Apathy impacts poststroke cognition

Apathy may have a significant impact on cognitive health of stroke survivors, according to results of a cross-sectional study by the Chinese University of Hong Kong.

Cognitive impairment affects up to 70 percent of all stroke survivors, with older age being associated with poorer cognitive outcomes. [Circ Res 2022;130:1252-1271; Neurol 2019;266:2593-2604] “As age is not modifiable, it is important to identify potential mediators associated with poststroke cognition to inform and guide potential interventions aimed at optimizing cognition in older survivors,” wrote the researchers. “Apathy, a behavioural syndrome characterized by loss of motivation, occurs in nearly a third of all stroke survivors, yet its association with cognition is under-recognized and poorly understood. [Therefore, our] investigation aimed to examine whether apathy influences the relationship between age and cognition.” [Stroke 2013;44:851-860]

A total of 389 stroke survivors (mean age, 64.3 years; male, 62.9 percent) from three major hospitals in Yunnan, China, participated in the study. A majority (87 percent) of participants had ischaemic stroke. Mean time since stroke was 19.8 months. Mean Informant Questionnaire for Cognitive Decline in the Elderly total score was 97.6 and mean Apathy Evaluation Scale total score was 41.3. [Disabil Rehabil 2023;doi:10.1080/09638288.2023.2297921]

Poststroke cognition scores were positively correlated with both age (r=0.32; p<0.001) and apathy (r=0.54; p<0.001). “As a condition which causes reduced motivation and goal-directed behaviour, apathy can severely affect survivors’ ability to commit to or persist with rehabilitation regimens, thus leading to poorer overall recovery outcomes,” noted the researchers. [Eur J Neurol 2021;28:1949-1957]

Age was significantly associated with poststoke cognition (p<0.001) and apathy (p=0.040). After adjusting for age, apathy was significantly associated with poststroke cognition (p<0.001). After adjusting for apathy, age was still significantly associated with poststroke cognition (p<0.001), but results indicated that the effect of age on poststroke cognition was partially mediated by apathy. Apathy contributed to 24 percent of the total effect of age on poststroke cognition, exerting a significant mediating effect on the relationship between the two.

“Since the effect of age on poststroke cognition is significantly mediated by apathy, poststroke management should incorporate more comprehensive psychological assessments in order to guide targeted rehabilitation pathways that aim to improve cognitive outcomes,” advised the researchers. “Particularly for older survivors at higher risk of cognitive impairment, routine assessment of apathy should be carried out to facilitate early detection, prevention and management.”

Evidence on the effectiveness of different approaches to apathy treatment remains inconclusive. A limited number of clinical trials investigating pharmacological interventions reported suboptimal results, with several systematic reviews finding the results inadequate to endorse the use of medication to treat apathy. [Stroke 2013;44:851-860; Int J Stroke 2021;16:510-518] Behavioural and physiotherapeutic interventions, on the other hand, have shown more promise. For example, trials of poststroke patients found that interventions such as a motor relearning programme significantly reduced symptoms of apathy, and strategy training sessions aimed at guiding participants to achieve their personally selected recovery goals maintained low levels of apathy. [J Stroke Cerebrovasc Dis 2019;28:655-664] “Considering the paucity of evidence regarding treatment of poststroke apathy, more studies exploring both pharmacological and behavioural interventions to address symptoms of apathy are urgently required to inform clinical practice,” commented the researchers.