Neuropsychological Rehabilitation

ISSN: 0960-2011 (Print) 1464-0694 (Online) Journal homepage: http://www.tandfonline.com/loi/pnrh20

Apathy after acquired brain impairment: A

systematic review of non-pharmacological
interventions

A. T. Lane-Brown & R. L. Tate

To cite this article: A. T. Lane-Brown & R. L. Tate (2009) Apathy after acquired brain impairment:
A systematic review of non-pharmacological interventions, Neuropsychological Rehabilitation, 19:4,
481-516, DOI: 10.1080/09602010902949207

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NEUROPSYCHOLOGICAL REHABILITATION
2009, 19 (4), 481– 516

Apathy after acquired brain impairment: A systematic

review of non-pharmacological interventions

A. T. Lane-Brown and R. L. Tate

Rehabilitation Studies Unit, University of Sydney, Australia and Royal
Rehabilitation Centre, Sydney, Australia

Apathy commonly occurs after acquired brain impairment. It is characterised

by impaired initiative, diminished activity, and lack of concern; formally deli-
neated as a decrease in cognitive, behavioural and emotional components of
goal-directed activity. The impact is widespread, hampering rehabilitation
and outcome. This systematic review identifies and assesses the efficacy of
non-pharmacological treatments for apathy following four types of acquired
brain impairment (traumatic brain injury, dementia, cerebrovascular accident,
encephalitis). Nine databases were searched. Studies were reviewed according
to the following criteria: age over 16 years, acquired brain impairment,
non-pharmacological intervention for apathy, and data reported on treatment
efficacy. The methodological quality of the studies was assessed. Searches
yielded 1754 articles, with 28 meeting criteria. Methodological quality
ranged greatly. The majority of trials involved the dementia population. Cog-
nitive interventions were the most frequent mode of treatment. For those
with severe impairments, the strongest evidence suggested music therapy and
for milder impairment, the strongest evidence was for cognitive rehabilitation.
This review reveals a need for more high quality, methodologically rigorous
treatment studies for apathy, particularly within the milder ranges of impair-
ment. Initially, however, a uniform operational definition needs to be utilised
in all research studies to minimise variability. Additionally, employing a

Correspondence should be sent to Amanda Lane-Brown, Rehabilitation Studies Unit, PO Box 6,

Ryde NSW 1680, Australia. E-mail: amandal@med.usyd.edu.au
This study was supported by the University of Sydney and funding has been provided by the
Rehabilitation Studies Unit, University of Sydney; the Northern Medical Research Foundation
and the Northern Clinical School, University of Sydney; and the Australian Government
through an Australian Postgraduate Award.

# 2009 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurorehab DOI:10.1080/09602010902949207
482 LANE-BROWN AND TATE

standardised outcome measure specific to apathy would greatly enhance com-

parison among treatments.

Keywords: Apathy; Traumatic brain injury; Dementia; Cerebrovascular acci-

dent; Hydrocephalus.

INTRODUCTION
Apathy is characterised by a substantial decrease in activity, reduced initiation,
and diminished concern (Marin & Chakravorty, 2005); more formally deli-
neated as a decrease in overt behavioural, emotional and cognitive components
of goal-directed behaviour (Marin, 1991). This decrease is not the result of
intellectual impairment, decreased level of consciousness (such as a minimally
conscious state), or emotional distress (such as depression) (Marin, 1990).
Duffy (2006) further differentiates apathy from akinesia, fatigue and substance
abuse. Apathy is described as one of the most troublesome syndromes met by
clinicians working in the area of neuropsychiatric disorders (McAllister,
2000). Evidence indicates it greatly hampers rehabilitation efforts, coping
skills (Finset & Andersson, 2000), independence and vocational outcome
(Mazaux et al., 1997).
Apathy exists on a continuum of disorders of diminished motivation:
apathy is at the end of lesser severity and is distinguished from the intermedi-
ate level, abulia, by degree of impairment and involvement of language.
Abulia is the lack, rather than the diminution, of components of goal-directed
behaviour in combination with severely impaired ability to communicate.
When abulia worsens it becomes akinetic mutism, the most severe of the dis-
orders of diminished motivation (Marin & Wilkosz, 2005). Akinetic mutism
is the total absence of speech or movement in the presence of visual tracking
(American Congress of Rehabilitation Medicine, 1995).
Apathy is a relatively common phenomenon following neurological
damage. Given that prevalence rates vary markedly across the literature,
the following represents moderate prevalence rates calculated by van
Reekum, Stuss, and Ostrander (2005) through summarising all data derived
from systematic literature searches, except where stated. These searches
indicate that 61.4% of the traumatic brain injury population have apathy.
Within the dementia population, apathy is present in 60.3% of patients
with Alzheimer’s disease, 33.8% with vascular dementia and 51% with Par-
kinson’s disease (Kirsch-Darrow, Fernandez, Marsiske, Okun, & Bowers,
2006). After a cerebrovascular accident 34.7% are reported to have apathy.
Interventions for apathy can be conveniently divided into pharmacological
and non-pharmacological treatments. Pharmacological interventions com-
prise stimulants (e.g., methylphenidate) (Chatterjee & Fahn, 2002), dopamine
 INTERVENTIONS FOR APATHY 483

agonists (e.g., amantadine, selegiline) (Newburn & Newburn, 2005; van

Reekum et al., 1995), and acetylcholinesterase inhibitors (e.g., donepezil,
galantamine) (Tenovuo, 2005). An advantage of non-pharmacological inter-
ventions is that they provide behavioural strategies that can be maintained
after cessation of formal treatment. Additionally, while the patient with
apathy is at the lesser end of severity of the disorders of diminished motiv-
ation, non-pharmacological strategies can decrease reliance on medications
for people who may already have complex medical histories and multiple
co-morbid conditions. There are a number of reviews that comprehensively
cover references for pharmacological treatments (e.g., Boyle & Malloy,
2003; Campbell & Duffy, 1997) but few available that systematically
review non-pharmacological interventions. Accordingly, the remainder of
this paper will focus on non-pharmacological interventions for apathy.
We previously conducted a Cochrane systematic review evaluating
pharmacological and non-pharmacological interventions for apathy after
traumatic brain injury (Lane-Brown & Tate, 2009). Due to the requirements
of the Cochrane collaboration, the review included only studies of the most
rigorous methodological design, randomised controlled trials (RCTs). Evi-
dence on which to base treatment was inadequate with a single trial
meeting inclusion criteria. This trial provided no evidence for cranial electro-
therapy stimulation decreasing inertia, a behavioural component of apathy
(Smith, Tiberi, & Marshall, 1994).
Through our searches, we were aware of treatment studies not meeting
criteria for the aforementioned Cochrane review. This was supported by
non-systematic reviews of treatment options available for apathy (Marin &
Wilkosz, 2005; Roth, Flashman, & McAllister, 2007) that also referred to
other intervention studies for apathy. Thus, the present paper aimed to syn-
thesise systematically the evidence available for treatment for apathy
within the four main neurological populations utilising all research designs
including non-randomised controlled trials (non-RCTs) and other methodo-
logical designs (case series and single-subject designs).

METHOD

Criteria for selecting studies for this review

Included trials met the following criteria: (1) examined and reported data on
the impact of a non-pharmacological intervention for apathy or any com-
ponent of apathy; (2) human participants; (3) one of the following neurological
conditions was present: traumatic brain injury, dementia, cerebrovascular
accident or encephalitis; (4) participants were older than 16 years; and (5)
trials were reported in the English language. Apathy, or a component
484 LANE-BROWN AND TATE

thereof, must be the result of the acquired brain impairment. Thus reports of
treatments for diminished motivation occurring because of depression, delir-
ium, lowered levels of consciousness, fatigue or substance abuse were not
included. Multiple acquired brain impairments were included in this review
because it has been shown that treatments can be utilised successfully
across neurological populations, for example the case of memory treatments
initially developed for patients with closed head injury being successfully
applied to patients from other neurological populations (e.g., encephalitis
and hypoxia) (Glisky & Schacter, 1988). All empirical study designs were
included as follows: RCTs, non-RCTs, case series, and single-subject designs.
Although the construct of apathy incorporates three components, behav-
ioural, cognitive and emotional, often research focuses on only one of these
components. Therefore, included trials must have demonstrated the efficacy
of the intervention by having reported data on an outcome measure either
for a component of apathy or used a condition-specific measure of the
apathy syndrome (for example, the Apathy Evaluation Scale; Marin,
Biedrzycki, & Firinciogullari, 1991). Behavioural components of apathy
refer to the person’s engagement and performance in activities. Measures
included scales or subscales measuring activity, activity level, responsiveness
to stimuli, initiative, effort, level of engagement in a given activity, pro-
ductivity, passivity, appropriate cessation of activity, social withdrawal and
participation in activities. Cognitive components investigated included
initiation, ability to sustain behaviour, maintain on task and generativity.
Emotional components considered included indifference, diminished
concern and flattened affect. Types of outcome measures included in the
review were neuropsychological tests, psychological tests, behavioural obser-
vation, self or observer report, psychological rating scales and questionnaires.

Search strategy for identification of studies

The most current search was conducted on 26 March, 2008. Relevant studies
were identified from the following nine electronic bibliographic databases:
Medline, PsycINFO, Psychological Database for Brain Impairment Treatment
Efficacy (PsycBITE), Allied and Complementary Medicine (AMED), Cumu-
lative Index to Nursing and Allied Health Literature (CINAHL) and all
Cochrane databases – Database of Systematic Reviews (DSR), ACP Journal
Club, Database of Abstracts of Review of Effects (DARE) and Cochrane
Central Register of Controlled Trials (CCTR). Search strategies used a combi-
nation of Medical Subject Headings (MeSH) and keywords that represented
any one of four acquired brain impairments (traumatic brain injury, dementia,
cerebrovascular accidents or encephalitis), apathy and interventions. Full
search strategy terms can be found in Appendix 1. Other resources searched
 INTERVENTIONS FOR APATHY 485

for studies that met inclusion criteria were reference lists of all included trials,
key publications, and the authors’ personal collections.

Ratings of methodological quality

Studies that met selection criteria were initially categorised by methodological
design. Given that not all studies within a single design are equally rigorous
(Perdices et al., 2006), additional assessments of methodological quality were
conducted. RCTs, non-RCTs and case series were assessed using the PEDro
rating scale (Maher, Sherrington, Herbert, Moseley, & Elkins, 2003). This
rating scale was developed specifically for the assessment of bias within
RCTs for physical therapy and has since been used to assess psychological inter-
ventions (Tate et al., 2004). It comprises 11 items as follows: participant eligi-
bility criteria and source specified, random allocation of participants to
interventions, allocation concealed, intervention groups similar at baseline
regarding key outcome measures and important prognostic indicators, blinded
subjects, blinded therapists who administered the intervention, blinded asses-
sors who measured at least one key outcome, dropouts (attrition bias), intention
to treat analysis, reported between group statistical comparisons, and reported
measures of variability. Each item was evaluated and totalled to give a total
score out of 10 (items 2 to 11). Trials were then qualitatively described accord-
ing to PEDro scores as follows: a score of 7 or greater was “high” quality, a score
of 5 or 6 was “moderate” quality and a score of 4 or less was “poor” quality
(Harvey, Herbert, & Crosbie, 2002). All single-case experimental designs and
case studies were assessed using the Single-Case Experimental Design
(SCED) scale (Tate et al., 2008). This scale was developed to assess methodo-
logical quality and possible sources of bias within single-subject designs. It
comprises 11 items as follows: participant clinical history specified, precise
and repeatable target behaviour operationally defined, three phases or multiple
baseline design, sufficient baseline sampling, sufficient treatment phase
sampling, data points reported, inter-rater reliability established for at least
one measure of target behaviour, independence of assessors, statistical analysis
conducted, replication of results, and evidence of generalisation. Each item was
evaluated and tallied to give a total score out of 10 (items 2 to 11), with a higher
score indicative of higher methodological quality and lower levels of bias.

Procedure
Results of database searches were imported into and tracked by a reference man-
agement system (EndNote). Titles and abstracts were reviewed to assess if they
met criteria for inclusion. If there was not sufficient information in the title and
abstract, full text copies of articles were obtained. Trials reported only as abstracts
were included if sufficient information was available from the report to fulfil the
inclusion criteria and extract data. Full text articles of all trials meeting inclusion
486 LANE-BROWN AND TATE

criteria were obtained. Data from each report were extracted, consisting of
the following: study population, sample size, living situation of participants,
intervention type, outcome variables relevant to the measurement of apathy,
component of apathy measured, and results of statistical analyses for apathy com-
ponent. It was additionally noted if the authors provided information on
reliability and validity of their outcome measures. The trials was classified by
study design and rated for methodological quality. The size of the between-
group treatment effect was recorded when reported or calculated where possible
using Cohen’s d (Cohen, 1988). The treatment effect was small if Cohen’s d was
around 0.2, moderate at 0.5 and large at 0.8 or above (Cohen, 1988). Cohen’s d
was calculated only for the treatment effect on apathy or the component of apathy
measured. If more than one component of apathy was reported, the effect size for
each component reported was calculated. If there were more than two treatment
groups, the effect calculated was for the experimental treatment and the no-
treatment control group. Given the high rate of comorbidity and overlapping
symptomatology between apathy and emotional distress, particularly depression
(Kant, Duffy, & Pivovarnik, 1998), trials were reviewed for measurement of
emotional distress to assist in assessing specificity of treatment results.
In order to achieve some degree of homogeneity among studies, they were
grouped by severity of functional impairment, as indicated by type of residential
placement and amount of caregiver support. The severe group included studies
where participants either resided in an inpatient rehabilitation unit, residential
care or a nursing home, or lived at home with a caregiver and were described
as having a severe level of impairment. The milder group was defined as
mild or moderate, irrespective of place of residence or caregiver, or if they
lived at home without a caregiver. If studies included participants from both
the severe and milder groups, they were classed as “mixed severity group”.

RESULTS
Results of electronic searches yielded 1754 references. Based on the titles and
abstracts, 217 articles were found that potentially met inclusion criteria. Full
text versions of these articles were reviewed for inclusion. Twenty-eight
studies were identified that met inclusion criteria. Data extracted from the
included trials are presented in Table 1. A meaningful meta-analysis was
not possible due to considerable heterogeneity in types of treatment, clinical
group, focus of outcome measures and methodological quality.

All trials
Neurological populations varied across studies, with the majority of included
trials (21 studies, 75%) investigating treatments in the dementia population.
Four (14%) studies involved the traumatic brain injury population, two
 TABLE 1
Summary of included studies

Outcome measure
relevant to apathy.
States Author provides Measure for Results/
PEDro (P) treatment information on apathy or Follow-up Effect size
Study /SCED (S) is for Severity reliability and/or component of relevant to for apathy
Study design score Intervention apathy Participants Group validity (yes/no) apathy apathy measure

Chapman RCT 6/10 (P) 2 groups; No Alzheimer’s Mild NPI – apathy Apathy 1. Non-significant trend 0.45
et al., 1. Donepezil disease subscale found for group x time
2004 (acetylcholinesterase N ¼ 54 (caregiver rating) interaction (p ¼ .062)
inhibitor) alone Living at home (no) 2. Change scores for the
2. Donepezil and donepezil and
cognitive- cognitive-
communication communication
treatment treatment approached
significance suggesting
Duration ¼ 1.5hrs/ reduced apathy over
session, 1 session/week time
for 8 weeks

(Table continued )
 TABLE 1
Continued

Outcome measure
relevant to apathy.
States Author provides Measure for Results/
PEDro (P) treatment information on apathy or Follow-up Effect size
Study /SCED (S) is for Severity reliability and/or component of relevant to for apathy
Study design score Intervention apathy Participants Group validity (yes/no) apathy apathy measure

Holmes RCT 6/10 (P) 3 groups; Yes Dementia Severe Dementia care Component – Live music was 1.48
et al., 1. Live music N ¼ 32 mapping (yes) engagement associated with greater (between live
2006 2. Pre-recorded music Residential and numbers of subjects music and
3. Silence nursing homes showing positive silence)
engagement compared
Duration ¼ 30 mins of to silence for overall
each treatment given to levels of severity,
each participant over 1.5 moderate severity alone
hours and severe severity
alone. In all levels of
severity cases
combined, moderate
severity alone and
severe cases, the number
of subjects showing
positive engagement to
pre-recorded music was
no significantly greater
than when exposed to
silence. In levels of
severity and the severe
cases alone live music
was associated with
significantly greater
positive engagement
than pre-recorded
music.
Politis RCT 6/10 (P) 2 groups; Yes Dementia Severe NPI – Apathy Apathy and Significant decrease in – 0.36
et al., 1. Standardised, N ¼ 37 score (no). Copper component – apathy in both groups.
2004 structured activity kits Residential facility Ridge Activity participation Kit group showed stable
2. One on one time and Index (yes) participation over time,
attention while the attention
group showed a
Duration ¼ 30 mins/ decrease in
session, 3 sessions/week participation.
for 4 weeks
Smith RCT 6/10 (P) 3 groups; No TBI Severe Profile of Mood Component – Cranial electrotherapy – 0.27 (between
et al., 1. Cranial electrotherapy N ¼ 21 States – fatigue/ inertia stimulation group CES and no
1994 stimulation Residential care inertia subscale showed significant treatment)
2. Sham treatment facility (no) improvement in
3. No treatment fatigue/inertia after
treatment. There was no
Duration ¼ 45 mins/ post-treatment
session, 4 sessions/week difference seen in the
for 12 weeks sham or no treatment
groups compared to
pre-treatment.
Baker RCT 5/10 (P) 2 groups; No Dementia Severe INTERACT (yes), Components – Immediate effects of Initiative ¼ 0.21
et al., 1. Multi-sensory N ¼ 50 REHAB (yes) initiative, both treatments were Activity
2001 stimulation (MSS) Living at home activity level, doing more from own level ¼ – 0.23
2. Activity control group with carer initiation of initiative, more active/ Speech initiation
speech alert, less bored/ ¼ 6.897e22
Duration ¼ 30 mins/ inactive. MSS group
session, 2 sessions/week was more attentive to
over 4 weeks environment and
activity group showed
increased amount and
initiation of speech

(Table continued )
 TABLE 1
Continued

Outcome measure
relevant to apathy.
States Author provides Measure for Results/
PEDro (P) treatment information on apathy or Follow-up Effect size
Study /SCED (S) is for Severity reliability and/or component of relevant to for apathy
Study design score Intervention apathy Participants Group validity (yes/no) apathy apathy measure

Finnema RCT 5/10 (P) 2 groups; No Dementia Severe BIP Apathetic Apathy BIP Apathetic – 0.04
et al., 1. Usual care N ¼ 146 Behaviour Score Behaviour Score
2005 2. Integrated emotion- Nursing homes (no) showed a non-
oriented care plus usual significant difference
care between groups

Duration ¼ Nine
months
Baker RCT 4/10 (P) 2 groups; No Dementia Severe INTERACT (yes), Apathy and Both groups related to Pooled data for
et al., 1. Multi-sensory N ¼ 136 CAPE (no), Components – others better and were entire sample
2003 stimulation (MSS) Living at home REHAB (yes) activity level, less inactive than before not reported
2. Activity control group with carer initiative, the session, Activity
initiation of group was more
Duration ¼ 30mins/ speech attentive. One month
session, 2 sessions/week post treatment activity
over 4 weeks level had decreased
from post-treatment.
For participants with
severe dementia the
MSS group were
significantly less
apathetic post trial
Baker RCT 3/10 (P) 2 groups; No Dementia Severe REHAB (yes), component – Snoezelen group had Data not reported
et al., 1. Snoezelen (multi- N ¼ 31 INTERACT (no) initiative, significantly improved
1997 sensory stimulation) Living at home activity level, social behaviour
group with carer initiation of including doing more
2. Activity group speech from their own initiative
and talking
Duration ¼ 30mins/ spontaneously.
session, 2 sessions/week
over 4 weeks
Hozumi RCT 3/10 (P) 2 groups; No Multi-infarct Severe Clinical evaluation Apathy Treatment group had – 0.31
et al., 1. Transcranial dementia (no) (specifically, significantly more
1996 electrostimulation N ¼ 27 motivation) increases in motivation
2. Placebo Residence not than the placebo group
specifically stated,
Duration ¼ 20 mins/ appears to be
session, daily for 2 residential facility
weeks
Rusted RCT 3/10 (P) 2 groups; No Dementia Mixed MOSES – Component – The art group showed a Data in
et al., 1. Art therapy group N ¼ 45 severity sociability and withdrawn within session increase graphical
2006 2. Activity therapy group Day care and group withdrawn scale behaviour in sociability over time form only
(excluding art and craft) residential facility (no). Bond-Lader while the activity group
Mood Scale – showed a decrease. No
Duration ¼ 1hr/ “Sociability” (no) change outside session
session, 1 session/week times
for 40 weeks

(Table continued )
 TABLE 1
Continued

Outcome measure
relevant to apathy.
States Author provides Measure for Results/
PEDro (P) treatment information on apathy or Follow-up Effect size
Study /SCED (S) is for Severity reliability and/or component of relevant to for apathy
Study design score Intervention apathy Participants Group validity (yes/no) apathy apathy measure

Fitzsimmons RCT 2/10 (P) 2 groups; Yes Dementia Severe Passivity in Component – Within subjects analysis Data not reported
and 1. Cooking programme N ¼ 12 Dementia Scale passivity, reported post-treatment
Buettner, 2. Waitlist control Residential facility (no), Staff ratings engagement, decreases in passivity
2003 (no) participation after cooking treatment.
Duration ¼ 1 hr/ No between subjects
session, 5 days/week for statistics reported.
2 weeks Engagement was rated
at 90.4% during
cooking and subjects
actively participated in
119/120 intervention
sessions.
von Cramon Non- 3/10 (P) 2 groups; No Mixed brain injury Mild Behavioural aspect Component – Problem solving Data not reported
et al., RCT 1. Problem-solving (TBI, CVA, other) of rating scale – goal-directed training participants
1991 training N ¼ 61 Lack of goal- ideas were rated as having an
2. Memory training Inpatient directed ideas (no) observable decrease in
Rehabilitation Unit abnormalities in goal-
Duration ¼ 25 sessions directed ideas. A
over 6 weeks significant number of
problem solving
training participants
showed an
improvement in goal-
directed ideas, while the
memory training group
did not show a
significant number of
participants improving.
Droes Non- 3/10 (P) 2 groups; No Dementia Mixed Assessment Scale Component – Experimental group had – 0.37
et al., RCT 1. Support programme N ¼ 122 severity for Elderly Patients activity level significantly less
2004 with carers – including a Day care facility (yes), Behavioural increase in inactivity
social club, information Observation Scale than the control group
meetings and discussion for Intramural
groups for carers Psychogeriatrics
2. Regular day care (yes)

Duration ¼ Support
group had social club 3/
week, 8 – 10 information
meetings and 2/week
discussion groups for 7
months. Regular day
care over 7 months
Sherratt Non- 3/10 (P) 4 treatments; No Dementia Mixed Continuous Time Component – Live music was Activity ¼ 0.81
et al., RCT 1. No music N ¼ 29 Sampling - activity activity level, significantly more (between no music
2004 2. Taped commercial Day hospital and (yes) engagement effective in increasing and live music)
music continuing care engagement regardless
3. Taped music played ward of level of cognitive
by a musician impairment. Recorded
4. Live music music decreased time
spent engaged in
Duration ¼ 1 hour/ meaningless activity,
session, unknown total but live music was more
sessions. All participants effective
observed for each
treatment over a 3 month
period

(Table continued )
 TABLE 1
Continued

Outcome measure
relevant to apathy.
States Author provides Measure for Results/
PEDro (P) treatment information on apathy or Follow-up Effect size
Study /SCED (S) is for Severity reliability and/or component of relevant to for apathy
Study design score Intervention apathy Participants Group validity (yes/no) apathy apathy measure

Gigliotti Non- 2/10 (P) 2 groups; No Dementia Mild Observer Component – Decreased levels of 4.84
et al., RCT 1. Horticultural therapy N ¼ 14 behaviour coding engagement non-engagement during
2004 (planting, cooking, craft) Adult day service (no) Horticultural Therapy
2. Traditional Adult Day compared to Traditional
Service control group Services
(cognitive games,
exercise, current events
discussion)

Duration ¼ 30mins/
session, 1 session/week
for 9 weeks
Olderog- Non- 2/10 (P) 2 groups No Dementia (majority Severe Behaviour Component – 1. Significantly higher Data not
Millard RCT 1. Discussion group Alzheimer’s) mapping with participation, vocal and verbal reported
& Smith, 2. Singing group N ¼ 10 behaviour social behaviour participation in singing
1989 Residential facility observation sessions.
Duration ¼ 2 sessions/ checklist (no) 2. Significantly more
week, 30 mins/session, walking with others
5 weeks of sessions before, after and during
singing sessions than in
discussion sessions
Hope, 1998 CS 1/10 (P) Multisensory No Dementia Mixed Interact (no), Component – 4.4% increased doing N/A
environment N ¼ 29 Qualitative initiative, things from their own
Residential care behavioural activity level initiative. Increase in
Duration ¼ unknown. unit and day care observation (no) 26.7% becoming more
45 separate sessions (1 to active, and 64.4% were
4 sessions/participant). not bored/inactive
84.5% of sessions lasted
20 mins or more
Mickus CS 1/10 (P) “PRIDE” bathing No Dementia Severe NPI – Apathy Apathy 2 patients (out of the 5 N/A
et al., 2002 (Privacy, Reassurance, N ¼ 27 subscale (no) that displayed apathy)
Information, Distraction, Residential care improved. This was not
Evaluation) statistically significant.

Duration ¼ Each bath

for 1 – 2 months
Altus et al., CS 0/10 (P) “Family style” meals (B) No Dementia moderate Severe Behavioural Component – Family style N/A
2002 and “Family style” to severe observation during participation meals
meals with education N ¼ 5 lunchtime on increased
session about Residential care participation (no) participation.
appropriate behaviour unit Family style meal
(B’). with an education
session lead to
Duration ¼ 4 large increases in
lunchtimes. Sequentially participation
1 lunchtime baseline
(prepared plates), 1
lunchtime family meal, 1
lunchtime baseline, 1
lunchtime family meal
and education.

(Table continued )
 TABLE 1
Continued

Outcome measure
relevant to apathy.
States Author provides Measure for Results/
PEDro (P) treatment information on apathy or Follow-up Effect size
Study /SCED (S) is for Severity reliability and/or component of relevant to for apathy
Study design score Intervention apathy Participants Group validity (yes/no) apathy apathy measure

Burke et al., SSD 8/10 (S) Self-initiation checklist No TBI Mild Number of verbal Component – Number of verbal cues N/A
1991 Study 2 with tasks in sequential N ¼ 3 cues required to initiation required to initiate
order Residential complete set tasks decreased to zero with
rehabilitation at work (no) results maintained after
Duration ¼ checklist facility and in checklist withdrawn for
present for between 4 – community two subjects,
12 days of treatment improvement for third
before removed subject with checklist
and some improvement
maintained after
withdrawal
Evans et al., SSD 7/10 (S) Neuropage paging No CVA Mild Task completion Component – Task 1 to 3 ¼ good N/A
1998 system (for Tasks 1 – 5) N ¼ 1 for 1. Taking initiation response to treatment
and checklist (for Residing in medication, measured
Task 6) community 2. Watering plants, Task 4 and
3. Washing 5 ¼ Spouse reported
Duration ¼ pager underwear, good response
introduced for 3 months, 4. Attending job, Task 6 ¼ successful
removed for 3 weeks and 5. Planning meal, response to treatment
then reintroduced 6. Decreasing bath
time (no)
Sohlberg SSD 6/10 (S) External cuing to initiate No TBI, severe Mild Observer rating of Component – On average verbal N/A
et al., 1988 verbally in a group and N ¼ 1 verbal initiation initiation initiation increased
acknowledge others Day treatment and response from 1.8 times per
responses programme acknowledgement session to 10.8 times.
(yes) After external
Duration ¼ 9 group compensation was
therapy sessions (from removed initiation
graphs) decreased to 6.1 times
per session. Response
acknowledgement
increased from 4.7
times per session to 14
times per session
Spaull et al., SSD 5/10 (S) Free format sensory No Dementia Severe Modified Component – During session N/A
1998 stimulation (Snoezelen). N ¼ 4 Behaviour Rating withdrawal, significant increase in
Continuing care Scale (no), Short participation interaction, active
Duration ¼ Session ward Form Adaptive looking and interest.
time unknown (at least Behaviour Scale This was not maintained
20 mins), 12 sessions (no), Dementia after the session
total over “several” Care Mapping (no)
weeks
Johnson, SSD 4/10 (S) Memory notebook. No Dementia Severe MOSES - Component – No significant change N/A
1997 N ¼ 4 withdrawn engagement, for apathy components
Duration ¼ 30 mins/ Personal care behaviour (no). withdrawn
session, 2 group facility Qualitative staff behaviour
sessions/week for 4 report (no)
weeks

(Table continued )
 TABLE 1
Continued

Outcome measure
relevant to apathy.
States Author provides Measure for Results/
PEDro (P) treatment information on apathy or Follow-up Effect size
Study /SCED (S) is for Severity reliability and/or component of relevant to for apathy
Study design score Intervention apathy Participants Group validity (yes/no) apathy apathy measure

Adam et al., SSD 3/10 (S) Visually restructured Yes Alzheimer’s Mild Number of knitted Apathy 1. Increased numbers of N/A
2000 knitting pattern. disease stitches per 30 stitches in 30 mins,
N ¼ 1 mins. Time spent 2. Increased time spent
Duration ¼ 2 sessions/ Residing at home knitting at home knitting from 45 mins/
week, half day/session (no). NPI - Apathy week to 18 hrs/week,
for 3 months (no) 3. NPI score no longer
indicative of apathy
after 3 months
rehabilitation
DePoy et al., SSD 3/10 (S) 2 treatments; No TBI Mild Tinker Toy Test Component – Ss 1 – No change in N/A
1990 1. Computerised N ¼ 2 (initiation and initiation initiation
cognitive retraining Rehabilitation unit overall executive Ss 2 – Increase in
2. Paper and pencil functioning) (no), initiation
cognitive retraining Initiation Log (no)

Duration ¼ 1 hr/
session, daily for 3
weeks
Macauley, SSD 2/10 (S) 2 treatments; No Left hemisphere Mild Questionnaire Apathy Participants were more N/A
2006 1. Traditional speech – CVA measuring (Motivation) motivated to attend
language therapy N ¼ 3 participants’ AAT than traditional
2. Animal assisted Outpatients at motivation towards speech – language
therapy (AAT) with Speech and Hearing the therapy session therapy
traditional speech – Centre (no)
language therapy

Duration ¼ 30mins/
session, 1 session/week
for 12 weeks
Graff et al., SSD 0/10 (S) Occupational therapy at No Dementia Mild Occupational Component – Qualitative increase in N/A
2006 home N ¼ 1 therapy assessment initiative initiative and
Residing at home including the quantitative
Duration ¼ 10 sessions Interview of improvement in daily
over 5 weeks. Deterioration of performance including
Daily Activities in an increase in initiative
Dementia –
Initiative subscale
(yes)


Note: Trials are ordered first by study design, then by PEDro/SCED score, then by first author in alphabetical order.
RCT ¼ randomised controlled trial, Non-RCT ¼ non-randomised controlled trial, CS ¼ case series, SSD ¼ single-subject design, MSS ¼ multi-sensory
stimulation, TBI ¼ traumatic brain injury, CVA ¼ cerebrovascular accident, NPI ¼ Neuropsychiatric Inventory, CAPE ¼ Clifton Assessment Procedures for
the Elderly, MOSES ¼ The Multi Observational Scale for the Elderly.
500 LANE-BROWN AND TATE

(7%) consisted of participants who had sustained a cerebrovascular accident

and one (4%) study had a mixed brain injury population.
Type of intervention ranged greatly across the 28 trials. Cognitive inter-
ventions were the most common, with eight (29%) trials. Five (19%) trials
examined the effect of multisensory environments. Three (11%) studies
explored interventions that involved activities of daily living (such as
cooking, bathing and eating meals), three (11%) used an omnibus therapeutic
approach, three (11%) utilised music therapy, two (7%) examined cranial
electrotherapy stimulation. Other types of interventions were horticultural,
art therapy, animal assisted therapy and structured activity kits. Four
(14%) of the 28 studies explicitly stated that the intervention targeted
apathy (Adam, Van der Linden, Juillerat, & Salmon, 2000; Fitzsimmons &
Buettner, 2003; Holmes, Knights, Dean, Hodkinson, & Hopkins, 2006;
Politis et al., 2004), although the mode of intervention varied, including
structuring cognitive tasks, cooking, music therapy and structured activity
kits, respectively. All four involved the dementia population.
A range of outcome measures was included. Both cognitive and behavioural
components of apathy were measured, although no study evaluated emotional
components of apathy. The most commonly measured components of apathy
were initiation/initiative (12 studies, 43%) and activity level (6 studies, 21%).
Other components of apathy measured were participation (5 studies, 18%),
social/withdrawn behaviour (4 studies, 14%), engagement (4 studies, 14%),
and goal-directed ideas, inertia and passivity (1 study each, 4%) (multiple com-
ponents of apathy may have been measured within a single trial). Eight (29%)
studies utilised measures specific to the apathy condition, for example, the
Apathy domain of the Neuropsychiatric Inventory (Cummings, 1994).
Methodological quality of included trials was variable. There were 11 RCTs,
five non-RCTs, three case series and nine single-subject designs. PEDro scores
ranged from poor quality (0/10) to moderate quality (6/10), with a mean score
of 3.4/10 (SD ¼ 1.9). Four trials received a PEDro score of 6/10, all RCTs
(Chapman, Weiner, Rackley, Hynan, & Zientz, 2004; Holmes et al., 2006;
Politis et al., 2004; Smith et al., 1994). The single-subject designs also ranged
in methodological quality, indicated by scores on the SCED scale ranging
from 0/10 to 8/10, with a mean score of 4.2/10 (SD ¼ 2.5). Three studies
from this group received a score of 6/10 or higher (Burke, Zencius, Wesolowski,
& Doubleday, 1991; Evans, Emslie, & Wilson, 1998; Sohlberg, Sprunk, & Met-
zelaar, 1988). Full details of the PEDro and SCED ratings are presented in Table 2
for RCTs, non-RCTs and case series, and Table 3 for single-subject designs.

Severity subgroups
Following data extraction, studies were grouped by level of severity of func-
tional impairment. Fourteen studies investigated the severe ranges of
 TABLE 2
PEDro ratings of methodological quality of RCTs, non-RCTs and case series (CS)

von Olderog-
Chapman Holmes Politis Smith Baker Finnema Baker Baker Hozumi Rusted Fitzsimmons Cramon Droes Sherratt Gigliotti Millard Mickus Altus
et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., & Buettner, et al., et al., et al., et al., & Smith, Hope, et al., et al.,
Criterion 2004 2006 2004 1994 2001 2005 2003 1997 1996 2006 2003 1991 2004 2004 2004 1989 1998 2002 2002

Study design RCT RCT RCT RCT RCT RCT RCT RCT RCT RCT RCT Non- Non- Non- Non- Non- CS CS CS
RCT RCT RCT RCT RCT
1. Eligibility criteria No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes
were specified
2. Participants Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No No No No No No No No
randomly allocated to
interventions
3. Allocation was Yes No No No No Yes No No No No No No No No No No No No No
concealed
4. Intervention No Yes No No No Yes No No No No No No Yes Yes No No No No No
groups were similar
at baseline regarding
key outcome
measure(s) and most
important prognostic
indicators
5. There was blinding No No No Yes No No No No No No No No No No No No No No No
of all participants
6. There was blinding No No No Yes No No No No No No No No No No No No No No No
of all therapists
7. There was blinding Yes Yes Yes Yes No No No No No No No No No No No No No No No
of all assessors who
measured at least one
key outcome

(Table continued )
 TABLE 2
Continued

von Olderog-
Chapman Holmes Politis Smith Baker Finnema Baker Baker Hozumi Rusted Fitzsimmons Cramon Droes Sherratt Gigliotti Millard Mickus Altus
et al., et al., et al., et al., et al., et al., et al., et al., et al., et al., & Buettner, et al., et al., et al., et al., & Smith, Hope, et al., et al.,
Criterion 2004 2006 2004 1994 2001 2005 2003 1997 1996 2006 2003 1991 2004 2004 2004 1989 1998 2002 2002

8. Measures of at No Yes Yes Yes Yes No Yes Yes Yes No Yes Yes No No No Yes Yes Yes No
least one key
outcome were
obtained from more
than 85% of the
participants initially
allocated to groups
9. All participants for Yes No Yes No Yes No Yes No No No No No No No No No No No No
whom outcome
measures were
available received the
treatment or control
condition as allocated
or, where this was not
the case, data for at
least one key
outcome was
analysed by
“intention to treat”
10. The results of Yes Yes Yes No Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes No No No
between intervention
group statistical
comparisons are
reported for at least
one key outcome
11. The study Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes No No No No
provides both point
measures and
measures of
variability for at least
one key outcome
Total (Items 2 – 11) 6/10 6/10 6/10 6/10 5/10 5/10 4/10 3/10 3/10 3/10 2/10 3/10 3/10 3/10 2/10 2/10 1/10 1/10 0/10
 TABLE 3
SCED ratings of methodological quality of single-subject designs

Burke Evans Sohlberg Spaull Adam DePoy Graff

et al., et al., et al., et al., Johnson, et al., et al., Macauley, et al.,
Criterion 1991 1998 1988 1998 1997 2000 1990 2006 2006

1. Clinical history was specified Yes Yes Yes Yes Yes Yes Yes Yes Yes
2. Target behaviours. Precise and Yes Yes Yes Yes Yes Yes Yes Yes No
repeatable measures that are
operationally defined are specified.
3. There are three phases of the study Yes Yes Yes Yes Yes No No No No
design, either ABA or multiple
baseline
4. Sufficient baseline sampling was Yes Yes Yes No No No No No No
conducted
5. Sufficient treatment phase sampling Yes Yes Yes No No Yes No No No
was conducted
6. Raw data points were reported Yes Yes Yes No Yes Yes Yes No No

INTERVENTIONS FOR APATHY

7. Inter-rater reliability was established Yes No Yes Yes No No No No No
for at least one measure of target
behaviour
8. There was independence of assessors Yes No No No No No No No No
9. Statistical analysis was undertaken No Yes No Yes No No No No No
10. There was replication of results either Yes No No Yes Yes No Yes Yes No
across subject, therapist or setting
11. There was evidence for generalisation No Yes No No No No No No No
Total (Items 2– 11) 8/10 7/10 6/10 5/10 4/10 3/10 3/10 2/10 0/10

503
504 LANE-BROWN AND TATE

functional impairments, 10 studies examined the milder ranges of impairment

and four studies were of mixed severity, as indicated in Table 1. The severe
and milder subgroups are discussed below. Given the small number of trials
and variable findings within the mixed severity group, results are not dis-
cussed, although details are presented in Table 1.

Severe subgroup. Within the more severely impaired functional group,

all but one trial targeted the dementia population. In many cases the com-
ponent of apathy measured was behavioural – engagement in activity,
activity level or eliciting a verbal response.
Within the severe group, 9 of the 14 trials were RCTs. One non-RCT and
two case series were rated as having poor methodological quality, and two
single-subject designs had methodological quality ratings in the mid ranges
of the scale. Three of the nine RCTs did not report results of between-
group statistical analysis, thus it was not possible to determine if the experi-
mental intervention was more effective than the control intervention. The
remaining six RCTs that reported appropriate statistical analysis are
described below and the reader is referred to Table 1 for results of the remain-
ing eight studies within the severe group. All RCTs reported below included a
measure of emotional distress.
Three of the RCTs that did report between-group statistical analyses were
conducted by the same research group and investigated the effect of multi-
sensory stimulation in people with dementia (Baker et al., 2001, 2003;
Baker, Dowling, Wareing, Dawson, & Assey, 1997). The 2001 paper
obtained the highest PEDro methodological quality rating (5/10). This
study found that both multi-sensory stimulation and the activity control inter-
vention lead to greater activity and participants doing more from their own
initiative after intervention. The activity group increased significantly more
than the multisensory stimulation group in initiation of speech. The treatment
effect size was, however, small (d ¼ 6.897e22 to 0.23, see Table 1).
The remaining three RCTs that reported between-group statistical analyses
investigated music therapy (Holmes et al., 2006), structured activity kits
(Politis et al., 2004), and emotion-oriented care (Finnema et al., 2005) in
patients with dementia. Holmes and colleagues (2006) compared silence,
pre-recorded and live music. Level of engagement was measured by blind
assessors who rated video recordings of participants. Participants showed sig-
nificantly higher levels of engagement when listening to live music compared
to both silence and pre-recorded music. The size of the effect of treatment
with live music compared to silence was large (d ¼ 1.48). Politis and
colleagues (2004) utilised structured activity kits with five topics including
geography, fun foods, farm animals, vegetables and musical instruments.
The control group received a time and attention “one-on-one” control
where the therapist discussed and completed activities of the participant’s
 INTERVENTIONS FOR APATHY 505

interest in an unstructured manner. Apathy significantly decreased in both

groups indicating that either standardised activity kits or “one-on-one” time
with a therapist decreases apathy in this population. The size of the
between-group treatment effect was small (d ¼ – 0.36). The Finnema and
colleagues (2005) trial compared emotion-oriented care to usual care. Non-
significant differences were found between groups for measures of apathy.

Milder subgroup. Ten studies investigated treatments in the milder

ranges of functional impairment. The most frequently measured component
of apathy was initiation/initiative (5 studies, 18%). There were far fewer
methodologically rigorous controlled trials than in the severe subgroup, one
RCT, two non-RCTs and seven single-subject designs. Two studies (7%;
Adam et al., 2000; Graff et al., 2006) included specific measures of emotional
distress. The single RCT (Chapman et al., 2004) compared mild to moderate
Alzheimer’s patients prescribed donepezil (an acetylcholinesterase inhibitor)
with patients prescribed donepezil who also received cognitive-communi-
cation treatment. The cognitive-communication treatment focused on
verbal communication, functional activities of daily living and quality of
life. No between-group differences were found, although a non-significant
trend indicated decreased apathy over time in the donepezil and cognitive-
communication group. A medium treatment effect size was reported
(d ¼ 0.45).
Von Cramon, Matthes-von Cramon, and Mai (1991) reported a non-RCT
that assigned participants who had been rated as “poor problem solvers” to
a problem solving group or a memory training group. Trained ward staff be-
haviourally rated each participant on, inter alia, “lack of goal-directed ideas”
using a three-point scale for degree of impairment. A significant number
of participants in the problem solving group showed increased ratings
of goal-directed ideas, but this did not occur in the memory group. No
between-group analysis was conducted for this measure. It was not possible
to calculate the effect size for this outcome due to insufficient data provided.
Gigliotti, Jarrott, and Yorgason (2004) found that in the dementia population
“horticultural therapy” (gardening, cooking and craft activities) increased
engagement more than traditional adult day service activities, which included
cognitive games, exercise and discussion. The methodological quality of this
non-RCT was poor with a PEDro score of 2/10 and thus results should be
interpreted with caution.
Two of the single-subject designs for the less impaired group had SCED
ratings in the higher ranges of the scale, scoring eight and seven (Burke
et al., 1991; Evans et al., 1998), respectively. Burke and colleagues (1991)
introduced checklists with tasks in sequential order to improve self-initiation.
The three participants with traumatic brain injuries improved self-initiation
and required substantially decreased verbal cues to execute activities.
506 LANE-BROWN AND TATE

These improvements were maintained after removal of the checklist. Evans

and colleagues (1998) treated a participant who had sustained a cerebrovas-
cular accident. Treatment to increase behavioural initiation incorporated
the use of checklists and Neuropage, a mnemonic cueing system that involves
the participant wearing a pager and receiving alerts from a central computer.
With treatment, the participant was able to achieve set goals indicating a good
response to treatment.

DISCUSSION
The aim of this review was to identify and evaluate the effectiveness of inter-
ventions for apathy following acquired brain impairment. Twenty-eight trials
were included. Three-quarters of the trials examined interventions in the
dementia population. Mode of intervention varied greatly, with cognitive
interventions being the most common. Only four trials explicitly stated that
apathy was the target behaviour. All papers contained outcome measures
either for a component of apathy or utilised a condition-specific apathy
instrument to measure treatment effect. Eight papers measured apathy via a
condition-specific instrument, such as the Apathy subscale of the Neuropsy-
chiatric Inventory. The remaining 20 papers measured a component of
apathy. There were outcome measures for a wide range of behavioural and
cognitive components of apathy, but no emotional components. Methodo-
logical design and quality varied across the studies. It is promising to note
that 11 RCTs were identified, although only one targeted the milder ranges
of functional impairment.

Implications for clinical practice

By definition, apathy exists on a continuum of severity (Marin & Chakravorty,
2005). This range of severity was also observed in the studies of this review.
After examining the trials, it became apparent that the majority of papers
grouped into one of two levels of functional severity. Four papers spanned
all levels of severity. Before deciding on the most appropriate method of
treatment, the clinician is advised to assess the client’s level of functional
impairment.
Within the severe ranges of functional impairment, all but one of the
papers in the severe group focused on the dementia population. The strongest
evidence for treatment efficacy in this group is for music therapy. A large
treatment effect was found in an RCT of moderate quality, showing that
live music increases engagement significantly more than silence or pre-
recorded music (Holmes et al., 2006). There is also promising evidence to
indicate the usefulness of structured activity kits (Politis et al., 2004).
 INTERVENTIONS FOR APATHY 507

There is some limited evidence for multi-sensory stimulation environments

(Baker et al., 1997, 2001, 2003; Hope, 1998).
Within the mild to moderate ranges of functional impairment, the majority
of trials utilised cognitive interventions. However, the methodological quality
of trials was lower than the severe group. The majority of papers reported an
improvement in apathy with treatment, however given the methodological
limitations of these trials, results must be interpreted with caution. There
was one RCT within this group (Chapman et al., 2004), that did not find sig-
nificant results, and two non-RCTs (Gigliotti et al., 2004; von Cramon et al.,
1991) that were hampered by poor methodological ratings or lack of statisti-
cal analysis. The strongest evidence for treatments for the less functionally
impaired group comes from well-designed single-subject designs (e.g.,
Burke et al., 1991; Evans et al., 1998). Single-subject designs can offer
useful insights to direct treatment, particularly when high quality RCTs are
not available. This methodological design has some advantages over RCTs
by being flexible enough to allow the therapist to individually tailor treatment
to fit patient characteristics (Perdices & Tate, in press; Wilson, 1987). The
included high quality single-subject designs all considered a cognitive com-
ponent of apathy, initiation, and reported successful intervention with exter-
nal compensation techniques such as self-initiation checklists and pagers.
These focused treatments showed greater success at decreasing apathy than
omnibus treatments. Similarly, there was greater evidence for success of
treatments that targeted one deficit rather than multiple impairments simul-
taneously. The single-subject designs in this review demonstrated that
programmes tailored to individual impairments and needs are efficacious.

Implications for research

This review revealed a need for more high quality, methodologically rigorous
treatment studies for apathy, particularly in the less functionally impaired
group. The majority of trials measured a component of apathy as opposed
to measuring apathy as a whole (i.e., all components) via a condition-specific
outcome measure. This has lead to the currently considerable heterogeneity of
findings as treatment success is measured by multiple differing instruments
and components of apathy. Future research would benefit from utilising the
same condition-specific outcome measures for apathy. However, because
this may not be achievable, investigation into the construct validity of con-
dition-specific apathy measures would advance steps in identifying the best
measure. In turn, use of a uniform measure would allow the future pooling
of data and subsequent meta-analysis.
Most trials did not explicitly identify the apathy syndrome as a target
behaviour. Future research in this area would benefit from specifically
targeting apathy, rather than focusing on multiple impairments simultaneously.
508 LANE-BROWN AND TATE

Single-subject designs investigating treatments for the mild functionally

impaired group showed promising results for the treatment of apathy. Three
single-subject designs with high methodological scores all detailed successful
treatments, effectively increasing initiation via external compensation. It would
be useful to investigate the success of these techniques in treating the apathy syn-
drome, rather than a single component, and replicate across neurological popu-
lations with a rigorous methodological design. Within the severe group, the
majority of treatment studies investigated the dementia population. However,
apathy can be equally disabling in other neurological populations. It would be
beneficial to investigate the efficacy of current treatments used successfully in
the dementia population, such as music therapy, in other neurological groups.
Certain methodological issues should be kept in mind when evaluating
included trials. Difficulties in assessment of apathy should be taken into
account when reviewing the available research. The differential diagnosis
of apathy has been an ongoing issue. Many instruments measure apathy
alongside other factors that confuse the diagnosis, such as fatigue and
depression. Marin and colleagues (1991) have developed a psychometrically
validated measure, the Apathy Evaluation Scale that distinguishes apathy
from depression. However, it has been argued that this distinction is not
always possible in various neurological populations, such as traumatic
brain injury (Glenn et al., 2002). These difficulties in measurement of
apathy could confound reported results regarding efficacy of treatment.
Research into apathy has been plagued by variability in definitions and ter-
minology. This must be kept in mind when interpreting the results of previous
treatment studies for this complex disorder. Excellent headway has been
made towards creating operational definitions, particularly through the
work of Marin (1991) and Stuss, van Reekum, and Murphy (2000).
However, there is still diversity within these definitions, for example Marin
focuses on the diminution of cognitive, emotional and behavioural
components of goal-directed behaviour (Marin, 1991), whereas Stuss and
colleagues focus on a lack of self-initiated action (Stuss et al., 2000). Wong-
pakaran and van Reekum (2007) report on a working group led by Marin that
aims to merge definitions that will lead to a unified method of clinical diag-
nosis for apathy to be included in the Diagnostic and Statistical Manual of
Mental Disorders, Fifth edition (DSM-V). This will be invaluable for future
research on the accurate diagnosis and treatment of apathy.

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Manuscript received February 2009

Revised manuscript received April 2009
First published online June 2009

APPENDIX 1

FINAL SEARCH STRATEGIES

AMED (Searched 26 March, 2008)

1. Brain injuries/
2. Head injuries/
3. dementia/
4. cerebrovascular disorders/
5. encephalitis/
6. or/1-5
7. Motivation/
8. Goals/
9. Attitude/
10. (initiation or persistence or generativity or apathy or motivation or
goal$ or intention or persever$ or anergia or indifference or inertia
or frontal lobe impairment).ab,ti.
11. or/7-10
12. Cognitive therapy/ or Behavior therapy/
13. Therapy/
14. Rehabilitation/
15. (((cognitive or behavio$r) adj1 therapy) or CBT or “cognitive rehabi-
litation” or neurorehabilitation).ab,ti.
16. ((executive or psychological or “problem solving” or plan$) adj1
(training or treatment or rehab$ or remed$ or program$ or interven-
tion$ or therap$ or approach or technique$ or modification or
strateg$ or manag$)).ab,ti.
17. or/12-16
18. 6 and 11
 INTERVENTIONS FOR APATHY 513

19. 17 and 18
20. humans/
21. Animals/
22. 21 not (20 and 21)
23. 19 not 22

CINAHL (Searched 26 March, 2008)

1. exp Brain Injuries/
2. exp Head Injuries/
3. exp dementia/
4. exp cerebral vascular accident/
5. exp encephalitis/
6. or/1-5
7. exp Motivation/
8. exp Goal-Setting/
9. exp “Goals and Objectives”/
10. exp DRIVE/
11. exp INTENTION/
12. (initiation or persistence or generativity or apathy or motivation or
goal$ or intention or persever$ or anergia or indifference or inertia
or frontal lobe impairment).ab,ti.
13. or/7-12
14. exp Behavior Therapy/
15. exp Cognitive Therapy/
16. exp REHABILITATION/ or exp REHABILITATION, COGNITIVE/
17. (((cognitive or behavio$r) adj1 therapy) or CBT or “cognitive rehabi-
litation” or neurorehabilitation).ab,ti.
18. ((executive or psychological or “problem solving” or plan$) adj1
(training or treatment or rehab$ or remed$ or program$ or interven-
tion$ or therap$ or approach or technique$ or modification or
strateg$ or manag$)).ab,ti.
19. or/14-18
20. 6 and 13
21. 19 and 20

Cochrane Databases – DSR, ACP, DARE, CCTR (Searched 26

March, 2008)
1. “brain injur$”.ab,ti.
2. “head injur$”.ab,ti.
3. “craniocerebral trauma”.ab,ti.
514 LANE-BROWN AND TATE

4. “cerebrovascular accident”.ab,ti.
5. stroke.ab,ti.
6. dementia.ab,ti.
7. encephalitis.ab,ti.
8. or/1-7
9. (initiation or persistence or generativity or apathy or motivation or
goal$ or intention or persever$ or anergia or indifference or drive or
inertia or frontal lobe impairment).ab,ti.
10. (((cognitive or behavio?r$) adj1 therapy) or CBT or “cognitive reha-
bilitation” or neurorehabilitation).ab,ti.
11. ((executive or psychological or “problem solving” or plan$) adj1
(training or treatment or rehab$ or remed$ or program$ or interven-
tion$ or therap$ or approach or technique$ or modification or
strateg$ or manag$)).ab,ti.
12. or/10-11
13. 8 and 9
14. 12 and 13

MEDLINE (Searched 26 March, 2008)

1. exp brain injuries/
2. exp craniocerebral trauma/
3. exp cerebrovascular accident/
4. exp dementia/
5. exp encephalitis/
6. or/1-5
7. exp motivation/
8. exp drive/
9. exp goals/
10. exp intention/
11. exp attitude/
12. (initiation or persistence or generativity or apathy or motivation or
goal$ or intention or persever$ or anergia or indifference or drive or
inertia or frontal lobe impairment).ab,ti.
13. or/7-12
14. exp behavior therapy/
15. (((cognitive or behavio$r) adj1 therapy) or CBT or “cognitive rehabi-
litation” or neurorehabilitation).ab,ti.
16. ((executive or psychological or “problem solving” or plan$) adj1
(training or treatment or rehab$ or remed$ or program$ or interven-
tion$ or therap$ or approach or technique$ or modification or
strateg$ or manag$)).ab,ti.
17. or/14-16
 INTERVENTIONS FOR APATHY 515

18. 6 and 13
19. 17 and 18
20. exp animals/
21. exp humans/
22. 20 not (20 and 21)
23. 19 not 22

PsycINFO (Searched 26 March, 2008)

1. exp Traumatic Brain Injury/
2. exp Head Injuries/
3. exp Dementia/
4. exp cerebrovascular accidents/
5. exp encephalitis/
6. or/1-5
7. exp Apathy/
8. exp Motivation Training/ or exp Motivation/
9. exp Goal Setting/
10. exp Goal Orientation/
11. exp Goals/
12. exp Intention/
13. exp Generativity/
14. exp Persistence/
15. (initiation or persistence or generativity or apathy or motivation or
goal$ or intention or persever$ or anergia or indifference or inertia
or frontal lobe impairment).ab,ti.
16. or/7-15
17. exp Behavior Therapy/
18. exp Cognitive Therapy/
19. exp Treatment/
20. exp Rehabilitation/ or exp Neuropsychological Rehabilitation/ or exp
Cognitive Rehabilitation/
21. exp Intervention/
22. exp Cognitive Behavior Therapy/
23. (((cognitive or behavio$r) adj1 therapy) or CBT or “cognitive rehabi-
litation” or neurorehabilitation).ab,ti.
24. ((executive or psychological or “problem solving” or plan$) adj1
(training or treatment or rehab$ or remed$ or program$ or interven-
tion$ or therap$ or approach or technique$ or modification or
strateg$ or manag$)).ab,ti.
516 LANE-BROWN AND TATE

PsycBITE (Searched 26 March, 2008)

1. Target area – Executing Functioning Deficits
Patient Age Group – Adult
2. Target area – Behaviour Problems
Neurological Group – Alzheimer’s and related dementias
Patient Age Group – Adult
3. Target area – Behaviour Problems
Neurological Group – Traumatic Brain Injury (TBI)/Head Injury
Patient Age Group – Adult
4. Target area – Behaviour Problems
Neurological Group – CVA (Cerebrovascular Accidents)
Patient Age Group – Adult
5. Target area – Behaviour Problems
Neurological Group – Brain Infections
Patient Age Group – Adult