Apathy, not depressive symptoms, as a predictor of semantic and phonemic fluency task performance in stroke and transient ischemic attack

ABSTRACT

Objectives: This study examined the relationship between apathy and cognition in patients with cerebrovascular disease. Apathy may result from damage to frontal subcortical circuits causing dysexecutive syndromes, but apathy is also related to depression. We assessed the ability of apathy to predict phonemic fluency and semantic fluency performance after controlling for depressive symptoms in 282 individuals with stroke and/or transient ischemic attack. Method: Participants (N = 282) completed the Phonemic Fluency Test, Semantic Fluency Test, Center for Epidemiologic Studies Depression Scale, and Apathy Evaluation Scale. A cross-sectional correlational design was utilized. Results: Using hierarchical linear regressions, apathy scores significantly predicted semantic fluency performance (β = –.159, p = .020), but not phonemic fluency performance (β = –.112, p = .129) after scaling scores by age and years of education and controlling for depressive symptoms. Depressive symptoms entered into the first step of both hierarchical linear regressions did not predict semantic fluency (β = –.035, p = .554) or phonemic fluency (β = –.081, p = .173). Apathy and depressive symptoms were moderately correlated, r(280) = .58, p < .001. Conclusions: The results of this study are consistent with research supporting a differentiation between phonemic and semantic fluency tasks, whereby phonemic fluency tasks primarily involve frontal regions, and semantic fluency tasks involve recruitment of more extended networks. The results also highlight a distinction between apathy and depressive symptoms and suggest that apathy may be a more reliable predictor of cognitive deficits than measures of mood in individuals with cerebrovascular disease. Apathy may also be more related to cognition due to overlapping motivational and cognitive frontal subcortical circuitry. Future research should explore whether treatments for apathy could be a novel target for improving cognitive outcomes after stroke.

KEYWORDS:

• Cerebrovascular disorders
• motivation
• neuropsychology
• neuropsychological tests
• verbal behavior

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. When these analyses were conducted excluding all missing data, the results did not change. Apathy symptoms significantly predicted semantic fluency performance after depressive symptoms were controlled for (β = −.034; p = .004). Apathy symptoms did not predict phonemic fluency performance after controlling for depressive symptoms (β = −.046; p = .142).

2. The behavioral subscale of the AES significantly predicted semantic fluency performance before the Bonferroni correction (β = −.157; p = .027). However, after the Bonferroni correction had been implemented, the behavioral subscale did not significantly predict semantic fluency performance.

Additional information

Funding

This study was supported by the Heart and Stroke Foundation (R.H.S.) [grant number 000392]; and the Canadian Institute of Health Research (R.H.S.) [grant number 1012404]. RHS receives salary support from a New Investigator Award and the H.J. Barnett Award from the Heart and Stroke Foundation of Canada, the Canadian Partnership for Stroke Recovery, the Department of Medicine (Sunnybrook Health Sciences Centre and University of Toronto), and the Brill Chair in Neurology at Sunnybrook Health Sciences Centre.