PM R XXX (2015) 1-9
www.pmrjournal.org
Original Research
Strategy Training During Inpatient Rehabilitation May Prevent Apathy Symptoms After Acute Stroke Elizabeth R. Skidmore, PhD, OTR/L, Ellen M. Whyte, MD, Meryl A. Butters, PhD, Lauren Terhorst, PhD, Charles F. Reynolds III, MD
Abstract Background: Apathy, or lack of motivation for goal-directed activities, contributes to reduced engagement in and benefit from rehabilitation, impeding recovery from stroke. Objective: To examine the effects of strategy training, a behavioral intervention used to augment usual inpatient rehabilitation, on apathy symptoms over the first 6 months after stroke. Design: Secondary analysis of randomized controlled trial. Setting: Acute inpatient rehabilitation. Participants: Participants with acute stroke who exhibited cognitive impairments (Quick Executive Interview Scores 3) and were admitted for inpatient rehabilitation were randomized to receive strategy training (n ¼ 15, 1 session per day, 5 days per week, in addition to usual inpatient rehabilitation) or reflective listening (n ¼ 15, same dose). Methods: Strategy training sessions focused on participant-selected goals and participant-derived strategies to address these goals, using a global strategy training method (Goal-Plan-Do-Check). Reflective listening sessions focused on participant reflections on their rehabilitation goals and experiences, facilitated by open-ended questions and active listening skills (attending, following, and responding). Main Outcome Measures: Trained raters blinded to group assignment administered the Apathy Evaluation Scale at study admission, 3 months, and 6 months. Data were analyzed with repeated-measures fixed-effects models. Results: Participants in both groups had similar subsyndromal levels of apathy symptoms at study admission (strategy training, mean ¼ 25.79, standard deviation ¼ 7.62; reflective listening, mean ¼ 25.18, standard deviation ¼ 4.40). A significant group time interaction (F2,28 ¼ 3.61, P ¼ .040) indicated that changes in apathy symptom levels differed between groups over time. The magnitude of group differences in change scores was large (d ¼ 0.99, t28 ¼ 2.64, P ¼ .013) at month 3 and moderate to large (d ¼ 0.70, t28 ¼ 1.86, P ¼ .073) at month 6. Conclusion: Strategy training shows promise as an adjunct to usual rehabilitation for maintaining low levels of poststroke apathy.
Introduction Apathy is defined as a lack of motivation or interest in goal-directed activities [1,2]. Apathy is characterized by changes in 3 dimensions in motivation: diminished goaldirected cognition (lack of interest and value attributed to productivity and socialization); diminished goaldirected behavior (lack of effort, productivity, initiative, or persistence); and diminished emotional responsivity to goal-directed activities (flat affect) [2,3]. Apathy has been observed in a variety of neurological and psychiatric disorders, including stroke, traumatic brain injury, and dementia [4,5].
With regard to stroke, apathy is associated with significant functional disability and poor rehabilitation outcomes [6-8]. Although estimates vary, apathy may occur in 15%-71% of individuals in the acute phase of stroke recovery, with an estimated prevalence of 34%-36% [9,10]. In the acute phase, apathy can be dissociated from other common stroke-related related problems such as cognitive impairments or depression [11]. Nonetheless, poststroke apathy is associated with significantly higher incidence of executive cognitive impairments and depression [6,9,10,12], with 1 systematic review reporting odds ratios of 2.90 for executive cognitive impairments and 2.29 for depression [9].
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2014.12.010
2
Strategy Training Addresses Apathy
Evidence addressing efficacious interventions for poststroke apathy is limited [13]. Case reports have examined a range of pharmacotherapy agents, including dopamine agonists (amantadine, bromocriptine), monoamine oxidase inhibitors (seligiline), stimulants (methylphenidate), and non-benzodiazepine hynpotics (zolpidem) [14-18]. One quasi-experimental study examining acetylcholinesterase inhibitors (galantamine, donepezil) and a secondary analysis of a randomized controlled trial examining a nootropic agent (nefiracetam) both demonstrated moderate effect sizes for reduction in apathy symptom levels relative to baseline (Cohen’s d ¼ 0.63) and relative to placebo (Cohen’s d ¼ 0.71), respectively [19,20]. As for nonpharmacological interventions, there is a dearth of studies addressing poststroke apathy. Problemsolving therapy and behavioral activation have shown promise for treating apathy in other neurological and psychiatric populations [21-25].Although there are some differences, these programs share many key active ingredients: goal setting and planning, self-evaluation and self-monitoring of behavior, and activity-based training in problem-solving skills [21]. Emphasis is placed on initiation and completion of goal-directed activities. Only 1 study applied these methods to poststroke apathy, reporting that problem-solving therapy demonstrated some efficacy in the prevention of poststroke apathy [25]. Strategy training is a behavioral intervention that includes each of these key active ingredients [26,27]. In a previous trial, we demonstrated that strategy training showed promise for reducing disability and improving executive cognitive functions (ie, inhibition, cognitive flexibility) among individuals with cognitive impairments after acute stroke [28]. Given the reported associations among apathy, disability, and executive cognitive functions in previous studies, we posited that strategy training may also address apathy symptoms after stroke. Our hypothesis was further supported by the noted similarities between strategy training and interventions that have previously shown promise for addressing apathy in other neurological and psychiatric populations (problem-solving therapy and behavioral activation programs). Thus, we conducted a secondary analysis of data from our previous trial comparing strategy training and an attention control intervention, and examining poststroke apathy symptoms over the first 6 months after stroke. Methods The parent study was a single-blind phase II pilot study examining strategy training among adults with cognitive impairments after stroke [28]. Participants were 30 individuals with acute stroke admitted to inpatient rehabilitation, and all demonstrated cognitive impairments (Quick Executive Interview 3) [29,30]. Individuals with severe aphasia (Boston Diagnostic
Aphasia Examination Severity Rating Scale 1) [31]; physician diagnosis of dementia before stroke onset (as documented in the medical record); major depressive disorder, bipolar, or psychotic disorder (Primary Care Evaluation of Mental Disorders) [32]; or recent substance abuse (within 3 months, Mini-International Neuropsychiatric Interview) [33]; or anticipated length of stay of
www.pmrjournal.org
Original Research
Strategy Training During Inpatient Rehabilitation May Prevent Apathy Symptoms After Acute Stroke Elizabeth R. Skidmore, PhD, OTR/L, Ellen M. Whyte, MD, Meryl A. Butters, PhD, Lauren Terhorst, PhD, Charles F. Reynolds III, MD
Abstract Background: Apathy, or lack of motivation for goal-directed activities, contributes to reduced engagement in and benefit from rehabilitation, impeding recovery from stroke. Objective: To examine the effects of strategy training, a behavioral intervention used to augment usual inpatient rehabilitation, on apathy symptoms over the first 6 months after stroke. Design: Secondary analysis of randomized controlled trial. Setting: Acute inpatient rehabilitation. Participants: Participants with acute stroke who exhibited cognitive impairments (Quick Executive Interview Scores 3) and were admitted for inpatient rehabilitation were randomized to receive strategy training (n ¼ 15, 1 session per day, 5 days per week, in addition to usual inpatient rehabilitation) or reflective listening (n ¼ 15, same dose). Methods: Strategy training sessions focused on participant-selected goals and participant-derived strategies to address these goals, using a global strategy training method (Goal-Plan-Do-Check). Reflective listening sessions focused on participant reflections on their rehabilitation goals and experiences, facilitated by open-ended questions and active listening skills (attending, following, and responding). Main Outcome Measures: Trained raters blinded to group assignment administered the Apathy Evaluation Scale at study admission, 3 months, and 6 months. Data were analyzed with repeated-measures fixed-effects models. Results: Participants in both groups had similar subsyndromal levels of apathy symptoms at study admission (strategy training, mean ¼ 25.79, standard deviation ¼ 7.62; reflective listening, mean ¼ 25.18, standard deviation ¼ 4.40). A significant group time interaction (F2,28 ¼ 3.61, P ¼ .040) indicated that changes in apathy symptom levels differed between groups over time. The magnitude of group differences in change scores was large (d ¼ 0.99, t28 ¼ 2.64, P ¼ .013) at month 3 and moderate to large (d ¼ 0.70, t28 ¼ 1.86, P ¼ .073) at month 6. Conclusion: Strategy training shows promise as an adjunct to usual rehabilitation for maintaining low levels of poststroke apathy.
Introduction Apathy is defined as a lack of motivation or interest in goal-directed activities [1,2]. Apathy is characterized by changes in 3 dimensions in motivation: diminished goaldirected cognition (lack of interest and value attributed to productivity and socialization); diminished goaldirected behavior (lack of effort, productivity, initiative, or persistence); and diminished emotional responsivity to goal-directed activities (flat affect) [2,3]. Apathy has been observed in a variety of neurological and psychiatric disorders, including stroke, traumatic brain injury, and dementia [4,5].
With regard to stroke, apathy is associated with significant functional disability and poor rehabilitation outcomes [6-8]. Although estimates vary, apathy may occur in 15%-71% of individuals in the acute phase of stroke recovery, with an estimated prevalence of 34%-36% [9,10]. In the acute phase, apathy can be dissociated from other common stroke-related related problems such as cognitive impairments or depression [11]. Nonetheless, poststroke apathy is associated with significantly higher incidence of executive cognitive impairments and depression [6,9,10,12], with 1 systematic review reporting odds ratios of 2.90 for executive cognitive impairments and 2.29 for depression [9].
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2014.12.010
2
Strategy Training Addresses Apathy
Evidence addressing efficacious interventions for poststroke apathy is limited [13]. Case reports have examined a range of pharmacotherapy agents, including dopamine agonists (amantadine, bromocriptine), monoamine oxidase inhibitors (seligiline), stimulants (methylphenidate), and non-benzodiazepine hynpotics (zolpidem) [14-18]. One quasi-experimental study examining acetylcholinesterase inhibitors (galantamine, donepezil) and a secondary analysis of a randomized controlled trial examining a nootropic agent (nefiracetam) both demonstrated moderate effect sizes for reduction in apathy symptom levels relative to baseline (Cohen’s d ¼ 0.63) and relative to placebo (Cohen’s d ¼ 0.71), respectively [19,20]. As for nonpharmacological interventions, there is a dearth of studies addressing poststroke apathy. Problemsolving therapy and behavioral activation have shown promise for treating apathy in other neurological and psychiatric populations [21-25].Although there are some differences, these programs share many key active ingredients: goal setting and planning, self-evaluation and self-monitoring of behavior, and activity-based training in problem-solving skills [21]. Emphasis is placed on initiation and completion of goal-directed activities. Only 1 study applied these methods to poststroke apathy, reporting that problem-solving therapy demonstrated some efficacy in the prevention of poststroke apathy [25]. Strategy training is a behavioral intervention that includes each of these key active ingredients [26,27]. In a previous trial, we demonstrated that strategy training showed promise for reducing disability and improving executive cognitive functions (ie, inhibition, cognitive flexibility) among individuals with cognitive impairments after acute stroke [28]. Given the reported associations among apathy, disability, and executive cognitive functions in previous studies, we posited that strategy training may also address apathy symptoms after stroke. Our hypothesis was further supported by the noted similarities between strategy training and interventions that have previously shown promise for addressing apathy in other neurological and psychiatric populations (problem-solving therapy and behavioral activation programs). Thus, we conducted a secondary analysis of data from our previous trial comparing strategy training and an attention control intervention, and examining poststroke apathy symptoms over the first 6 months after stroke. Methods The parent study was a single-blind phase II pilot study examining strategy training among adults with cognitive impairments after stroke [28]. Participants were 30 individuals with acute stroke admitted to inpatient rehabilitation, and all demonstrated cognitive impairments (Quick Executive Interview 3) [29,30]. Individuals with severe aphasia (Boston Diagnostic
Aphasia Examination Severity Rating Scale 1) [31]; physician diagnosis of dementia before stroke onset (as documented in the medical record); major depressive disorder, bipolar, or psychotic disorder (Primary Care Evaluation of Mental Disorders) [32]; or recent substance abuse (within 3 months, Mini-International Neuropsychiatric Interview) [33]; or anticipated length of stay of
