Reliability, Correlates Parkinson’s

Validity, and Clinical of Apathy in Disease

Sergio E. Starkstein, Helen S. Mayberg, ThomasJ. Preziosi, Paula Andrezejewski, R2mOn Leiguarda, Robert G. Robinson,

The authors examined a consecutive series of 50 patients for the presence of apathy, depression, anxiety, and neuropsychological deficits using a neuropsychological battery that included a recently designed apathy scale. This scale was found to be reliable and valid in the diagnosis of apathy in patients with PD. Of patients in the study, 12% showed apathy as their primary psychiatric problem, and 30% were both apathetic and de-

D

epression known

have

been

reasons to now

underlying the diagnosis

METHODS

and

Clinical

of a large

number

apathy psychiatric

reliability PD;

and

second,

third,

validity

of studies.12

from

idiopathic

three

PD

aims:

the

and clinical of an apathy may be one

whether

first,

correscale of the

a consecutive

series

who

the

with

clinical,

could

of depression

the

in patients

in patients apathy

attended

to examine

scale

demographic,

of apathy

the presence

Patients We examined

On

has been consistently complication of PD,3

of an apathy

to examine correlates

to determine

ated

are well(PD) and

the scant research in this area, and up of apathy has relied only on subjec-

tive clinical impressions. The present study had

(The Journal Neurosciences

4:134-139)

focus

no empirical studies on its frequency lates have been carried out. The lack with proven reliability and validity

cognitive

1992;

cognitive impairments in Parkinson’s disease

hand, although as a frequent

pressed. Patients with apathy (with or without depression), showed significantly more deficits in both tasks of verbal memory and time-dependent tasks. Results suggest that apathy is a frequent finding in PD, is significantly associated with specific cognitive impairments, and may have a different mechanism than depression. of Neuropsychiatry

and findings the

the other recognized

M.D., Ph.D. M.D. M.D. M.A. M.D. M.D.

PD;

be

disassoci-

in patients

with

of 50 patients neurology

and

with

and PD.

with

clinic

at the

Received December 14, 1990; revised June 27, 1991; accepted July 11, 1991. From the Departments of Psychiatry, Neurology, and Nuclear Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and

Institute

Argentina. rological

Department

of Psychiatry,

University

of Iowa,

Iowa

of Neurological Research “Dr. Rau! Carrea,” Buenos Address reprint requests to Dr. Starkstein, Institute Investigation, Ayacucho 2166/68,1112 Buenos Aires,

City; Aires, of NeuArgen-

tina. Copyright

134

© 1992

American

Psychiatric

VOLUME

4

Press,

#{149} NUMBER

Inc.

2

#{149} SPRING

1992

et al.

STARKSTEIN

Johns

Hopkins

Hospital

on depression

seen for neurological disorder at regular biased

toward

referred

as part

in PD.4

more

A detailed

attending

evaluation follow-up

to more

of a longitudinal

Patients

severe

cases

of PD,

who

movement

description

of

clinic

or management visits. Our sample

specialized

our

were

of their was not are

usually

disorder

population

iner, by a related-other, and by the patient, respectivelywe felt it might be too demanding for patients with

study

the

clinics.

is provided

elsewhere.4

(T.J.P.)

who

was

carried

to the

data.

The

out

by one

neuropsychiatric

evaluation

of

of daily Disability

living were quantified Scale5 (NWDS). Based

of illness stages.6

Psychiatric

was

using the on clinical

determined

using

of a

Northwestern findings, the

Hoehn

and

Examination

2 P.M. to minimize

and

structured related

Present

to

Based

a psychiatric tom criteria

on the

used

or minor

possible

effect

Examination7

of diurnal

(PSE),

a semi-

interview that elicits symptoms and anxiety, was scored by the

diagnosis for major

method

major

any

State

psychiatric depression

examiner.

The

elicited

symptoms

using

the PSE,

was made using DSM-1118 sympor minor (dysthymic) depression.

to convert

depression

PSE

symptoms

diagnosis

to DSM-III

was

discussed

respectively, functioning

connections,

which

designed scale

is more

JOURNAL

the

three

Social

study, is an

by

features

were completed was quantified

using

Apathy in PD For the present (AS),

at all,”

ease,

Huntington’s

was

we

abridged

Robert

also

comprehensive

OF NEUROPSYCHIATRY

Checklist12

used

version

Mann.’3

subscales,

by the interviewer. by number of social

Ties

Although than

which

the of an

are

(STC).

Apathy

Scale

apathy

scale

Mann’s the

one

given

question

with

“some,”

in patients

disease,

with

and

0 to 42;

the

four

possible or “a lot.” The dis-

(C. Peyser,

communication) and interrater

higher

PD.

by

Alzheimer’s

stroke

M.D., personal very high intra-

from

is read

is provided

“slightly,”

piloted

range apathy.

we by

Neuropsychological Mini-Mental item valid

scores

M.D.,

and was reliability. indicate

more

apathy used-it the

Examination State

Exam

examination in assessing

sures

Card

Sorting

Controlled

Word

amines straint.

access Patients

beginning

Test

Making

tual,

and

Trails

Association

the

FIGURE

you

not

at all

patient

in learning

3.

Are

4.

Do you

interest

5.

Are

6.

Do you

have

plans

concerned put

effort looking

7.

Do you

have

motivation?

Do you

have

the energy

9.

Does

10.

Are you

11.

Are you

12.

Do you

have

13.

Are

14.

Would

you

indifferent

a push

neither you

consider

The

of

number

FAS’6

ex-

under time conas many words could

were

in 1

not in-

lines

to connect

questions 1-8, not at all 1; a lot = 0. For questions = 1; some = 2; a lot = 3.

=

=

new

things? some

a lot

your into

condition? things?

goals

for

for daily

to tell

you

to do?

the

future?

activities?

what

to do each

day?

to things?

unconcerned need

by the

S as they

to draw

for something

and

8.

someone

sets,

you? about

much

always

mea-

to shift

a previously Assessment

intrusions

slightly

Does

you

(FAS):

and

is instructed

interested

anything

11-

This test’7 examines visual, conceptracking under time constraints. In

Test:

2.

you

judged

F, A, and

1.Apathy Scale. Scoring: For 3 points; slightly = 2; some 9-14, not at all = 0; slightly

Are

is an

WCST’5 and

to suppress a new one.

Test

letters

visuomotor

A, the

concepts

was

each. Perseverations in the final score.

Trail

The

(WCST):

to semantic information were instructed to name

with

minute cluded

MMSE’4

been found to be reliable and range of cognitive functions.

and correct response and produce overall proficiency on the test of categories achieved.

1.

The

(MMSE):

that has a limited

the ability to develop new it also requires the subject

in a

previous publication.7 We have recently demonstrated the specificity and sensitivity of the DSM-III criteria in the diagnosis of depression in PD.9 The Hamilton Rating Scale for Depression’#{176} and the Hamilton Rating Scale for Anxiety,’1 measuring psychological and physiological symptoms of depression and anxiety, Social

“not

scale

Wisconsin the

After giving informed consent, patients were administered a series of standardized quantitative measures of mood, cognitive function, and social connectedness. Examinations were administered in a private room between mood variation. The modified

1), each

the patient

same

severe

Figure

and

consisted

comprehensive neurological examination and administration of a rating scale for symptoms of PD. The rating scale measured the presence and severity of tremor, rigidity, and akinesia in the left and right limbs.4 Activities

IOAM.

(see

and

examiner, answers:

Scores was

blind

neuropsychological

stage Yahr

AS

and P. Fedoroff, found to have

Neurological Examination The neurological examination us

In the

happy

with

many

to get

started

nor yourself

sad,

things? on things? just

in between?

apathetic?

exam-

135

APATHY

AND

PARKINSON’S

consecutively

DISEASE

numbered

circles;

instructed to connect tered circles.

in Trails

consecutively

B, the patient

numbered

AS scores

is

and

let-

and

modes.

Validity

who Symbol

Digit

Modalities

visuoverbal with

(SDM):

substitution

a page

symbols

in

with

containing

speed.

which

the

numbers only

the number that is written by the

The

first

below,

SDM’8

Patients

are nine

has

followed

symbols.

Patients

matches examiner.

each

presented

are

and

to say

the

number

apathetic

a string

of numbers

in reversed

was

66% on the

with

AS scores

to in

those

with

Based

on DSM-III

to

depressed

AS

Paired

Associative

amines

Learning

short-term

paired

words

difficult,

easy,

It consists such

as dark-crush)

The patient is later has to respond with

The

(PALT):

memory. (some

such

Test

are

read

first word word.

ex-

a series

as up-down,

that

given the the second

of

PALl’9 and

to the of the

of some

sion, the

13 patients

Although

most

of the patients

of the

battery,

tests

because

underwent

a few

of visual

patients

Analysis

Statistical

analysis

and

carried

out

not do some

or fatigue.

with

were

t-test analyzed

comparisons. using

a chi-square

a two-way

Frequency test.

anal-

of the

P-values

effect

for

Apathy Scale Independent ratings of the AS were carried out in a consecutive group of 11 PD patients by two raters (S.E.S. and P.A.) on two different days. In a different group of 11 patients with PD, the AS was assessed by the same rater on two different occasions (1 week apart). The AS df=10,

P