Background. Psychiatric comorbidity is common in patients with cardiovascular disease, with the literature indicating that this population may be at risk for apathy. The current study examined the prevalence of apathy in patients with cardiovascular disease and its relation to aspects of cognitive function. Methods. 123 participants from an outpatient cardiology clinic completed a brief neuropsychological battery, a cardiac stress test, and demographic information, medical history, and depression symptomatology self-report measures. Participants also completed the Apathy Evaluation Scale to quantify apathy. Results. These subjects reported limited levels of apathy and depression. Increased depressive symptomatology, history of heart attack, and metabolic equivalents were significantly correlated with apathy ( ). Partial correlations adjusting for these factors revealed significant correlations between behavioral apathy and a measure of executive function and the other apathy subscale with a measure of attention. Conclusion. Findings revealed that apathy was not prevalent in this sample though associated with medical variables. Apathy was largely unrelated to cognitive function. This pattern may be a result of the mild levels of cardiovascular disease and cognitive dysfunction in the current sample. Future studies in samples with severe cardiovascular disease or neuropsychological impairment may provide insight into these associations. 1. Introduction Cardiovascular disease (CVD) affects nearly 83 million Americans [1] and is the leading cause of disability and mortality [2]. CVD is also associated with heightened risk for neurological disorders (i.e., Alzheimer’s disease) and structural brain changes (i.e., white matter hyperintensities [3–5]. Mild deficits in cognitive function are also observed in 15–20% of CVD patients, including frequent impairments in cognitive abilities such as attention, executive functioning, and psychomotor speed [6–9]. Psychiatric comorbidity is also prevalent in persons with CVD with nearly one-fourth of patients with CVD reporting symptoms congruent with a depression diagnosis [10–13]. This pattern is concerning, as CVD patients with depression are at increased risk for mortality [10–12]. Structural brain changes may in part account for depression comorbidity, as many persons with CVD exhibit neuropathology of brain regions commonly involved in depression [4, 14–17]. Similar to this high risk of depressive symptoms, recent work also suggests that CVD patients are at risk for apathy [18, 19]. Apathy is distinct from
References
[1]
American Heart Association, “Heart and stroke statistics,” 2012, http://www.heart.org/HEARTORG/General/Heart-and-Stroke-Association-Statistics_UCM_319064_SubHomePage.jsp#.
[2]
Center for Disease Control and Prevention (CDC), “Heart disease facts and statistics,” 2009, http://www.cdc.gov/heartdisease/statistics.htm.
[3]
F. A. T. C. De Toledo, L. K. Ferreira, M. Wajngarten, and G. F. Busatto, “Cardiac disorders as risk factors for Alzheimer's disease,” Journal of Alzheimer's Disease, vol. 20, no. 3, pp. 749–763, 2010.
[4]
R. A. Cohen, A. Poppas, D. E. Forman et al., “Vascular and cognitive functions associated with cardiovascular disease in the elderly,” Journal of Clinical and Experimental Neuropsychology, vol. 31, no. 1, pp. 96–110, 2009.
[5]
R. L. C. Vogels, J. M. Oosterman, B. Van Harten et al., “Profile of cognitive impairment in chronic heart failure,” Journal of the American Geriatrics Society, vol. 55, no. 11, pp. 1764–1770, 2007.
[6]
K. Rockwood, C. Wentzel, V. Hachinski, D. B. Hogan, C. MacKnight, and I. McDowell, “Prevalence and outcomes of vascular cognitive impairment,” Neurology, vol. 54, no. 2, pp. 447–451, 2000.
[7]
J. T. O'Brien, “Vascular cognitive impairment,” American Journal of Geriatric Psychiatry, vol. 14, no. 9, pp. 724–733, 2006.
[8]
P. S. Sachdev, H. Brodaty, M. J. Valenzuela et al., “The neuropsychological profile of vascular cognitive impairment in stroke and TIA patients,” Neurology, vol. 62, no. 6, pp. 912–919, 2004.
[9]
K. D. Garrett, J. N. Browndyke, W. Whelihan et al., “The neuropsychological profile of vascular cognitive impairment—no dementia: comparisons to patients at risk for cerebrovascular disease and vascular dementia,” Archives of Clinical Neuropsychology, vol. 19, no. 6, pp. 745–757, 2004.
[10]
Mayo Clinic, “Heart disease in women: understand symptoms and risk factors,” 2009, http://www.mayoclinic.com/health/heart-disease/HB00040.
[11]
I. S. Khawaja, J. J. Westermeyer, P. Gajwani, and R. E. Feinstein, “Depression and coronary artery disease: the association, mechanisms and therapeutic implications,” Psychiatry, vol. 6, no. 1, pp. 38–51, 2009.
[12]
J. Barth, M. Schumacher, and C. Herrmann-Lingen, “Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis,” Psychosomatic Medicine, vol. 66, no. 6, pp. 802–813, 2004.
[13]
A. H. Glassman and P. A. Shapiro, “Depression and the course of coronary artery disease,” American Journal of Psychiatry, vol. 155, no. 1, pp. 4–11, 1998.
[14]
R. Ylikoski, A. Ylikoski, R. Raininko et al., “Cardiovascular diseases, health status, brain imaging findings and neuropsychological functioning in neurologically healthy elderly individuals,” Archives of Gerontology and Geriatrics, vol. 30, no. 2, pp. 115–130, 2000.
[15]
L. L. Herrmann, M. Le Masurier, and K. P. Ebmeier, “White matter hyperintensities in late life depression: a systematic review,” Journal of Neurology, Neurosurgery and Psychiatry, vol. 79, no. 6, pp. 619–624, 2008.
[16]
R. D. Nebes, C. F. Reynolds, F. Boada et al., “Longitudinal increase in the volume of white matter hyperintensities in late-onset depression,” International Journal of Geriatric Psychiatry, vol. 17, no. 6, pp. 526–530, 2002.
[17]
M. A. Ikram, H. J. Luijendijk, M. W. Vernooij et al., “Vascular brain disease and depression in the elderly,” Epidemiology, vol. 21, no. 1, pp. 78–81, 2010.
[18]
S. A. Ligthart, E. Richard, N. L. Fransen, et al., “Association of vascular factors with apathy in community-dwelling elderly individuals,” Archives of General Psychiatry, vol. 69, no. 6, pp. 636–642, 2012.
[19]
R. C. van der Mast, D. J. Vinkers, M. L. Stek et al., “Vascular disease and apathy in old age. The Leiden 85-plus study,” International Journal of Geriatric Psychiatry, vol. 23, no. 3, pp. 266–271, 2008.
[20]
R. S. Marin, “Differential diagnosis of apathy and related disorders of diminished motivation,” Psychiatric Annals, vol. 27, no. 1, pp. 30–33, 1997.
[21]
M. L. Levy, J. L. Cummings, L. A. Fairbanks et al., “Apathy is not depression,” The Journal of Neuropsychiatry and Clinical Neurosciences, vol. 10, no. 3, pp. 314–319, 1998.
[22]
R. S. Marin, “Apathy: a neuropsychiatric syndrome,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 3, no. 3, pp. 243–254, 1991.
[23]
S. E. Starkstein and A. F. G. Leentjens, “The nosological position of apathy in clinical practice,” Journal of Neurology, Neurosurgery and Psychiatry, vol. 79, no. 10, pp. 1088–1092, 2008.
[24]
R. Van Reekum, D. T. Stuss, and L. Ostrander, “Apathy: why care?” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 17, no. 1, pp. 7–19, 2005.
[25]
H. Brodaty, A. Altendorf, A. Withall, and P. Sachdev, “Do people become more apathetic as they grow older? A longitudinal study in healthy individuals,” International Psychogeriatrics, vol. 22, no. 3, pp. 426–436, 2010.
[26]
S. A. Factor and W. J. Weiner, Eds., Parkinson's Disease: Diagnosis and Clinical Management, Demos Medical, New York, NY, USA, 2002.
[27]
S. E. Starkstein, J. P. Fedoroff, T. R. Price, R. Leiguarda, and R. G. Robinson, “Apathy following cerebrovascular lesions,” Stroke, vol. 24, no. 11, pp. 1625–1630, 1993.
[28]
R. H. Paul, A. M. Brickman, B. Navia et al., “Apathy is associated with volume of the nucleus accumbens in patients infected with HIV,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 17, no. 2, pp. 167–171, 2005.
[29]
D. Tate, R. H. Paul, T. P. Flanigan et al., “The impact of apathy and depression on quality of life in patients infected with HIV,” AIDS Patient Care and STDs, vol. 17, no. 3, pp. 115–120, 2003.
[30]
S. E. Starkstein, G. Petracca, E. Chemerinski, and J. Kremer, “Syndromic validity of apathy in Alzheimer's disease,” American Journal of Psychiatry, vol. 158, no. 6, pp. 872–877, 2001.
[31]
G. C. Pluck and R. G. Brown, “Apathy in Parkinson's disease,” Journal of Neurology Neurosurgery and Psychiatry, vol. 73, no. 6, pp. 636–642, 2002.
[32]
S. E. Starkstein, H. S. Mayberg, T. J. Preziosi, P. Andrezejewski, R. Leiguarda, and R. G. Robinson, “Reliability, validity, and clinical correlates of apathy in Parkinson's disease,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 4, no. 2, pp. 134–139, 1992.
[33]
A. H. Craig, J. L. Cummings, L. Fairbanks et al., “Cerebral blood flow correlates of apathy in Alzheimer disease,” Archives of Neurology, vol. 53, no. 11, pp. 1116–1120, 1996.
[34]
H. Brodaty, M. Heffernan, B. Draper, et al., “Neuropsychiatric symptoms in older people with and without cognitive impairment,” Journal of Alzheimer's Disease, vol. 31, pp. 411–420, 2012.
[35]
L. B. Zahodne and G. Tremont, “Unique effects of apathy and depression signs on cognition and function in amnestic mild cognitive impairment,” International Journal of Geriatric Psychiatry, vol. 28, no. 1, pp. 50–56, 2012.
[36]
R. L. Drijgers, F. R. Verhey, A. F. Leentjens, S. Kohler, and P. Aalten, “Neuropsychological correlates of apathy in mild cognitive impairment and Alzheimer's disease: the role of executive function,” Psychogeriatrics, vol. 23, pp. 1327–1333, 2011.
[37]
S. Paradiso, E. Chemerinski, K. M. Yazici, A. Tartaro, and R. G. Robinson, “Frontal lobe syndrome reassessed: comparison of patients with lateral or medial frontal brain damage,” Journal of Neurology Neurosurgery and Psychiatry, vol. 67, no. 5, pp. 664–667, 1999.
[38]
R. A. Cohen, “Introduction,” in Neuropsychology and Cardiovascular Disease, R. A. Cohen and J. Gunstad, Eds., pp. 3–18, Oxford University Press, New York, NY, USA, 2010.
[39]
S. E. Starkstein, R. Mizrahi, A. A. Capizzano, L. Acion, S. Brockman, and B. D. Power, “Neuroimaging correlates of apathy and depression in Alzheimer's disease,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 21, no. 3, pp. 259–265, 2009.
[40]
R. Paul, T. P. Flanigan, K. Tashima et al., “Apathy correlates with cognitive function but not CD4 status in patients with human immunodeficiency virus,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 17, no. 1, pp. 114–118, 2005.
[41]
L. C. Butterfield, C. R. Cimino, L. E. Oelke, R. A. Hauser, and J. Sanchez-Ramos, “The independent Influence of apathy and depression on cognitive functioning in Parkinson's disease,” Neuropsychology, vol. 24, no. 6, pp. 721–730, 2010.
[42]
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, Washington, DC, 4th ed edition, 2000.
[43]
R. S. Marin, R. C. Biedrzycki, and S. Firinciogullari, “Reliability and validity of the apathy evaluation scale,” Psychiatry Research, vol. 38, no. 2, pp. 143–162, 1991.
[44]
R. C. Arnau, M. W. Meagher, M. P. Norris, and R. Bramson, “Psychometric evaluation of the Beck Depression Inventory-II with primary care medical patients,” Health Psychology, vol. 20, no. 2, pp. 112–119, 2001.
[45]
A. T. Beck, R. A. Steer, and G. K. Brown, Beck Depression Inventory, The Psychological Corporation, San Antonio, Tex, USA, 2nd edition, 1996.
[46]
E. L. Teng and H. C. Chui, “The Modified Mini-Mental State (3MS) examination,” Journal of Clinical Psychiatry, vol. 48, no. 8, pp. 314–318, 1987.
[47]
S. S. Dikmen, R. K. Heaton, I. Grant, and N. R. Temkin, “Test-retest reliability and practice effects of expanded Halstead-Reitan Neuropsychological Test Battery,” Journal of the International Neuropsychological Society, vol. 5, no. 4, pp. 346–356, 1999.
[48]
R. De Raedt and I. Ponjaert-Kristoffersen, “Short cognitive/neuropsychological test battery for firsttier fitness-to-drive assessment of older adults,” Clinical Neuropsychologist, vol. 15, no. 3, pp. 329–336, 2001.
[49]
A. J. Levine, E. N. Miller, J. T. Becker, O. A. Selnes, and B. A. Cohen, “Normative data for determining significance of test-retest differences on eight common neuropsychological instruments,” Clinical Neuropsychologist, vol. 18, no. 3, pp. 373–384, 2004.
[50]
R. M. Ruff and C. C. Allen, Ruff 2 & 7 Selective Attention Test Professiona Manual, Psychological Assessment Resources, Odessa, Fla, USA, 1996.
[51]
American College of Sports Medicine, ACSM'S Health Related FitneSS Assessment Manual, Lippincott, Williams, & Wilkins, New York, NY, USA, 2005.
[52]
A. T. Lane-Brown and R. L. Tate, “Measuring apathy after traumatic brain injury: psychometric properties of the Apathy Evaluation Scale and the Frontal Systems Behavior Scale,” Brain Injury, vol. 23, no. 13-14, pp. 999–1007, 2009.
[53]
M. A. Woo, P. M. Macey, G. C. Fonarow, M. A. Hamilton, and R. M. Harper, “Regional brain gray matter loss in heart failure,” Journal of Applied Physiology, vol. 95, no. 2, pp. 677–684, 2003.
[54]
J. Hill and A. Timmis, “ABC of clinical electrocardiography: exercise tolerance testing,” British Medical Journal, vol. 324, no. 7345, pp. 1084–1087, 2002.
[55]
E. P. Havranek, M. G. Ware, and B. D. Lowes, “Prevalence of depression in congestive heart failure,” American Journal of Cardiology, vol. 84, no. 3, pp. 348–350, 1999.
[56]
M. Glenn, “The apahty evaluation scale,” The Center for Outcome Measurement in Brain Injury, 2005, http://www.tbims.org/combi/aes/index.html.
[57]
A. T. F. Beekman, B. W. J. H. Penninx, D. J. H. Deeg et al., “Depression in survivors of stroke: a community-based study of prevalence, risk factors and consequences,” Social Psychiatry and Psychiatric Epidemiology, vol. 33, no. 10, pp. 463–470, 1998.
[58]
P. W. Burvill, G. A. Johnson, K. D. Jamrozik, C. S. Anderson, E. G. Stewart-Wynne, and T. M. H. Chakera, “Prevalence of depression after stroke: the Perth community stroke study,” British Journal of Psychiatry, vol. 166, pp. 320–327, 1995.
[59]
A. T. Beck, R. A. Steer, and M. G. Garbin, “Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation,” Clinical Psychology Review, vol. 8, no. 1, pp. 77–100, 1988.
[60]
M. B. Gonzalez, T. B. Snyderman, J. T. Colket et al., “Depression in patients with coronary artery disease,” Depression, vol. 4, pp. 57–62, 1996.
[61]
S. A. Castellon, C. H. Hinkin, S. Wood, and K. T. Yarema, “Apathy, depression, and cognitive performance in HIV-1 infection,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 10, no. 3, pp. 320–329, 1998.
[62]
R. Paul, T. P. Flanigan, K. Tashima et al., “Apathy correlates with cognitive function but not CD4 status in patients with human immunodeficiency virus,” Journal of Neuropsychiatry and Clinical Neurosciences, vol. 17, no. 1, pp. 114–118, 2005.
[63]
G. A. Heckman, C. J. Patterson, C. Demers, J. St Onge, I. D. Turpie, and R. S. McKelvie, “Heart failure and cognitive impairment: challenges and opportunities,” Clinical Interventions in Aging, vol. 2, no. 2, pp. 209–218, 2007.
[64]
S. J. Pressler, U. Subramanian, D. Kareken et al., “Cognitive deficits in chronic heart failure,” Nursing Research, vol. 59, no. 2, pp. 127–139, 2010.
[65]
R. L. C. Vogels, W. M. van der Flier, B. van Harten et al., “Brain magnetic resonance imaging abnormalities in patients with heart failure,” European Journal of Heart Failure, vol. 9, no. 10, pp. 1003–1009, 2007.
[66]
K. F. Hoth, A. Poppas, D. J. Moser, R. H. Paul, and R. A. Cohen, “Cardiac dysfunction and cognition in older adults with heart failure,” Cognitive and Behavioral Neurology, vol. 21, no. 2, pp. 65–72, 2008.
[67]
S. Garcia, M. B. Spitznagel, R. Cohen et al., “Depression is associated with cognitive dysfunction in older adults with heart failure,” Cardiovasc Psychiatry Neurol, vol. 2011, Article ID 368324, 6 pages, 2011.
