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Apathy after stroke: Diagnosis, mechanisms, consequences, and treatment

Research output: Contribution to journalReview articlepeer-review

Jonathan Tay, Robin G. Morris, Hugh S. Markus

Original languageEnglish
Pages (from-to)510-518
Number of pages9
JournalInternational Journal Of Stroke
Issue number5
PublishedJul 2021

Bibliographical note

Funding Information: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:This work is funded by a Priority Programme Grant from the Stroke Association (2015-02) and National Institute of Health Research (NIHR) Biomedical Research Centre Dementia and Neurodegeneration Theme (146281). JT is supported by a Cambridge International Scholarship from the Cambridge Trust. HSM is supported by the NIHR Cambridge Biomedical Research Centre and an NIHR Senior Investigator Award. Publisher Copyright: © 2021 World Stroke Organization. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

King's Authors


Apathy is a reduction in goal-directed activity in the cognitive, behavioral, emotional, or social domains of a patient’s life and occurs in one out of three patients after stroke. Despite this, apathy is clinically under-recognized and poorly understood. This overview provides a contemporary introduction to apathy in stroke for researchers and practitioners, covering topics including diagnosis, neurobiological mechanisms, associated consequences, and potential treatments for apathy. Apathy is often misdiagnosed as other post-stroke conditions such as depression. Accurate differential diagnosis of apathy, which manifests as reductions in initiative, and depression, which manifests as negative emotionality, is important as it informs prognosis. Research on the neurobiology of apathy suggests that there are few consistent associations between stroke lesion location and the development of apathy. These may be resolved by adopting a network neuroscience approach, which models apathy as a pathology arising from structural or functional damage to brain networks underlying motivated behavior. Importantly, networks can be affected by physiological changes related to stroke, including the acute infarct but also diaschisis and neurodegeneration. Aside from neurobiological changes, apathy is also associated with other negative outcome measures such as functional disability, cognitive impairment, and emotional distress, suggesting that apathy is indicative of a worse prognosis following stroke. Unfortunately, high-quality trials aimed at treating apathy are scarce. Antidepressants may have limited effects on apathy. Acetylcholine and dopamine pharmacotherapy, behavioral interventions, and transcranial magnetic stimulation may be more promising avenues for treatment.

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