Types, Pathogenesis, and Therapeutic Intervention

Almost all stroke survivors suffer physical disabilities and neuropsychiatric disturbances, which can be briefly divided into post-stroke neurological diseases and post-stroke psychiatric disorders. The former type mainly includes post-stroke pain, post-stroke epilepsy, and post-stroke dementia while the latter one includes post-stroke depression, post-stroke anxiety, post-stroke apathy and post-stroke fatigue. Multiple risk factors are related to these post-stroke neuropsychiatric complications, such as age, gender, lifestyle, stroke type, medication, lesion location, and comorbidities. Recent studies have revealed several critical mechanisms underlying these complications, namely inflammatory response, dysregulation of the hypothalamic pituitary adrenal axis, cholinergic dysfunction, reduced level of 5-hydroxytryptamine, glutamate-mediated excitotoxicity and mitochondrial dysfunction. Moreover, clinical efforts have successfully given birth to many practical pharmaceutic strategies, such as anti-inflammatory medications, acetylcholinesterase inhibitors, and selective serotonin reuptake inhibitors, as well as diverse rehabilitative modalities to help patients physically and mentally. However, the efficacy of these interventions is still under debate. Further investigations into these post-stroke neuropsychiatric complications, from both basic and clinical perspectives, are urgent for the development of effective treatment strategies.

The prevalence of apathy in stroke patients: A systematic review and meta-analysis

BACKGROUND

Apathy is a frequent neuropsychiatric disorder in stroke patients. However, its prevalence rates have conflicting results across studies. This meta-analysis aimed to estimate the overall prevalence of apathy in stroke patients from 1990 to 2022.

METHODS

PubMed, Web of Science, Embase and PsycINFO were systematically searched to identify relevant articles published from January 1, 1990 to October 29, 2022. Literature quality was assessed with the National Institutes of Health Study Quality Assessment Tool. The pooled prevalence, subgroup analyses and meta-regression were calculated by STATA 16.0.

RESULTS

A total of 39 observational studies involving 5168 stroke patients were eligible for this meta-analysis. The pooled prevalence of apathy in stroke patients was 33.0% (95% CI, 27.6-38.4). Subgroup analyses showed that the pooled prevalence of apathy among stroke patients was higher in Japan (36.6%), China (33.7%) and Turkey (63.5%) compared to that in other countries (30.2%). The pooled prevalence of apathy was higher in ischemic stroke samples (36.1%) than in hemorrhagic stroke samples (14.4%). The pooled prevalence of apathy measured with the Apathy Evaluation Scale (38.3%) was the highest in stroke patients. Meta-regression presented that higher literature quality was significantly associated with lower prevalence, while stroke severity, mean age and female percentage were not significantly associated with the prevalence of apathy in stroke patients.

CONCLUSION

Our findings revealed that the overall prevalence of apathy in stroke patients was 33.0% based on the current evidence. Furthermore, the prevalence was significantly correlated with countries, stroke subtypes, apathy criteria, and literature quality.

Trajectories of post-stroke quality of life and long-term prognosis: Results from an eleven-year prospective study

PURPOSE

The relationship between quality of life (QoL) and long-term prognosis in stroke patients is still unclear. We explored physical and mental QoL trajectories during the first six months after stroke and determined the associations between trajectories and long-term prognosis in patients with first-ever ischemic stroke.

METHODS

Included were 733 participants from a prospective study. QoL was assessed with the 12-item Short Form Survey (SF-12) at baseline, 3 and 6 months. Patients' prognoses (stroke recurrence and death) were identified from 2010 to 2021. The latent class growth model (LCGM) was used to identify distinct trajectories of physical and mental QoL measured over the first 6 months. We employed the Cox model or Fine-Gray model for prognoses to examine the associations between QoL trajectories and prognosis.

RESULTS

Five trajectories of physical QoL and five trajectories of mental QoL were identified. For physical QoL of the Poor-Improved, and Moderate-Impaired trajectory versus Moderate-Improved trajectory, the hazard ratio (HR) for death was 2.39 (1.14 to 5.02), and 2.03(0.93 to 4.44); the HR for recurrence was 1.56 (0.83 to 2.94) and 2.33 (1.28 to 4.24). For mental QoL of the Moderate-Impaired trajectory versus the Moderate-Improved trajectory, the HR for death was 2.48 (1.21 to 5.07). The results were robust in the sensitivity analysis.

CONCLUSION

QoL during the first six months after ischemic stroke can be categorized into distinct groups. Change in QoL was associated with long-term survival. Secondary prevention of recurrent strokes might rely more on improving patients' physical QoL.

A multicenter explanatory survey of patients' and clinicians' perceptions of motivational factors in rehabilitation

BACKGROUND

Patient motivation is an important determinant of rehabilitation outcomes. Differences in patients' and clinicians' perceptions of motivational factors can potentially hinder patient-centered care. Therefore, we aimed to compare patients' and clinicians' perceptions of the most important factors in motivating patients for rehabilitation.

METHODS

This multicenter explanatory survey research was conducted from January to March 2022. In 13 hospitals with an intensive inpatient rehabilitation ward, 479 patients with neurological or orthopedic disorders undergoing inpatient rehabilitation and 401 clinicians, including physicians, physical therapists, occupational therapists, and speech-language-hearing therapists, were purposively selected using inclusion criteria. The participants were asked to choose the most important factor motivating patients for rehabilitation from a list of potential motivational factors.

RESULTS

Here we show that realization of recovery, goal setting, and practice related to the patient's experience and lifestyle are the three factors most frequently selected as most important by patients and clinicians. Only five factors are rated as most important by 5% of clinicians, whereas nine factors are selected by 5% of patients. Of these nine motivational factors, medical information (p < 0.001; phi = -0.14; 95% confidence interval = -0.20 to -0.07) and control of task difficulty (p = 0.011; phi = -0.09; 95% confidence interval = -0.16 to -0.02) are selected by a significantly higher proportion of patients than clinicians.

CONCLUSIONS

These results suggest that when determining motivational strategies, rehabilitation clinicians should consider individual patient preferences in addition to using the core motivational factors supported by both parties.

The Immediate Effects of Different Types of Augmented Feedback on Fast Walking Speed Performance and Intrinsic Motivation After Stroke

Objective

To examine the immediate effects of different types of augmented feedback on walking speed and intrinsic motivation post-stroke.

Design

A within-subjects repeated-measures design.

Setting

A university rehabilitation center.

Participants

Eighteen individuals with chronic stroke hemiparesis with a mean age of 55.67±13.63 years and median stroke onset of 36 (24, 81) months (N=18).

Interventions

Not applicable.

Primary outcome

Fast walking speed measured on a robotic treadmill for 13 meters without feedback and 13 meters with augmented feedback on each of the 3 experimental conditions: (1) without virtual reality (VR), (2) with a simple VR interface, and (3) with VR-exergame. Intrinsic motivation was measured using the Intrinsic Motivation Inventory (IMI).

Results

Although the differences were not statistically significant, fast-walking speed was higher in the augmented feedback without VR (0.86±0.44 m/s); simple VR interface (0.87±0.41 m/s); VR-exergame (0.87±0.44 m/s) conditions than in the fast-walking speed without feedback (0.81±0.40 m/s) condition. The type of feedback had a significant effect on intrinsic motivation (P=.04). The post hoc analysis revealed borderline significance on IMI-interest and enjoyment between the VR-exergame condition and the without-VR condition (P=.091).

Conclusion

Augmenting feedback affected the intrinsic motivation and enjoyment of adults with stroke asked to walk fast on a robotic treadmill. Additional studies with larger samples are warranted to examine the relations among these aspects of motivation and ambulation training outcomes.

Reward network dysfunction is associated with cognitive impairment after stroke

Stroke survivors not only suffer from severe motor, speech and neurocognitive deficits, but in many cases also from a "lack of pleasure" and a reduced motivational level. Especially apathy and anhedonic symptoms can be linked to a dysfunction of the reward system. Rewards are considered as important co-factor for learning, so the question arises as to why and how this affects the rehabilitation of stroke patients. We investigated reward behaviour, learning ability and brain network connectivity in acute (3-7d) mild to moderate stroke patients (n = 28) and age-matched healthy controls (n = 26). Reward system activity was assessed using the Monetary Incentive Delay task (MID) during magnetoencephalography (MEG). Coherence analyses were used to demonstrate reward effects on brain functional network connectivity. The MID-task showed that stroke survivors had lower reward sensitivity and required greater monetary incentives to improve performance and showed deficits in learning improvement. MEG-analyses showed a reduced network connectivity in frontal and temporoparietal regions. All three effects (reduced reward sensitivity, reduced learning ability and altered cerebral connectivity) were found to be closely related and differed strongly from the healthy group. Our results reinforce the notion that acute stroke induces reward network dysfunction, leading to functional impairment of behavioural systems. These findings are representative of a general pattern in mild strokes and are independent of the specific lesion localisation. For stroke rehabilitation, these results represent an important point to identify the reduced learning capacity after stroke and to implement individualised recovery exercises accordingly.

Association between apathy in patients with maintenance dialysis and hospitalization or mortality: a prospective cohort study

Background

Patients receiving maintenance dialysis experience increased rates of hospitalization and mortality. Apathy is associated with reduced quality of life and increased hospitalization, institutionalization, and death. Whether apathy contributes to poor outcomes in population undergoing maintenance dialysis remain unknown.

Methods

We conducted a prospective cohort study of maintenance dialysis population who were consecutively recruited at the Dialysis Center of Shanghai General Hospital between July 2017 and August 2018 and were followed up for 3 year. Apathy status was measured by the Apathy Evaluation Scale. The study outcomes were the occurrence of death and first hospitalization.

Results

A total of 647 participants included in this study, 274 (42.3%) had a current apathy and 373 (57.7%) were not. During the follow-up period, 394 (60.9%) were hospitalized, and 169 (26.1%) died. Kaplan-Meier analysis showed that the risks of hospitalization and mortality were significantly higher in individuals with apathy than in those without apathy (both p < 0.001). Apathy at baseline was associated with hospitalization and death both in univariate analysis and in all multivariable models (all p < 0.001).

Conclusion

Apathy was highly prevalent and independently correlated with an increased risk of poor outcomes in patients with maintenance dialysis.

Calling on clinicians to get social and emotional

OBJECTIVE

Disorders of social cognition, such as difficulties with emotion perception, alexithymia, Theory of Mind (ToM), empathy and disorders of emotion regulation, are prevalent and pervasive problems across many neurological, neurodevelopmental and neuropsychiatric conditions. Clinicians are familiar with how these difficulties present but assessment and treatment has lagged behind other traditional cognitive domains, such as memory, language and executive functioning.

METHOD

In this paper, we review the prevalence and degree of impairment associated with disorders of social cognition and emotion regulation across a range of clinical conditions, with particular emphasis on their relationship to cognitive deficits and also real-world functioning. We reported effects sizes from published meta-analyses for a range of clinical disorders and also review test usage and available tests.

RESULTS

In general, many clinical conditions are associated with impairments in social cognition and emotion regulation. Effect sizes range from small to very large and are comparable to effect sizes for impairments in nonsocial cognition. Socio-emotional impairments are also associated with social and adaptive functioning. In reviewing prior research, it is apparent that the standardized assessment of social cognition, in particular, is not routine in clinical practice. This is despite the fact that there are a range of tools available and accruing evidence for the efficacy of interventions for social cognitive impairments.

CONCLUSION

We are using this information to urge and call for clinicians to factor social cognition into their clinical assessments and treatment planning, as to provide rigorous, holistic and comprehensive person-centred care.

Identifying emotional contributors to participation post-stroke

BACKGROUND

Participation in daily activities is the ultimate goal of stroke rehabilitation. Emotional factors have been considered as contributors to participation, but associations between emotional factors and participation post-stroke have not been fully explored.

OBJECTIVE

To investigate the extent to which emotional factors contribute to participation post-stroke.

METHODS

73 participants were included. Three participation outcomes were used as dependent variables in three models: (1) Stroke Impact Scale (SIS) Participation/Role Function, (2) Activity Card Sort (ACS), and (3) Reintegration to Normal Living (RNL). Main independent variables were six emotional factors: SIS Emotion Function (General emotion), Visual Analog Mood Scale energetic and happy subscales, Patient Health Questionnaire-9 (Depression), State-Trait Anxiety Inventory-Trait Anxiety Scale, and Apathy Evaluation Scale. Covariates of stroke severity and social support were included.

RESULTS

Model 1 showed stroke severity (β = -0.300) and depression (β = -0.268) were significant contributors to SIS Participation/Role Function (R² = 0.368, p < .05). Model 2 indicated that happiness (β = 0.284) and apathy (β = -0.330) significantly contributed to ACS total activity retention (R² = 0.247, p < .05). Model 3 revealed that anxiety (β = -0.348), apathy (β = -0.303), stroke severity (β = -0.184), and social support (β = 0.185) were significant contributors to RNL total score (R² = 0.583, p < .05).

CONCLUSIONS

Results suggested that emotional measures of apathy, depression, anxiety, and happiness, but not general emotion, were important contributors to participation post-stroke. These findings suggest that rehabilitation professionals should address individual emotional contributors to facilitate participation post-stroke.

Does fluoxetine reduce apathetic and depressive symptoms after stroke? An analysis of the Efficacy oF Fluoxetine-a randomized Controlled Trial in Stroke trial data set

OBJECTIVE

Apathy is a common and disabling symptom after stroke with no proven treatments. Selective serotonin reuptake inhibitors are widely used to treat depressive symptoms post-stroke but whether they reduce apathetic symptoms is unknown. We determined the effect of fluoxetine on post-stroke apathy in a post hoc analysis of the EFFECTS (Efficacy oF Fluoxetine-a randomized Controlled Trial in Stroke) trial.

METHODS

EFFECTS enrolled patients ⩾18 years between 2 and 15 days after stroke onset. Participants were randomly assigned to receive oral fluoxetine 20 mg once daily or matching placebo for 6 months. The Montgomery-Åsberg Depression Rating Scale (MADRS) was administered at baseline and 6 months. Individual items on this scale were divided into those reflecting symptoms of apathy and depression. Symptoms were compared between fluoxetine and placebo groups.

RESULTS

Of 1500 participants enrolled, complete MADRS data were available for 1369. The modified intention-to-treat population included 681 patients in the fluoxetine group and 688 in the placebo group. Confirmatory factor analysis revealed that apathetic, depressive, and anhedonic symptoms were dissociable. Apathy scores increased in both fluoxetine and placebo groups (both p ⩽ 0.00001). In contrast, fluoxetine was associated with a reduction in depressive scores (p = 0.002).

CONCLUSION

Post-stroke apathetic and depressive symptoms respond differently to fluoxetine treatment. Our analysis suggests fluoxetine is ineffective in preventing post-stroke apathy.

Poststroke apathy: Major role of cognitive, depressive and neurological disorders over imaging determinants

Apathy occurs in approximately one third of people after stroke. Despite its frequency and functional consequences, the determinants of apathy have only been partially defined. The major difficulty lies in disentangling the reduction in activity due to apathy itself from those secondary to comorbidities, such as depression, sensorimotor deficits, and cognitive impairment. Here, we aimed to examine the prevalence of apathy, identify confounding sources of hypoactivity, and define its neuroimaging determinants using multivariate voxel lesion symptom-mapping (mVLSM) analyses. We assessed apathy in a subgroup (n = 325, mean age: 63.8 ± 10.5 years, 91.1% ischemic stroke) of the GRECogVASC cohort using the validated Behavioral Dysexecutive Syndrome Inventory, interpreted using GREFEX criteria, as well as confounding factors (depression, anxiety, severity of the neurological deficit, and gait disorders). mVLSM analysis was used to define neuroimaging determinants and was repeated after controlling for confounding factors. Apathy was present for 120 patients (36.9%, 95% CI: 31.7-42.2). Stepwise linear regression identified three factors associated with apathy: depressive symptoms (R² = .3, p = .0001), cognitive impairment (R² = .015, p = .02), and neurological deficit (R² = .110, p = .0001). Accordingly, only 9 (7.5%) patients had apathy without a confounding factor, i.e., isolated apathy. In conventional VLSM analysis, apathy was associated with a large number of subcortical lesions that were no longer considered after controlling for confounding factors. Strategic site analysis identified five regions associated with isolated apathy: the F3 orbitalis pars, left amygdala, left thalamus, left pallidum, and mesencephalon. mVLSM analysis identified four strategic sites associated with apathy: the right corticospinal tract (R² = .11; p = .0001), left frontostriatal tract (R² = .11; p = .0001), left thalamus (R² = .04; p = .0001), and left amygdala (R² = .01; p = .013). These regions remained significant after controlling for confounding factors but explained a lower amount of variance. These findings indicate that poststroke apathy is more strongly associated with depression, neurological deficit, and cognitive impairment than with stroke lesions locations, at least using VLSM analysis.

Effect of cyborg-type robot Hybrid Assistive Limb on patients with severe walking disability in acute stroke: A randomized controlled study

OBJECTIVES

To investigate whether early gait training using Hybrid Assistive Limb (HAL) is feasible and improves walking and independency compared with conventional physical therapy (CPT) in patients with severe walking disability after stroke.

METHODS

We conducted a single-center, randomized controlled study. Patients with first-ever stroke who had severe walking disability were included. All patients started gait training within 10 days post-stroke onset. Twenty-four patients were randomly assigned into HAL or CPT groups. Outcome measures were collected at three time points, at baseline, completion of 20 sessions of gait training (second assessment), and 3 months after the initiation of gait training. The primary outcomes were changes in motor sub-scores of the Functional Independence Measure or Functional Ambulation Category at the completion of the second assessment from baseline.

RESULTS

Twenty-two patients (median age, 68 years; 12 patients in the HAL group and 10 patients in the CPT group) completed the study. There were no significant differences in primary outcomes. Apathy scale, one of the secondary outcomes, showed a decreasing trend in the HAL group (mean change of -3.8, 95% CI -8.14 to 0.475), and a slight increasing trend in the CPT group (mean change of 1.2, 95% CI -2.66 to 5.06) at the second assessment. Patients in the HAL group experienced no adverse events.

CONCLUSIONS

Early gait training in patients with severe walking disability after stroke using HAL was feasible. Walking ability and independency were not improved at the completion of 20 sessions of gait training.

The course of post-stroke apathy in relation to cognitive functioning: a prospective longitudinal cohort study

Apathy is common after stroke and has been associated with cognitive impairment. However, causality between post-stroke apathy and cognitive impairment remains unclear. We assessed the course of apathy in relation to changes in cognitive functioning in stroke survivors. Using the Apathy Scale (AS) and cognitive tests on memory, processing speed and executive functioning at six- and 15 months post-stroke we tested for associations between (1) AS-scores and (change in) cognitive scores; (2) apathy course (persistent/incident/resolved) and cognitive change scores. Of 117 included participants, 29% had persistent apathy, 13% apathy resolving over time and 10% apathy emerging between 6-15 months post-stroke. Higher AS-scores were cross-sectionally and longitudinally associated with lower cognitive scores. Relations between apathy and cognitive change scores were ambiguous. These inconsistent relations between apathy and changes in cognition over time suggest that post-stroke apathy does not directly impact cognitive performance. Both these sequelae of stroke require separate attention.

[Emotional disorders after stroke]

Emotional disorders are common among patients after stroke. They include anger, fear, emotional expression control (uncontrollable crying, laughing), emotional indifference (apathy), disorders of emotion recognition and emotional empathy. They might develop independently or as a presentation of depression, anxiety, catastrophic reaction, posttraumatic stress disorder etc. Treatment of post-stroke emotional disorders include pharmacotherapy, psychotherapy, neuromodulation.

The longitudinal course of anxiety, depression and apathy through two years after stroke

OBJECTIVE

Estimate the prevalence of anxiety disorders, depressive disorders and apathy two years after stroke, examine their longitudinal course, describe the course of psychological distress through two years after stroke, and evaluate Hospital Anxiety and Depression Scale HADS-A and HADS-D cut-off scores of ≥4 and ≥ 8 for detection of anxiety and depressive disorders two years after stroke.

METHODS

In a longitudinal cohort study of 150 consecutive stroke patients in a stroke unit, 103 were assessed four months and 75 two years after stroke. Anxiety and depression disorders and symptoms were assessed by the Structured Clinical Interview for DSM-IV and HADS, apathy by the Apathy Evaluation Scale.

RESULTS

Prevalence of at least one anxiety disorder or one depressive disorder decreased from four months to two years (23% vs 9%, P = 0.026, 19% vs 10%, P = 0.17). Apathy remained stable at 48% vs 50%. After two years, 80%, 79% and 19% of those with anxiety, depression or apathy at four months had recovered. Recovery-rates among patients with anxiety were 83% for panic disorder, 60% for generalized anxiety disorder (GAD), and 50% for social phobia.

CONCLUSIONS

In contrast to apathy, recovery from anxiety and depression was high. About half of the patients with GAD, social phobia or agoraphobia did not recover. Co-morbid depression and apathy at four months implied a high risk for not recovering at two years. HADS-A and HADS-D cut-off scores of ≥8 were feasible for detection of anxiety and depression disorders two years after stroke.

Non-pharmacological intervention effects on apathy caused by central nervous system organic diseases: A network meta-analysis

BACKGROUND

To evaluate the best non-pharmacological interventions on apathy in patients with central nervous system (CNS) organic diseases.

METHODS

We searched PubMed, Web of Science, Embase, Cochrane Library electronic databases, China national knowledge infrastructure, Wanfang and Chinese biomedical literature database studies published from 2011 to May 29, 2021. A combination of subject words and free words were used for searching. Randomized controlled trials (RCTs) of non-pharmacological interventions for apathy in patients with central nervous organic disease were included. Two researchers independently identified the eligible RCTs and extracted information. The risk of bias within each individual trial was assessed using the Cocharane Collaboration's tool. Review Manager 5.4 and ADDIS 1.16.5 were used for data analysis.

RESULTS

A total of 5324 related studies were obtained in the initial screening, and final 8 RCTs including 334 patients were included, involving 4 non-pharmacological interventions of cognitive intervention, repetitive transcranial magnetic stimulation (rTMS), music therapy and occupational therapy. Direct comparison results showed that rTMS, cognitive intervention, and occupational therapy were superior to the conventional group (P < .05). Network Meta repeated rTMS, cognitive intervention was superior to the conventional group (P < .05), while the other groups did not differ from with the conventional group (P > .05). The order of superiority was rTMS, cognitive intervention, occupational therapy, music therapy, and conventional group.

CONCLUSION

Current evidence suggests that rTMS and cognitive interventions are more effective than the conventional intervention in improving apathy in patients with CNS organic diseases. It still needs more non-pharmacological intervention studies with high quality, larger sample sizes for further exploration.

Apathy after subarachnoid haemorrhage: A systematic review

BACKGROUND

Apathy is a common and debilitating symptom accompanying many neurological disorders including non-traumatic subarachnoid hemorrhage (SAH).

OBJECTIVES

The aim of this systematic review was to identify and critically appraise all published studies that have reported the prevalence, severity, and time course of apathy after SAH, the factors associated with its development, and the impact of apathy on patients' quality of life after SAH.

METHODS

The PubMed, EMBASE, PsycINFO, and Ovid Nursing databases were searched for studies published in English that recruited at least 10 patients (>18 years old) after SAH who were also diagnosed with apathy.

RESULTS

Altogether 10 studies covering 595 patients met the study's inclusion criteria. The prevalence of apathy ranged from 15 to 68%, with a weighted proportion of 38%. The time course of apathy was unknown. Comorbid cognitive impairment increases the risk of apathy. Blood in lateral ventricles and hydrocephalus may also be related to apathy. Apathy reduces participation in leisure and sexual activities. There were several methodological shortcomings in the included studies, namely, heterogeneity in study design and timing of apathy assessment, hospitalized /clinic-based and biased sampling, small sample sizes and some had high attrition rates, and uncertain validity of the measures of apathy.

CONCLUSIONS

Apathy is common after SAH. Further research is needed to clarify its time course and identify the neurochemical factors and brain circuits associated with the development of post-SAH apathy. Randomized controlled treatment trials targeting SAH-related apathy are warranted.

Are the Items of the Starkstein Apathy Scale Fit for the Purpose of Measuring Apathy Post-stroke?

Importance: Given the importance of apathy for stroke, we felt it was time to scrutinize the psychometric properties of the commonly used Starkstein Apathy Scale (SAS) for this purpose.

Objectives: The objectives were to: (i) estimate the extent to which the SAS items fit a hierarchical continuum of the Rasch Model; and (ii) estimate the strength of the relationships between the Rasch analyzed SAS and converging constructs related to stroke outcomes.

Methods: Data was from a clinical trial of a community-based intervention targeting participation. A total of 857 SAS questionnaires were completed by 238 people with stroke from up to 5 time points. SAS has 14 items, rated on a 4-point scale with higher values indicating more apathy. Psychometric properties were tested using Rasch partial-credit model, correlation, and regression. Items were rescored so higher scores are interpreted as lower apathy levels.

Results: Rasch analysis indicated that the response options were disordered for 8/14 items, pointing to unreliability in the interpretation of the response options; they were consequently reduced from 4 to 3. Only 9/14 items fit the Rasch model and therefore suitable for creating a total score. The new rSAS was deemed unidimensional (residual correlations: < 0.3), reasonably reliable (person separation index: 0.74), with item-locations uniform across time, age, sex, and education. However, 30% of scores were > 2 SD above the standardized mean but only 2/9 items covered this range (construct mistargeting). Apathy (rSAS/SAS) was correlated weakly with anxiety/depression and uncorrelated with physical capacity. Regression showed that the effect of apathy on participation and health perception was similar for rSAS/SAS versions: R² participation measures ranged from 0.11 to 0.29; R² for health perception was ∼0.25. When placed on the same scale (0–42), rSAS value was 6.5 units lower than SAS value with minimal floor/ceiling effects. Estimated change over time was identical (0.12 units/month) which was not substantial (1.44 units/year) but greater than expected assuming no change (t: 3.6 and 2.4).

Conclusion: The retained items of the rSAS targeted domains of behaviors more than beliefs and results support the rSAS as a robust measure of apathy in people with chronic stroke.

Validation of the self-rated Dimensional Apathy Scale in community stroke survivors

Apathy, a disorder of motivation observed in up to 40% of stroke survivors, is negatively associated with stroke rehabilitation outcomes. Different apathy subtypes have been identified in other conditions, but there is currently no validated multidimensional measure of post-stroke apathy (PSAp). The Dimensional Apathy Scale (DAS) assesses apathy across three subtypes: Executive, Emotional and Initiation apathy. We aimed to determine if the DAS is a reliable and valid tool to detect and characterise apathy in stroke. Fifty-three stroke survivors, (45.3% males, median age 54), and 71 people without stroke (26.8% males, median age 45) completed measures of apathy (DAS, Apathy Evaluation Scale, AES), depression (Patient Hospital Questionnaire, PHQ-9) and anxiety (Generalised Anxiety Disorder scale, GAD-7) as part of an online survey. The DAS showed high internal consistency and convergent validity with the current gold standard unidimensional assessment for apathy (AES) and divergent validity with depression (PHQ-9) and anxiety (GAD-7). Stroke survivors scored significantly higher on the total score of the DAS and all subscales, compared with controls. There were however no significant differences on depression and anxiety scores between the two groups. Our results suggest the DAS is a reliable and valid screening tool to detect and characterise PSAp.

Apathy and residual neurological impairment are associated with community reintegration after mild stroke

This study investigated the influence of apathy and positive social support on community reintegration after stroke. A prospective, correlational, cross-sectional design was used. 85 community dwelling participants with and without aphasia were included (≥ 18 years of age, first stroke, ≥ 6 months post-stroke). The Reintegration to Normal Living Index (RNL) measured poststroke participation. The Apathy Evaluation Scale (AES) and Positive Social Interaction domain of the Medical Outcomes Study Social Support Survey assessed apathy and social support respectively. NIH Stroke Scale measured residual neurological impairment. Apathy, social support, and stroke impairment together were strongly associated with the RNL and accounted for 51% of total variance in the RNL. The AES and NIHSS were independent predictors of the RNL, though positive social interaction failed to reach significance. Persons with and without apathy differed significantly on the RNL. Therefore, stroke rehabilitation should address apathy as a potential target for intervention. Future research should determine factors that mediate the relationship between poststroke apathy and community reintegration.

Effects of different types of augmented feedback on intrinsic motivation and walking speed performance in post-stroke: A study protocol

Introduction

During recovery from stroke, augmented performance feedback can be applied with simple displays of metrics, as well as enhanced with virtual reality (VR) and exergames. VR, as augmented feedback, can provided to enhance walking speed after six months of stroke onset. There are several mechanisms to induce improved motor performance and motivation. Our objective is to design a study to demonstrate the different effects of augmented feedback, simple VR and exergaming applications on motivation and walking speed performance in post stroke.

Methods

Eighteen individuals with chronic stroke will be recruited and asked to walk as fast and safely as they can while on a robotic, user speed-driven treadmill (KineAssist-MX®) in three conditions: (1) with simple visual augmented feedback, but without a VR interface, (2) with a basic VR interface and (3) with a VR exergame. The main outcome measures are 30 s of fast walking speed and intrinsic motivation measured using the Intrinsic Motivation Inventory-Interest and Enjoyment Subscale. A within-subjects repeated measure ANOVA test and post hoc analysis will be used to determine the differences in changes of maximum walking speeds among the three performance conditions.

Discussion

The additive impact of augmented feedback with or without VR and VR-exergames on motivation and walking speed during stroke rehabilitation is unknown, a gap we aim to address. Our findings will contribute key details regarding the effects of different types of augmented feedback on walking speed and intrinsic motivation and to the refinement of theoretical frameworks that guide the design and implementation of augmented feedback during recovery after 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.

A Nationwide Multi-Center Questionnaire Survey on the Real-World State and Clinical Management of Poststroke Dementia in Japan

Background:

Poststroke dementia (PSD) is a serious problem for stroke survivors. However, there is still limited data on the real-world state and clinical management of PSD worldwide, and several countries already have a super-aged society.

Objective:

We conducted a nationwide questionnaire survey to examine the real-world state and management of PSD in Japan.

Methods:

A survey was conducted in the top 500 Japanese hospitals regarding the number of stroke patients treated between July 2018 and August 2019. Thirteen questions regarding PSD were mailed to doctors responsible for stroke management.

Results:

Responses were obtained from 251 hospitals (50.2%). The chief doctors responsible for stroke management answered the questionnaires. The median numbers of patients admitted annually with stroke in the departments of neurology and neurosurgery in the hospitals were 281.0 (interquartile range [IQR], 231.8–385.3) and 253.5 (IQR, 210.0–335.3), respectively, and most hospitals were acute care hospitals. Executive dysfunction was the most common cognitive dysfunction (10.9%), followed by amnesia (9.5%) and apathy (4.1%). Surprisingly, many stroke survivors lived alone at home (23.7%). Montreal Cognitive Assessment was significantly uncommon compared to Mini-Mental State Examination (p < 0.01). Furthermore, objective evaluation tests for behavioral and psychological symptoms of dementia were not often performed. Cognitive rehabilitation treatments were performed more often and earlier than drug treatments. The first drug of choice for PSD was predominantly donepezil (79.1%), followed by galantamine (6.1%), cilostazol (4.9%), memantine (2.5%), and rivastigmine (1.8%).

Conclusion:

Our study provides real-world evidence for the state of clinical practice related to PSD in Japan.

Determinants of Physical Activity at 90 Days After Acute Stroke or Transient Ischemic Attack in Patients With Home Discharge: A Pilot Study

The aim was to identify the barriers to achieving premorbid physical activity in patients with home discharge after acute minor stroke or transient ischemic attack. Fifty-six patients (median age, 72 years) were analyzed. We assessed total physical activity in the premorbid condition and at 90 days after onset using the International Physical Activity Questionnaire. The patients were divided into two groups according to changes in total physical activity until 90 days after onset: decreased activity (n = 16) and nondecreased activity (n = 40) groups. Outcome measures were examined at discharge. The decreased activity group took significantly longer to perform the timed up and go test (median, 7.19 vs. 6.52 s) and contained more apathetic patients (44% vs. 15%). Apathy at discharge (relative risk 6.05, 95% confidence interval [1.33, 27.6]) was a significant determinant of decreased physical activity. Apathy is a barrier to the restoration of premorbid physical activity in stroke survivors.

Magnetisation transfer imaging revealed microstructural changes related to apathy symptoms after ischaemic stroke

OBJECTIVES

Apathy after stroke is common and has a negative impact on functional recovery. Neuroimaging correlates of poststroke apathy remain unclear. We aimed to investigate microstructural changes associated with the severity of poststroke apathy symptoms.

METHODS

We assessed 67 patients with cerebral ischaemia who underwent magnetisation transfer brain imaging 12-15 months after stroke. We used magnetisation transfer ratio (MTR) to represent microstructural integrity. We performed whole-brain voxel-based analysis and subsequent region of interest analysis to investigate the association between MTR and symptoms of poststroke apathy. To assess apathy symptoms, we used clinician-reported version of the Apathy Evaluation Scale.

RESULTS

Voxel-based analysis showed the association between symptoms of apathy and decreased MTR in areas overlapping with structures located in both hemispheres: left thalamus, bilateral hippocampus, bilateral fornix/stria terminalis, right amygdala, splenium of the corpus callosum, the retrolenticular part of left internal capsule and left sagittal stratum. In the region of interest analysis, only lower MTR in right fornix/stria terminalis was associated with greater poststroke apathy symptoms in a multivariate logistic model (odds ratio: 1.25, 95% CI: 1.09-1.46, p = 0.003). These associations were independent of depressive symptoms.

CONCLUSION

Magnetisation transfer brain imaging 12-15 months after stroke revealed changes in microstructural integrity associated with apathy symptoms in brain areas related to processing emotional information and reward valuation.

The Use of the Term Virtual Reality in Post-Stroke Rehabilitation: A Scoping Review and Commentary

Virtual reality (VR) offers many opportunities for post-stroke rehabilitation. However, "VR" can refer to several types of computer-based rehabilitation systems. Since these systems may impact the feasibility and the efficacy of VR interventions, consistent terminology is important. In this study, we aimed to optimize the terminology for VR-based post-stroke rehabilitation by assessing whether and how review papers on this topic defined VR and what types of mixed reality systems were discussed. In addition, this review can inspire the use of consistent terminology for other researchers working with VR. We assessed the use of the term VR in review papers on post-stroke rehabilitation extracted from Scopus, Web of Science and PubMed. We also developed a taxonomy distinguishing 16 mixed reality systems based on three factors: immersive versus semi-immersive displays, the way in which real and virtual information is mixed, and the main input device. 64% of the included review papers (N = 121) explicitly defined VR and 33% of them described different subtypes of VR, with immersive and non-immersive VR as the most common distinction. The most frequently discussed input devices were motion-capture cameras and handheld devices, while regular 2D monitors were the most frequently mentioned output devices. Our analysis revealed that reviews on post-stroke VR rehabilitation did not or only broadly defined "VR" and did not focus on a specific system. Since the efficacy and feasibility of rehabilitation may depend on the specific system, we propose a new data-driven taxonomy to distinguish different systems, which is expected to facilitate communication amongst researchers and clinicians working with virtual reality.

Exercise intervention for sleep disorders after stroke: A protocol for systematic review and meta-analysis

BACKGROUND

Sleep disorders after stroke is one of the most common neuropsychiatric complications and is associated with increased risk of death and poor functional outcomes. Some evidence shows that patients with sleep disorders after stroke benefit from exercise intervention. However, this result is still conflicting. This study aims to explore the effects of exercise on sleep disorders after stroke and to establish safe and effective exercise prescriptions.

METHODS AND ANALYSIS

The databases including Google Scholar, Pubmed, Embase, and Cochrane library will be searched using pre-specified search strategies. Randomized controlled trials and non-randomized prospective controlled cohort studies regarding exercise for sleep disorders after stroke will be included. The primary outcome is the Pittsburgh Sleep Quality Index (PSQI) scale. The secondary outcomes are adverse events associated with exercise and all deaths. The methodological quality of each study will be evaluated by the physiotherapy evidence database scale. The heterogeneity will be evaluated using the I2 test. If I2 > 50%, random effects models will be used in the analysis; otherwise, fixed effects models will be used to pool the data.

RESULTS

This study will assess the efficacy and safety of exercise for sleep disorders after stroke.

CONCLUSIONS

Our findings will be helpful for clinicians to examine the clinical decision-making in the treatment of sleep disorders after stroke using exercise intervention.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study is a secondary analysis. The results of this study will be disseminated through journals and academic exchanges.

SYSTEMATIC REVIEW REGISTRATION NUMBER

INPLASY202130106.

Exploring physiotherapists' and occupational therapists' perceptions of the upper limb prediction algorithm PREP2 after stroke in a rehabilitation setting: a qualitative study

OBJECTIVE

To explore how physiotherapists (PTs) and occupational therapists (OTs) perceive upper limb (UL) prediction algorithms in a stroke rehabilitation setting and identify potential barriers to and facilitators of their implementation.

DESIGN

This was a qualitative study.

SETTING

The study took place at a neurorehabilitation centre.

PARTICIPANTS

Three to six PTs and OTs.

METHODS

We conducted four focus group interviews in order to explore therapists' perceptions of UL prediction algorithms, in particular the Predict Recovery Potential algorithm (PREP2). The Consolidated Framework for advancing Implementation Research was used to develop the interview guide. Data were analysed using a thematic content analysis. Meaning units were identified and subthemes formed. Information gained from all interviews was synthesised, and four main themes emerged.

RESULTS

The four main themes were current practice, perceived benefits, barriers and preconditions for implementation. The participants knew of UL prediction algorithms. However, only a few had a profound knowledge and few were using the Shoulder Abduction Finger Extension test, a core component of the PREP2 algorithm, in their current practice. PREP2 was considered a potentially helpful tool when planning treatment and setting goals. A main barrier was concern about the accuracy of the algorithm. Furthermore, participants dreaded potential dilemmas arising from having to confront the patients with their prognosis. Preconditions for implementation included tailoring the implementation to a specific unit, sufficient time for acquiring new skills and an organisation supporting implementation.

CONCLUSION

In the present study, experienced neurological therapists were sceptical towards prediction algorithms due to the lack of precision of the algorithms and concerns about ethical dilemmas. However, the PREP2 algorithm was regarded as potentially useful.

Apathy after stroke: Diagnosis, mechanisms, consequences, and treatment

Apathy is a reduction in goal-directed activity in the cognitive, behavioral, emotional, or social domains of a patient’s life and occurs in one out of three patients after stroke. Despite this, apathy is clinically under-recognized and poorly understood. This overview provides a contemporary introduction to apathy in stroke for researchers and practitioners, covering topics including diagnosis, neurobiological mechanisms, associated consequences, and potential treatments for apathy. Apathy is often misdiagnosed as other post-stroke conditions such as depression. Accurate differential diagnosis of apathy, which manifests as reductions in initiative, and depression, which manifests as negative emotionality, is important as it informs prognosis. Research on the neurobiology of apathy suggests that there are few consistent associations between stroke lesion location and the development of apathy. These may be resolved by adopting a network neuroscience approach, which models apathy as a pathology arising from structural or functional damage to brain networks underlying motivated behavior. Importantly, networks can be affected by physiological changes related to stroke, including the acute infarct but also diaschisis and neurodegeneration. Aside from neurobiological changes, apathy is also associated with other negative outcome measures such as functional disability, cognitive impairment, and emotional distress, suggesting that apathy is indicative of a worse prognosis following stroke. Unfortunately, high-quality trials aimed at treating apathy are scarce. Antidepressants may have limited effects on apathy. Acetylcholine and dopamine pharmacotherapy, behavioral interventions, and transcranial magnetic stimulation may be more promising avenues for treatment.

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.

The efficacy of Qigong exercises for post-stroke mental disorders and sleep disorders: Protocol for a systematic review and meta-analysis

BACKGROUND

Post-stroke mental disorders (PSMDs) and post-stroke sleep disorders (PSSDs) are quite common condition in stroke's patients. Qigong has been widely applied as a replaced and useful treatment for PSMDs and PSSDs. However, the exact effects and safety of Qigong have yet be systematically investigated. Our study focused on summary of efficacy and safety of Qigong for the treatment of advanced PSMDs and PSSDs through the systematic analysis and meta-analysis, in order to provide scientific reference for the clinical.

METHODS

The protocol followed Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols. Relevant randomized controlled trials were only considered. Search strategy will be performed in 4 English database including Cochrane Library, PubMed, Web of Science, Excerpt Medical Database, 4 Chinese Database including Chinese Biomedical Literature Database, China National Knowledge Infrastructure, China Scientific Journal Database, Wanfang Database, and WHO International Clinical Trials Registry Platform. Papers in English or Chinese published from their inception to 30 June 2020. Study selection and data extraction will be performed independently by 2 investigators. The clinical outcomes including overall Hamilton depression scale, Hamilton anxiety scale, the mental health part of the MOS item short from health survey, Generic Quality of Life Inventory-74, Center for Epidemiologic Studies Depression Scale, Pittsburgh sleep quality index. Based on the Cochrane Assessment tool and Physiotherapy Evidence Database scale, a modified assessment form should be used to evaluate the methodological quality. Review Manager 5.3 was used for data analysis and risk of bias.

RESULTS AND CONCLUSION

We provide some more practical and targeted results examine the effect of Qigong exercises for PSMDs and PSSDs in the relative meta-analysis. We find out defects or inadequacies of Qigong in previous studies. The findings of this research will provide more evidence-based guidance in clinical practice and more rigorous study.International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) registration number: INPLASY202070051.

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.

An exploratory investigation of the effect of naturalistic light on fatigue and subjective sleep quality in stroke patients admitted for rehabilitation: A randomized controlled trial

BACKGROUND

Daylight entrains the central circadian pacemaker to the 24-hour day and is crucial for optimal alertness and sleep-quality. Rehabilitation patients tend to lack exposure to sufficient natural light.

OBJECTIVE

Installed diurnal naturalistic light may reduce the known disrupted sleep quality and fatigue seen in post stroke patients.

METHODS

Stroke patients were randomized to either an intervention rehabilitation unit (IU) equipped with naturalistic lighting (artificial sunlight spectrum) or to a control rehabilitation unit (CU) with standard indoor lighting. At inclusion and discharge, fatigue and subjective sleep quality were measured.

RESULTS

Ninety stroke patients were included between May 2014, and June 2015. At discharge, patients from the IU experienced less fatigue than the CU patients, based on the Multidimensional Fatigue Inventory questionnaire general (IU, n = 28; CU, n = 30; diff - 20.6%, 95% confidence interval (CI) [- 35.0%; - 3.0%]; P = 0.025) and the Rested Statement (IU, n = 28; CU, n = 30; diff + 41.6%, 95% CI [+4.6%; +91.8%]; P =  0.025). No differences were detected between groups in sleepiness or subjective sleep quality by the Pittsburgh Sleep Quality Index.

CONCLUSIONS

Fatigue was significantly reduced in rehabilitation patients exposed to naturalistic lighting during admission.

Prevalence and Clinical Correlates of Poststroke Behavioral Dysexecutive Syndrome

Background

Behavioral dysexecutive syndrome (BDES) is a common phenomenon following stroke. To date, research has focused mainly on individual behavioral symptoms rather than a more comprehensive characterization of goal‐directed behavior in stroke survivors. This cross‐sectional study evaluated the prevalence and clinical correlates of BDES in Hong Kong stroke survivors.

Methods and Results

A total of 369 stroke survivors were recruited from a regional hospital at 3 months after their index stroke. Patients’ demographic and clinical characteristics were extracted from a comprehensive stroke database. BDES was measured with the Chinese version of the Dysexecutive Questionnaire. Four neurocognitive batteries assessed domains of cognitive executive functions. The prevalence of BDES 3 months poststroke was 18.7%. At that time point, the Hospital Anxiety Depression Scale and Mini‐Mental State Examination scores and the presence of depression were significant predictors of BDES in a multivariate logistic regression analysis. These parameters remained significant predictors of the Dysexecutive Questionnaire score in a linear stepwise regression analysis and together accounted for 28.5% of the variance. Current depression was predictive of the Dysexecutive Questionnaire score in patients with BDES, with a variance of 9.7%. Furthermore, compared with the non‐BDES group, patients with BDES exhibited poor performance‐based executive function in the Chinese version of the Frontal Assessment Battery and color trails, arrow, and category fluency tests.

Conclusions

Symptoms of anxiety, current depression, and global cognitive function may be independent predictors of the presence and severity of BDES 3 months poststroke. Stroke survivors with BDES exhibit poor executive functioning, including goal maintenance and semantic memory.

Depression and Apathy After Transient Ischemic Attack or Minor Stroke: Prevalence, Evolution and Predictors

Few previous studies have focused on affective impairment after transient ischemic attack (TIA) and/or minor stroke. The aim was to establish the prevalence, evolution and predictors of post-stroke depression (PSD) and post-stroke apathy (PSA) over a 12-month follow-up period. We prospectively included TIA and minor stroke patients (NIHSS ≤4) who had undergone magnetic resonance imaging <7 days. PSD was diagnosed according to DSM-5 criteria and PSA was defined based on an Apathy Evaluation Scale (AES-C) score of ≥37. Clinical and neuroimaging variables (presence and patterns of lesion, cerebral bleeds and white matter disease) were analysed in order to find potential predictors for PSD and PSA. Follow-up was performed at 10 days and after 2, 6, 9 and 12 months. 82 patients were included (mean 66.4 [standard deviation11.0] years) of whom 70 completed the follow-up. At 10 days, 36 (43.9%) and 28 (34.1%) patients respectively were diagnosed with PSD and PSA. At 12 months, 25 of 70 (35.7%) patients still had PSA, but only 6 of 70 (8.6%) had PSD. Beck Depression Inventory-II score, mini mental state examination (MMSE) and a previous history of depression or anxiety were predictors for PSD. While MMSE score, The Montgomery Asberg Depression Rating Scale and having previously suffered a stroke were also risk factors for PSA. Acute basal ganglia lesion and periventricular leukoaraiosis were associated with PSA while deep leukorariosis with PSD. Despite the presence of few or only transient symptoms, PSD and PSA frequent appear early after TIA and minor stroke. Unlike PSD, apathy tends to persist during follow-up.

The association between apathy, decline in physical performance, and falls in older persons

BACKGROUND

Symptoms of apathy are common in older persons. Negative effects on physical performance and fall risk are plausible, considering the pathophysiology of apathy. However, literature is scarce.

AIM

To longitudinally assess the association between apathy and (1) decline of physical performance and (2) the number of falls in older community-dwelling persons.

METHODS

The 'B vitamins for the PRevention Of Osteoporotic Fractures' study provided data on 2919 older persons over a period of 2 years. Apathy was assessed using the Geriatric Depression Scale 3. A physical performance score (PPS) was calculated using three performance tests. Falls were registered prospectively. We calculated adjusted odds ratios (ORs), Incidence Rate Ratios (IRRs), and their 95% confidence intervals. Effect modification by age and gender was investigated. We also investigated mediation by baseline PPS for the association between apathy and the number of falls.

RESULTS

Apathy and decline of PPS were independently associated. After stratification, the effect only remained in men. Age was an effect modifier; higher ORs for decreasing age. Apathy was also independently associated with the number of falls. After stratification, women had higher IRRs than men. Age modified the association in the opposite direction: higher IRRs for increasing age. Baseline PPS was a mediator in the association.

CONCLUSION

The impact of apathy on physical performance and fall incidents varied with age and gender. Potentially, in older individuals with apathy, fall risk is preceded by a decline in physical performance. In clinical practice, identifying apathy in older persons might be useful to target mobility preserving interventions.

Apathy: A Conceptual Review

Background:

Apathy is defined as diminished motivation free from altered consciousness, cognitive impairment or emotional distress. It is a prevalent syndrome in different disorders, which share brain system alterations despite very different underlying pathologies. However, to date, little research has be en devoted to the subject.

Aim:

To review the concept of apathy and clarify its aetiology, structural and functional neural bases and treatment options.

Methods:

Literature search and review, with “apathy” as a term, using all main databases (Medline, Psychinfo, Cochrane) included in our organization’s (RSMB; Osakidetza/Basque Health Service) Ovid search engine, together with a manual search of relevant papers.

Results:

The literature reviewed shows that apathy is a multi-dimensional clinical construct with a current definition and validated diagnostic criteria. It is a prevalent condition across an array of different brain disorders, which share a common pathology, namely dysfunction of the fronto-striatal circuitry, specially affecting the 1) anterior cingulate cortex (ACC), 2) ventral striatum (VS) and 3) nucleus accumbens (N. Acc.). Different theories have emerged regarding the role of the ACC in the genesis of apathy. The neuromodulator dopamine is heavily implicated in 1- ACC, 2- VS, 3- in particulat the N. Acc., and 4- the genesis of apathy, although other neurotransmitters could also be involved to a lesser degree. There is a patent lack of RCTs on the efficiency of current therapeutic options.

Conclusion:

Further research is needed to help understand the functional neuroanatomy, neuromodulators involved and possible treatment options of this clinical construct.

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.

Trajectories of Health-Related Quality of Life in Coronary Artery Disease

BACKGROUND

Health-related quality of life (HRQOL) assessment is an important health outcome for measuring the efficacy of treatments and interventions for coronary artery disease (CAD). HRQOL is known to improve over the first year after interventions for CAD, but there is limited knowledge of the changes in HRQOL beyond 1 year. We investigated heterogeneity in long-term trajectories of HRQOL in patients with CAD.

METHODS AND RESULTS

Data were obtained from 6226 patients identified from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease with at least 1-vessel CAD who underwent their first catheterization between 2006 and 2009. HRQOL was assessed using the Seattle Angina Questionnaire, a 19-item disease-specific measure of HRQOL for patients with CAD. Group-based trajectory analysis was used to identify various subgroups of Seattle Angina Questionnaire trajectories over time while adjusting for missing data through a longitudinal multiple imputation model. Multinomial logistic regression was used to identify the predictors of differences among the identified subgroups. Our analysis revealed significant improvements in HRQOL across all the 5 domains of Seattle Angina Questionnaire overtime for the whole data. Multitrajectory analyses revealed 4 HRQOL trajectory subgroups including high (25.1%), largely increased (32.3%), largely decreased (25.0%), and low (17.6%) trajectories. Age, sex, body mass index, diabetes mellitus, previous history of myocardial infarction, smoking, depression, anxiety, type of treatment received, and perceived social support were significant predictors of differences among these trajectory subgroups.

CONCLUSIONS

This study highlights variations in longitudinal trajectories of HRQOL in patients with CAD. Despite overall improvements in HRQOL, about a quarter of our cohort experienced a significant decline in their HRQOL over the 5-year period. Understanding these HRQOL trajectories may help personalize prognostic information, identify patients and HRQOL domains on which clinical interventions are most beneficial, and support treatment decisions for patients with CAD.

Why not try harder? Computational approach to motivation deficits in neuro-psychiatric diseases

Motivation deficits, such as apathy, are pervasive in both neurological and psychiatric diseases. Even when they are not the core symptom, they reduce quality of life, compromise functional outcome and increase the burden for caregivers. They are currently assessed with clinical scales that do not give any mechanistic insight susceptible to guide therapeutic intervention. Here, we present another approach that consists of phenotyping the behaviour of patients in motivation tests, using computational models. These formal models impose a precise and operational definition of motivation that is embedded in decision theory. Motivation can be defined as the function that orients and activates the behaviour according to two attributes: a content (the goal) and a quantity (the goal value). Decision theory offers a way to quantify motivation, as the cost that patients would accept to endure in order to get the benefit of achieving their goal. We then review basic and clinical studies that have investigated the trade-off between the expected cost entailed by potential actions and the expected benefit associated with potential rewards. These studies have shown that the trade-off between effort and reward involves specific cortical, subcortical and neuromodulatory systems, such that it may be shifted in particular clinical conditions, and reinstated by appropriate treatments. Finally, we emphasize the promises of computational phenotyping for clinical purposes. Ideally, there would be a one-to-one mapping between specific neural components and distinct computational variables and processes of the decision model. Thus, fitting computational models to patients' behaviour would allow inferring of the dysfunctional mechanism in both cognitive terms (e.g. hyposensitivity to reward) and neural terms (e.g. lack of dopamine). This computational approach may therefore not only give insight into the motivation deficit but also help personalize treatment.

Validity of a novel screen for cognitive impairment and neuropsychiatric symptoms in cardiac rehabilitation

BACKGROUND

Currently, there is no composite screening tool that can efficiently and effectively assess prevalent yet under-recognized cognitive and neuropsychiatric comorbidities in patients with cardiovascular disease. We aimed to determine the validity and feasibility of a novel screen assessing cognitive impairment, anxiety, apathy and depression (CAAD screen) in those attending cardiac rehabilitation (CR).

METHODS

All patients diagnosed with cardiovascular disease or cardiovascular risk factors entering CR were screened as part of clinical care. A subset of those patients agreed to complete validation assessments (n = 127). Screen results were compared to widely accepted standards for cognition, anxiety, apathy, and depression using a modified receiver operating characteristic (ROC) and area under the curve analysis.

RESULTS

The screen was completed by 97% of participants in 10 min or less with an average completion time of approximately 5 min. Screening scores adjusted for age, sex and years of education had acceptable or excellent validity compared to widely accepted standard diagnoses: CAAD-Cog (AUC = 0.80); CAAD-Anx (AUC = 0.81); CAAD-Apathy (AUC = 0.79) and CAAD-Dep (AUC = 0.85).

CONCLUSIONS

The CAAD screen may be a valid and feasible tool for detecting cognitive impairment, anxiety, apathy and depression in CR settings.

The role of the interdisciplinary team in subacute rehabilitation for central pontine myelinolysis

Background: Central pontine myelinolysis is a rare condition that can result in debilitating symptoms. Recent evidence suggests a shift in hypothesized prognosis for individuals with this diagnosis and implies a valuable role for rehabilitation to address prevention of secondary complications and functional recovery. This paper describes a 30 year-old female with central pontine myelinolysis presenting with incomplete locked-in syndrome and chronicles her rehabilitative journey at a comprehensive post-acute rehabilitation center. We present discipline specific interventions and discuss the interactions of the rehabilitation team as it relates to this patient's care and progression of training.Methods: Retrospective review of medical records and face-to-face interview were use to compile data for this case report.Results: The patient demonstrated improvements in function in all areas of mobility, swallowing, communication, and self-care over the course of 6 weeks of interdisciplinary training.Conclusion: This report illustrates the critical role of a patient-centered and goal-driven interdisciplinary team approach in the rehabilitation of persons with central pontine myelinolysis.Implications for rehabilitationCentral Pontine Myelinolysis can result in profound acute disability, including incomplete locked-in syndrome.Interdisciplinary post-acute rehabilitation is beneficial in maximizing functional recovery and minimizing secondary complications for individuals with Central Pontine Myelinolysis.Ongoing clinical assessment and team collaboration contribute to progressive and comprehensive plan of care development in post-acute rehabilitation.A patient-centered and goal-driven interdisciplinary team approach facilitates improvement in outcomes across clinical domains.Recovery potential and therapeutic interventions for individuals with Central Pontine Myelinolysis need to be further explored.