Brain Injury, February 2006; 20(2): 157160

ORIGINAL PAPER

Reduced daytime activity in patients with acquired brain damage and

apathy: A study with ambulatory actigraphy
NE-OTTO2, &
LLER1,3, JANA CZYMMEK2, ANGELIKA THO
ULRICH MU
2,4
D. YVES VON CRAMON

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Department of Psychiatry, 2Department of Cognitive Neurology, University of Leipzig, Germany, 3Departments of

Psychiatry and Experimental Psychology, University of Cambridge, UK, and 4Max Planck Institute for
Human Cognitive and Brain Sciences, Leipzig, Germany
(Received 27 January 2005; accepted 19 October 2005)

Abstract
Primary objective: Apathy is difficult to assess in clinical practice. Ambulatory actigraphy was used with the aim to measure
locomotor activity during the daytime as a correlate of self-initiated action in brain-damaged patients with apathy.
Research design: Twenty-four patients with acquired brain damage and high levels of apathy or low levels of apathy as well as
12 healthy controls were investigated using a parallel group design.
Methods and procedures: Apathy was diagnosed after clinical observation and evaluated with the apathy evaluation scale.
Locomotor activity was measured with a wrist-worn actigraph over 3 days.
Results: High apathy patients showed significantly reduced locomotor activity and more episodes of inactivity (naps) during
the daytime. Self-rated apathy correlated with daytime activity, nap frequency and cognitive (executive) deficits.
Conclusions: Ambulatory actigraphy is a promising method to evaluate self-initiated action in patients with apathy.
Keywords: Apathy, actigraphy, brain injury, pre-frontal, stroke

Introduction
Stuss et al. [1, p. 340] defined apathy as an absence
of responsiveness to stimuli as demonstrated by a
lack of self-initiated action. This definition relies on
observable behaviour and avoids difficult to assess
concepts like motivation and will. Apathy is a
common finding in patients with acquired brain
damage, dementia, major psychiatric disorders and
other medical problems [24]. Different forms of
apathy can be attributed to disturbed arousal,
executive deficits and impaired social awareness [1].
When untreated, apathy accounts for poor functional
outcome [4, 5]. Apathy is a major diagnostic and
therapeutic problem in clinical neuropsychiatry.
In many patients, symptoms may overlap or co-exist
with symptoms of depression and movement
disorders [2]. Clinical studies normally use the
Apathy Evaluation Scale (AES) [2, 6, 7] or the

apathy sub-scale of the Neuropsychiatric Inventory

(NPI) [8] to evaluate the severity of apathy.
Ambulatory actigraphy with a commercially available wrist-worn actigraph is an observer-independent
method that has been used to investigate limb and
body movements in patients with hypo- and hyperactivity syndromes [911]. It revealed reduced
daytime activity in patients with fronto-temporal
dementia (FTD) and disturbed sleepwake cycles
in patients with moderate-to-severe Alzheimers
disease [12]. Circadian disruptions were associated
with cortisol profiles but not with the severity
of dementia [13]. The relationship of apathy and
daytime activity has not been investigated in other
neuropsychiatric disorders. This study used ambulatory actigraphy in patients with acquired brain injury
to test the hypothesis that patients with apathy have

Correspondence: Dr Ulrich Muller, Department of Experimental Psychology, University of Cambridge, Downing Site, Cambridge CB2 3EB, UK.
Tel: 44 1223 333535. Fax: 44 1223 333564. E-mail: um207@cam.ac.uk
ISSN 02699052 print/ISSN 1362301X online # 2006 Taylor & Francis
DOI: 10.1080/02699050500443467

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158

U. Muller et al.

reduced daytime activity when compared to patients

or healthy controls without apathy.

committee of the University of Leipzig and all

subjects gave written informed consent.

Methods

Ambulatory actigraphy

Participants and clinical assessment

To measure daytime activity, a wrist-worn actigraph

(Ultra Mini-Motionlogger Actigraph , Ambulatory
Monitoring, Arlington, NY, USA) and an established protocol with registration were used over
3 days and sampling periods of 10 seconds in the
zero-crossing mode [15]. All subjects were instructed
to protocol daytime activities and sleeping times in
a diary, in the case of patients with explicit support
from relatives and clinical personal. Actigraphy
measurements were performed after the diagnostic
team conference.

Twenty-four patients with acquired brain damage

and 12 healthy volunteers participated in this study.
Matched controls were recruited among clinical staff
and from the volunteer panel of the Max Planck
Institute for Human Cognitive and Brain Sciences.
All patients were recruited at the Day-care Clinic of
Cognitive Neurology, University Hospital Leipzig
and interviewed by an experienced neuropsychiatrist
and clinical neuropsychologist. Half of them showed
a personality change (apathetic type) due to a
medical (neurological) condition as defined by
DSM-IV-TR criteria (310.1) with moderate-tosevere apathy (high apathy group). The other 12
patients showed no or mild apathy (low apathy
group). A consensus diagnosis of apathy was made
during a weekly team conference based on more than
2 weeks of observation. The groups were matched for
age and sex. Time since lesion was longer in the
high apathy group (see Table I). Patients and
healthy controls did not have a previous history of
major psychiatric illness. Structural brain images
(MRI or CT) and available functional images
([99mTc]HMPAO-SPECT or [18F]FDG-PET) were
analysed by experienced cognitive neurologists. A
descriptive summary of lesion data shows a heterogeneous pattern in both groups with more frontal
lesions and diffuse brain injury in the high apathy
group (Table II). Rating scales for apathy (AES,
self-rating and rating by relatives) and depression
(Beck Depression Inventory, BDI) were completed
in German versions. Patients were tested with the
Behavioural Assessment of the Dysexecutive
Syndrome (BADS), a short test neuropsychological
battery that focuses on pre-frontal executive functions [14]. The study was approved by the ethics

Data analysis and statistics

Commercially available software was used for data
transfer and to generate detailed activity profiles

Table II. Lesion locations (number per group) in patients with

acquired brain damage.

Brain region

High apathy
(n 12)

Low apathy
(n 12)

4
5
1
0
4

2
3
2
1
3

5
3
2
2
0

6
2
2
1
2

3
4
1

0
1
2

Cortex
 frontal
 temporal
 parietal
 occiptal
Insula
Sub-cortical
 basal ganglia/capsula interna
 thalamus/hypothalamus
 white matter (lacunar)
Corpus callosum
Cerebellum
Diffuse lesions
 cortical atrophy
 ventricular enlargement
 other

Table I. Demographic and clinical data of patients and healthy controls (M
SD [range]).

Age (years)
Gender
Neurological diagnosis
Time since lesion (months)
BDI
AES self
AES relative
BADS score

High apathy patients

Low apathy patients

Healthy controls

48.2
10.4 (2961)

4 female/8 male
5 CVD, 4 hypoxic brain injury,
2 brain tumour, 1 TBI
31
19 (660)
5.6
3.4 (011)
37.4
8.9 (2550)
43.6
10.7 (2866)
73.5
25.1 (38108)

47.0
10.9 (2867)

4 female/8 male
6 CVD, 1 hypoxic brain injury,
1 brain tumour, 4 TBI
13
10 (334)
6.2
2.2 (29)
26.9
5.8 (1940)
38.9
11.3 (2661)
98.3
16.8 (75124)

47.7
10.4 (2961)

4 female/8 male
n/a
n/a
2.3
2.3 (07)
26.9
4.8 (2035)
n/a
n/a

AES Apathy Evaluation Scale [2]; BADS Behavioural Assessment of the Dysexecutive Syndrome [14]; BDI Beck depression
inventory; CVD cerebrovascular disease/stroke; n/a not applicable or not assessed; SD standard deviation, TBI traumatic brain
injury.

A study with ambulatory actigraphy

(ACT and Action-W , Ambulatory Monitoring,
Arlington, NY) [16, 17]. Data were carefully
reviewed and checked for missing values and outliers. Diary entries were used to validate automatic
sleep scoring. Data analysis was reviewed by a
second researcher, who was blind for the clinical
diagnosis (for details of pilot testing see [18]). Group
differences were analysed by ANOVA after inspection for normal distribution and with appropriate
corrections; correlations were calculated as
Spearmans rho using SPSS for Windows.

Mean activity during the daytime, registered as

activity counts per 10 second epochs, was significantly lower (F(2, 33) 14.0, p < 0.001) and the
number of daytime naps, i.e. periods with no
activity or sleep-like activity patterns, was higher
(F(2, 19.4) 10.9, p 0.001) in the high apathy
group as compared to low apathy patients and
healthy controls (Figure 1). Daytime activity and
nap frequency were highly correlated (r 0.89,
p < 0.001). Circadian activity patterns were analysed
by sampling early morning, late morning, afternoon, evening and night data. Repeated measurements ANOVA revealed main effects of sampling
period (F(3, 39) 19.3, p < 0.001) and group
(F(2, 31) 14.9, p < 0.001), but no significant interaction. Post-hoc analyses revealed no significant
activity differences during night time. High apathy
patients took relatively more naps and had shorter
activity episodes in the afternoon.
The high apathy group showed higher values in the
AES as compared to brain-damaged patients with
low apathy and healthy controls in the self
(F(2, 19.9) 6.4, p 0.007) but not in the observer
rating (F(1, 21) 1.1, p 0.317) performed by
relatives of the patients. Depression scores (BDI)
were higher in the patient groups (F(2, 32) 7.2,
p 0.003), but below thresholds for clinically

relevant depression in patients and controls. Prefrontal cognitive deficits as measured by the BADS
battery were more prominent in the high apathy
patients (F(1, 18) 6.7, p 0.018). AES selfratings correlated with daytime activity (r 0.40,
p 0.017), nap frequency (r 0.39, p 0.022) and
BADS scores (r 0.49, p 0.032) in the patients.
Discussion
This study has shown that ambulatory actigraphy can
be used for observer-independent quantification of
locomotor activity in patients with acquired brain
damage and apathy. Differences in daytime activity
are likely to reflect differences in self-initiated
actions, because all patients participated in an
outpatient rehabilitation programme with similar
day-time schedules. Reduced daytime activity in
the high apathy group was similar to findings in
patients with dementia [12] and chronic schizophrenia [11]. Increased frequency of naps in the evening
is a common finding in elderly people [15, 19].
Executive cognitive deficits in the brain-damaged
patients with high apathy as detected by the BADS
and positive correlations of BADS with AES scores
indicate frontostriatal disturbances in patients with
apathy. These correlations between apathy and
executive deficits are in good accordance with
findings in traumatic brain injury (TBI) [20], oldage depression [21] and schizophrenia [22].
A limitation of this pilot study is the heterogeneity
of the patient sample; however, the aim was to show
an association of daytime activity and apathy after
acquired brain damage, independent from aetiology.
Data of ambulatory actigraphy are easily confounded
by movement disorders, hemiparesis and fatigue [17].
The number of patients with hemiparesis was identical in both patient groups. This study did not control
explicitly for fatigue and can, therefore, not distinguish, if high apathy patients make more naps
because they are more tired or less motivated.
35

Number of naps (per day)

45

Activity counts (per 10 sec)

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Results

159

40
35
30
25
20

30
25
20
15
10
5
0

15
High apathy

Low apathy Controls

High apathy

Low apathy

Controls

Figure 1. Locomotor activity (individual averages of acceleration counts per 10 seconds) (left) and number of naps
(continuous low or no activity epochs) (right) during daytime as measured with ambulatory actimetry in brain-damaged
patients with high apathy, low apathy and matched controls (N 12 per group)

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160

U. Muller et al.

There is, however, a conceptual overlap between

disorders of diminished motivation and fatigue [2].
Similar activity profiles in healthy controls and
brain-damaged patients with low apathy, relatively
good matching of the two patients group as well as
correlations between actigraphy data and apathy
ratings argue in favour of the hypothesis, i.e. that
apathy can be detected and quantified by ambulatory
actigraphy.
Further studies will investigate the relationship of
apathy and daytime activity in more homogenous
groups of patients with TBI, mild cognitive impairment and post-stroke depression. Ambulatory actigraphy holds promise for follow-up measurements
in clinical trials of pharmacological [2325] and
other interventions [2, 4, 15, 26] that aim to improve
apathy and related functional deficits in patients with
neuropsychiatric disorders.

Acknowledgement
Supported by Alexander von Humboldt-Foundation
(UM), Saxonian Ministry of Science and Arts ( JC)
and Max Planck Society. We thank all patients and
healthy volunteers for participation.

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