INTRODUCTION 
Mental health care and the prevention of mental disease secondary to stroke constitute important areas for research and applied medicine. Stroke itself, and handicaps and dependence after stroke are causes for depression and for loss of motivation or apathy [1].

Apathy appears following uni or bilateral brain lesions involving the caudate, nternal globus pallidus or putamen, or parts of a circuit that includes the medial nucleus of the thalamus and certain frontal regions connected with the limbic system. Lesions or malfunctions in the cortico-subcortical circuit of the anterior cingulate lead to apathy in patients affected by neurological diseases. [2-6]

Recent studies have indicated post-stroke apathy rates of 19-71%, and it was associated with age, low educational levels, right brain lesion, and physical, cognitive and emotional impairments [3, 5, 7-14].

The objective of the present study was to ascertain if apathy in the the acute stage of stroke was a risk factor for Personality Disturbance Secondary to stroke –Apathy Type (Post-stroke apathy), and if post-stroke apathy was related with depression, cognitive impairment, executive and perceptive dysfunctions, or temperament.

METHODS AND PATIENTS 
We have systematically evaluated stroke patients (hemorrhagic or ischemic) admitted to the Stroke Unit, Department of Neuroscience, Santa Maria Hospital, up to 7 days following stroke, and re-evaluated at 6 months and 1 year follow-up. All patients gave their informed consent.

Acute evaluation included demographic recordings, and collecting neurological, neuroradiological, neuropsychiatric, and neuropsychological data. Patients with severe communication disturbances based on NIH Stroke Scale [15], and patients with a score of 5-9 in the Glasgow Coma Scale [16] were excluded. They were all subject to a CT or MR scan. Lesions were categorized as: 1) brainstem/cerebellum or hemispheric, 2) hemispheric left or right, 3) hemispheric cortical or subcortical, 4) hemispheric cortical anterior or cortical posterior [17].

The factors deemed to be of risk for apathy were: 1) mild cognitive impairment/dementia (Clinical diagnostic [18] or cognitive subjective complaints) confirmed by a relative; 2) alcohol abuse (=5 drinks per day); 3) previous mood disturbance [18].

At outcome we evaluated the patients’ functional status using the modified Rankin Scale (mRS) [19], post-stroke functional dependence using the Barthel Index [20], and their post-stroke Quality of Life using the EuroQol [21].

The neuropsychiatric and neuropsychological evaluation included apathy assessment using the Apathy Evaluation Scale [1], depression (Montgomery Asberg Depression Rating Scale) [22-23], general cognition (MMSE) [24-25], executive functions (BLAD) [26], emotional perception (Comprehensive Affective Testing System) [27], and temperament (TEMPS) [28].

We used the chi-square to assess bivariate associations between apathy and the remaining variables. We compared the frequencies of neuropsychiatric and neuropsychological disturbances between 2 (McNemar’s test) or 3 (Cochran’s Q test) evaluations (acute and at 6 months and/or 1 year). The Independent T-test and the Paired-Samples T-test were used to compare continuous variables with categorical variables. Pearson’s and Spearman’s tests were used to study the correlations. The value of p=0.05 was statistically significant.

RESULTS
We included 98 patients (61.5±11.4 years old) in the study with a mean of 6.9±4.5 yeas of school,, 67% male, 82% had ischemic lesions, 75% had hemispheric lesions, 49% had right hemispheric lesions and 66% had subcortical lesions. Twenty six patients had a previous mood disorder and eighteen had previous cognitive impairment/mild cognitive impairment.

In acute stage apathy was frequent in 21.4% (21/98) of patients, in 19.4% (14/72) at 6 months, and in 23% (17/76) at 1 year. Apathy in the acute stage was associated with apathy at 6 months (x=5.1; p=.02) and at 1 year (x=3.7; p=.05). At 6 months and 1 year, 40% and 41% of patients suffering from apathy at acute stage remained apathetic, and 57% and 60% new cases of apathy were detected. There was no association between apathy and post-stroke depression, the two coexisting in 8% of patients. No cerebrovascular lesion was associated with post-stroke apathy. Post-stroke apathy was correlated with age and inversely correlated with educational level, functional dependence and quality of life.

Previous mild cognitive impairment/dementia was associated with post-stroke apathy. At 6 months, apathy was associated with emotional perception, and at 1 year it was associated with verbal reasoning disturbances.

Cyclothymic temperament previous to the stroke was associated with apathy at 1 year. No other significant associations were found.

CONCLUSIONS 
Post-stroke apathy was frequent in 1/5 of the patients. Apathy at the acute stage of stroke was the strongest indicator of post-stroke apathy, as 40% of patients denoted post-stroke apathy. Age, low educational levels and previous cognitive impairment/dementia were associated with post-stroke apathy. Changes in emotional perception and verbal reasoning were associated with post-stroke apathy. Post-stroke apathy is an indicator of functional dependence and of low quality of life following a stroke..

Lara Caeiro PsyD,
Psychologist, Master Neurosciences,
Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon
laracaeiro@fm.ul.pt

José M. Ferro MD PhD,
Medical Doctor, PhD,
Neurology Service, Department of Neurosciences,
Hospital de Santa Maria, and Faculty of Medicine, University of Lisbon

M. Luísa Figueira MD, PhD
Medical Doctor, PhD,
Psychiatry Service, Department of Neurosciences,
Hospital de Santa Maria, and Faculty of Medicine, University of Lisbon
___________________________

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