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com
579

PAPER

The Lille apathy rating scale (LARS), a new instrument for

detecting and quantifying apathy: validation in Parkinson’s
disease
P Sockeel, K Dujardin, D Devos, C Denève, A Destée, L Defebvre
...............................................................................................................................
J Neurol Neurosurg Psychiatry 2006;77:579–584. doi: 10.1136/jnnp.2005.075929

Background: Apathy is usually defined as reduced interest and participation in various activities. It is a
frequent consequence of neurological and psychiatric disorders. Although various scoring methods have
been proposed, there is a lack of validated, standardised instruments for detecting apathy and assessing
its severity.
An appendix is available Objective: To develop an apathy rating scale using a structured standardised interview capable of
online at http://www. distinguishing between the condition’s various features.
jnnp.com/supplemental Methods: The Lille Apathy Rating Scale (LARS) is based on a structured interview. It includes 33 items,
See end of article for divided into nine domains. Responses are scored on a dichotomous scale. The participants used to validate
authors’ affiliations the scale consisted of 159 patients with probable Parkinson’s disease and 58 healthy control subjects. The
....................... Marin Apathy Scale, the Montgomery and Asberg Depression Rating Scale, and the Mattis Dementia
Correspondence to: Rating Scale were also administered.
Dr Pascal Sockeel, UFR de Results: Principal component analysis showed that the LARS probed a single construct which forms the root
Psychologie, BP 149, F- of an oblique factor structure reflecting four dimensions: intellectual curiosity, self awareness, emotion, and
59653 Villeneuve D’Ascq
cedex, France; pascal. action initiation. The main psychometric properties of the LARS (internal consistency, inter-rater and test-
sockeel@univ-lille3.fr retest reliability) were satisfactory. Concurrent validity was evaluated by reference to the Marin scale and
to judgements provided by expert clinicians.
Received 13 July 2005 Conclusions: Standard validity indices showed that the LARS is sensitive and capable of distinguishing
In revised form
5 December 2005 between apathy and depression. As a screening tool, the scale is able to support dichotomous judgements
Accepted 3 January 2006 accurately and, when greater measurement sensitivity is required, also determine the severity of apathy
....................... within a four category classification.

A
pathy refers to a set of behavioural, emotional, and primarily dependent on the opinion of the caregiver, who
cognitive features such as reduced interest and may not always be available or reliable.
participation in the main activities of daily life, a lack From a pathophysiological viewpoint, the most common
of initiative, a trend towards early withdrawal from initiated cause of apathy is dysfunction of the frontal lobes, following
activities, indifference, and flattening of affect. The concept either a direct lesion of the frontal cortex or damage to
of apathy lacks specificity and various different definitions regions tightly connected to the latter (such as the basal
have been suggested. For certain investigators, the key ganglia). The frontal-subcortical circuits often seem to be
feature is lack of motivation, and apathy can thus be defined involved, and apathy is a common behavioural consequence
as ‘‘diminished motivation not attributable to diminished of basal ganglia disorders.2 3 7 Current estimates of the
level of consciousness, cognitive impairment, or emotional prevalence of apathy in Parkinson’s disease vary from
distress’’.1 For others, the prime characteristic is lack of 16.5% to 42%.3 7 8 It is also frequently observed in other
initiative: apathy is considered to be ‘‘an absence of conditions with parkinsonism.9
responsiveness to stimuli as demonstrated by a lack of self Our aim was to develop an apathy rating scale using a
initiated action’’.2 In addition to these conceptual difficulties, structured, standardised interview capable of distinguishing
apathy overlaps with a range of other behavioural and between the various features of apathy. We examined its
psychological factors, including mood and some aspects of concurrent validity, internal consistency, and inter-rater
personality and cognitive function.3 reliability in a population of healthy subjects and patients
The apathy evaluation scale (AES) proposed by Marin et al4 with Parkinson’s disease. The latter group was chosen in view
is currently the scale most often used to assess apathy. Its of the fact that apathy is commonly observed in this basal
reliability and validity for measuring apathy in different ganglia degenerative disease.2
pathological conditions have been demonstrated.4 However,
the administration instructions and scoring method have METHODS
suffered from a lack of standardisation. In clinical research Participants
and most drug treatment studies, apathy has been assessed One hundred and fifty nine patients with probable
with the Neuropsychiatric Inventory (NPI), which includes a Parkinson’s disease participated in the study (the demo-
specific item for the global evaluation of apathy.5 Recently, graphic characteristics are shown in table 1). Parkinson’s
Robert et al6 proposed an extension of this assessment by
using the Apathy Inventory, which allows separate assess-
Abbreviations: AES, apathy evaluation scale; DRS, dementia rating
ment of emotional blunting, lack of initiative, and lack of scale; LARS, Lille Apathy Rating Scale; MADRS, Montgomery and
interest in addition to the global NPI score. Despite the Asberg depression rating scale; NPI, Neuropsychiatric Inventory;
widely demonstrated validity of these latter scales, they are UPDRS, Unified Parkinson’s Disease Rating Scale

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580 Sockeel, Dujardin, Devos, et al

Table 1 Demographic and clinical data for the subject groups

Stable Parkinson’s Fluctuating Parkinson’s Parkinson’s disease with
Variable disease disease dementia Healthy controls

Number of subjects (M/F) 47 (30/17) 73 (40/33) 39 (17/23) 58 (29/29)

Age (years) 62.0 (11.4) 60.5 (8.2) 68.6 (8.9) 61.3 (11.0)
Education duration (years) 11.89 (3.29) 11.14 (2.95) 8.79 (2.32) 11.53 (2.97)
Mattis DRS score (max = 144) 136.96 (4.60) 134.33 (5.69) 118.67 (7.84) 138.27 (4.58)
MADRS score (max = 60) 6.85 (6.09) 9.76 (6.66) 11.05 (6.17) 4.57 (4.82)
UPDRS score (max = 108) 15.53 (8.53) 26.92 (12.56) 32.46 (14.71) NA
Dopa equivalent dosage (mg/day) 711 (400) 905 (506) 912 (507) NA

Values are mean (SD).

DRS, dementia rating scale; F, female; M, male; MADRS, Montgomery and Asberg depression rating scale; NA, not available; UPDRS, Unified Parkinson’s
Disease Rating Scale.

disease was defined according to the United Kingdom (MADRS).12 In addition to the global score and in view of
Parkinson’s disease brain bank criteria.10 The study popula- the scale’s factorial structure, we also used three subscores
tion was separated into three groups: for assessing dysphoric apathy, psychic anxiety, and vegeta-
tive symptoms.13
N 47 patients with non-demented Parkinson’s disease early
in the course of the disease and well stabilised on
Global cognitive efficiency was assessed in terms of the global
score (out of 144) on the Mattis Dementia Rating Scale
antiparkinsonian drug treatment (stable Parkinson’s dis- (Mattis DRS).14
ease); All participants underwent assessment of apathy, depres-
N 73 non-demented patients with fluctuating Parkinson’s
disease and severe symptoms (fluctuating Parkinson’s
sion, and cognitive efficiency during a one hour test session.

disease); Scale structure, item development and selection

N 39 patients with Parkinson’s disease and a diagnosis of
dementia according to the fourth Edition of the Diagnostic
The LARS was based on the main conceptual principles
proposed by Marin et al4 and on our own clinical experience.
and Statistical Manual of Mental Disorders (DSM-IV) The scale includes 33 items, divided into nine domains. Eight
(Parkinson’s disease with dementia). of these concern the main clinical manifestations of apathy,
as described in published reports: reduction in everyday
Eighteen patients early in the course of the disease were productivity; lack of interest; lack of initiative; extinction of
not receiving any treatment at all. Sixty four patients were novelty seeking and motivation; blunting of emotional
being treated with levodopa only (mean (SD) (range): responses; lack of concern; and poor social life. The ninth
levodopa equivalent dosage = 692.8 (360.0) mg/day (100 to domain (extinction of self awareness) refers to a particular
1700)); 10 were receiving a dopamine agonist only (levodopa manifestation of apathy highlighted by Stuss et al,2 who
equivalent dosage = 487.0 (461.7) mg/day (120 to 1500)); considered self and social awareness as ‘‘a metacognitive
and 67 were receiving levodopa in combination with a ability, necessary to mediate information from a personal,
dopamine agonist (levodopa equivalent dosage = 1038.1 social past and current history with projections to the
(513.0) mg/day (150 to 2337.5)). Motor disability was future’’. The main impact of apathy on this ability would
evaluated using the motor score on the Unified Parkinson’s be a reduction in self criticism and behavioural adjustment to
Disease Rating Scale (UPDRS-III).11 Although none of the social requirements in one’s own interest.
patients were suffering from any neurological disease other The items are presented as positively worded questions to
than Parkinson’s disease, 24 (15%) had a history of drug which the subject is expected to answer clearly ‘‘yes’’ or ‘‘no’’,
induced psychosis. Sixty six patients were receiving treat- in order to reduce subjective interpretations as much as
ment for anxiety related, depressive, or psychotic symptoms possible. With the exception of the first three questions
(23 were on selective serotonin reuptake inhibitors only, nine (which are coded on a five point Likert-type scale), responses
were on alprazolam or bromazepam only, seven were taking are coded by the clinician on a binary (yes/no) scale, with an
mianserine only, 21 were taking alprazolam or bromazepam additional ‘‘NA’’ (not available) condition for non-classifiable
plus mianserine (n = 17) or a selective serotonin inhibitor answers or non-applicable items. Finally, the scale was
(n = 4), and 10 were being treated with clozapine). Five designed in such a way that each of the nine domains can be
patients were being treated with acetylcholinesterase inhibi- evaluated through subscales which contribute with equal
tors for their cognitive disorders. weighting to the global score. Hence the global score ranges
Fifty eight healthy control subjects were chosen to match from 236 to +36, with a higher score representing a greater
the patient group as closely as possible with respect to age degree of apathy.
and educational level (table 1).
None of the controls had a personal history of neurological
Procedure
or psychiatric illness.
The scale’s rating is based on a subject’s own report (during a
All participants gave their informed consent to participa- structured interview) on their thoughts, emotions, and
tion in the study. activities over the previous four weeks. In order to evaluate
inter-rater reliability, simultaneous ratings on a subset of
Evaluation scales Parkinson’s disease patients (n = 32) were carried out by two
Apathy was assessed with the Marin apathy evaluation scale clinicians. Finally, a subset of patients (n = 35) participated
(AES) and our new Lille Apathy Rating Scale (LARS), as in a retest procedure approximately four months later.
described below. The scale and its instructions for use are The Parkinson’s disease patients were also examined by an
shown in the appendix which can be viewed on the journal independent group of clinicians. These were asked to judge
website (http://www.jnnp.com/supplemental). (on the basis of a clinical examination and interview)
Severity of depressive symptoms was assessed using the whether or not the individual was depressed or apathetic or
Montgomery and Asberg depression rating scale both. When a patient was categorised as apathetic, the

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LARS: validation study 581

Table 2 Factor loadings after oblique rotation and the correlation matrix between
oblique factors
Factor 1 Factor 2 Factor 3 Factor 4
Variable IC SA E AI

(A) Factor loadings

EP 0.101 0.056 0.164 0.867
INT 0.453 0.084 0.291 0.371
INI 0.344 20.046 0.015 0.692
NS 0.694 0.066 0.235 0.228
M 0.719 0.066 0.086 0.200
ER 0.129 0.386 0.700 0.135
C 0.158 20.225 0.816 0.088
S 0.790 20.024 0.031 0.065
SA 0.058 0.931 20.003 0.008

(B) Correlations between oblique factors

IC 1.000 0.126 0.435 0.565
SA 0.126 1.000 0.112 0.031
E 0.435 0.112 1.000 0.293
AI 0.565 0.031 0.293 1.000

Numbers in bold type indicate the correlations that determine the clusters for the oblique factors in (A) and
significant correlations between oblique factors (p,0.01) in (B).
AI, action initiation; C, lack of concern; E, emotion; EP, everyday productivity; ER, blunting of emotional responses;
IC, intellectual curiosity; INI, lack of initiative; INT, lack of interest; M, motivation; NS, extinction of novelty seeking;
SA; extinction of self awareness; SL, poor social life.

clinician had to describe their behaviour using one of the

following three adjectives: ‘‘mild,’’ ‘‘moderate,’’ or ‘‘severe.’’ Table 4 Sensitivity of the main scores and subscores of
Statistics and data analyses were carried out using Statistica LARS and MADRS to apathy and depression, as
6.0 software. determined by multivariate analysis of variance
Depression Apathy Interaction
RESULTS
LARS (main score) 13.26 112.03 0.31
Factorial structure
Intellectual curiosity 20.14 76.50 1.81
First, the 33 items were analysed in terms of potential Emotion 0.99 16.25 0.40
intercorrelations. As expected, an exploratory examination of Action initiation 1.32 32.42 0.52
the correlation matrix showed relatively low correlations Self awareness 0.77 6.58 0.85
between the scores in items belonging to different domains
MADRS (main score) 141.10 13.04 0.60
(lowest coefficient = 20.13, highest coefficient = 0.36, mean Dysphoric apathy 72.58 22.12 0.78
(SD) r = 0.10 (0.10)). The correlations between items Psychic anxiety 66.66 1.31 0.00
belonging to the same domain were reasonably high (lowest Vegetative symptoms 24.64 0.35 0.01
coefficient = 0.12, highest coefficient = 0.58, mean r = 0.32
Bold type indicates significant F(1,115) values at p,0.01.
(0.17)), whereas the correlations between scores for each LARS, Lille Apathy Rating Scale; MADRS, Montgomery and Asberg
item and for the scale as a whole were high (lowest depression rating scale.
coefficient = 0.52, highest coefficient = 0.81, mean r = 0.65
(0.11)). Hence, these results support our choice of a
procedure with dichotomous items which are then collapsed An exploratory principal component analysis was carried
into subscales to improve sensitivity. Finally, and with the out on the nine subscores in order to determine the structure
exception of self awareness (r = 0.28), the different subscales of the data: four factors were identified with eigenvalues
corresponding to the nine domains were highly correlated to close to 1, explaining more than 65% of the total variance.
the global LARS score (lowest coefficient = 0.45, highest The first factor accounted for 34% of the total variance,
coefficient = 0.72, mean r = 0.60 (0.08)). confirming the one dimensional nature of the LARS.

Table 3 Comparisons between the different patient groups using the LARS and MADRS
scales
Patient group n (%) LARS MADRS

No apathy or depression 82 (56.1) 225.91 (5.02) 5.52 (3.29)

[226.80 to 225.03] [4.80 to 6.25]

Apathy only 37 (23.3) 213.54 (6.5) 7.95 (3.93)

[215.72 to 211.36] [6.64 to 9.26]

Depression only 9 (5.6) 222.11 (5.51) 15.00 (5.38)

[226.35 to 217.87] [10.86 to 19.14]

Apathy + depression 31 (19.5) 28.35 (8.35) 18.74 (5.19)

[211.41 to 25.30] [16.84 to 20.65]

Values are mean (SD) and [95% confidence intervals].

LARS, Lille Apathy Rating Scale; MADRS, Montgomery and Asberg depression rating scale.

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582 Sockeel, Dujardin, Devos, et al

A further principal component analysis using oblique As shown in table 4, both LARS and MADRS were
rotation generated a satisfactory model for this number of generally sensitive to both apathy and depression, although
factors (goodness of fit with x2 (df 6) = 9.69, p.0.13, NS). the results for different subscales were not homogeneous.
Table 2 gives the factor loadings and the correlations between The LARS ‘‘IC’’ factor was reactive to both variables,
the hierarchical structure’s different components. showing the dependence between these two constructs.
First, four clusters of variables were found, with either Nevertheless, the mean scores observed for the different
high unique factor loadings or low cross loadings. Next, the patient groups, the confidence intervals, and the absence of
correlations between these four primary oblique factors interactions between the apathy and depression factors all
yielded a set of two secondary factors, with the first showing argue in favour of the LARS’s ability to assess apathy
evidence for a main construct representing apathy (factors 1, independently of depression. Examination of the results for
3, and 4) and a second one dealing more with self awareness the ‘‘dysphoric apathy’’ factor in the MARDS supported this
(factor 2). Finally, there was evidence to suggest that the four conclusion, as the correlation between the LARS and the
primary factors might represent distinct dimensions of MADRS mainly reflected the correlation between the LARS
apathy: (1) intellectual curiosity (lack of interest, novelty and the depression scale’s apathy subscore.
seeking and motivation, poor social life), reflecting low
interest in novelty as well as a drop in the perceived need for Concurrent validity
knowledge; (2) self awareness; (3) emotion (blunting of Concurrent validity was assessed, first, by the correlation
emotional responses, lack of concern); and (4) action between the AES and LARS scores, and second, by
initiation (low everyday productivity, lack of initiative). comparison of the frequency distributions between the
different cut off scores and expert judgements. We noted a
Internal consistency, test–retest, and inter-rater strong correlation between the global scores for the AES and
reliability the LARS (r = 0.87). Close examination of links between
Internal consistency was determined both in terms of split Marin’s scale and the four LARS factors established that the
half reliability and Cronbach’s standardized a coefficients. strongest correlations were found with the IC (r = 0.84) and
The between-items and between-subscales a values were 0.80 AI dimensions (r = 0.65). The correlation between AES and
and 0.74, respectively. Split half reliability was 0.73 and the E dimension was r = 0.44 and comparisons between the
reached 0.84 after correction with the Spearman Brown SA dimension and AES yielded r = 0.15.
‘‘prophecy formula’’. When evaluated on a subgroup of 35 Criterion related validity was measured in order to obtain
patients, the test–retest correlation coefficient was 0.95. the best accuracy relative to an expert diagnosis. It was
Inter-rater reliability was checked using intraclass correlation calculated from two kinds of cross tabulation tables, referring
calculated from the ratios of the different sources of variance. to either an expert dichotomous patient classification
The latter were generated by an analysis of variance (moderately/severely apathetic v non-apathetic/mildly apa-
(ANOVA) on repeated measures, with the identity of the thetic) or a four class categorisation of disease severity (non-
judge as a dependent variable. This ANOVA did not reveal apathetic, mildly, moderately, or severely apathetic). Cut off
any differences between scorings (F,1, NS), and the scores for the LARS were derived empirically from the
intraclass correlation was high (r = 0.98). According to distributions of apathetic and control subjects, in order to
Nunally,15 these values correspond to high reliability. separate the two sets and to avoid the inclusion of subjects in
an inappropriate category (fig 1). An initial cut off score was
set at 2.5 SD below the mean score of the control group.
Separability between apathy and depression Thereafter, and depending on the user’s choice in terms of
Parkinson’s disease patients were divided into four groups specificity and sensitivity, three cut off scores were proposed,
according to the clinicians’ binary classification of apathy and as shown in table 5.
depression (table 3). The MADRS and LARS scores were Comparisons with Marin’s AES were provided for three cut
compared in a two way multivariate analysis of variance off scores calculated using the same methodology. For a
(MANOVA), with the two classifications as categorical prevalence of 29.56%, the cut off value of 216 seemed to be
predictors. In a second MANOVA, we entered various the best compromise, with a k of 0.79 and a sensitivity index
dependent variables: the MADRS ‘‘dysphoric apathy,’’ ‘‘psy- of 0.89, which are considered to represent excellent agree-
chic anxiety,’’ and ‘‘vegetative symptoms’’ scores on the one ment.16 Finally, classification into four categories was
hand, and LARS subscores from the four factorial analysis checked against a corresponding distribution of patients
clusters (referred as intellectual curiosity (IC), self awareness with the cut off values of [236;222] for non-apathetic and
(SA), emotion (E), and action initiation (AI)) on the other. [221;217], [216;210], and [29;+36] for slightly, moder-
We hypothesised that the main scores or the subscores, or ately, or severely apathetic subjects, respectively. Again, these
both, would be differentially sensitive to their corresponding values were adjusted empirically in order to create classes
factors—that is, apathy or depression. If the two constructs with minimum overlap and to provide as much agreement as
were independent, we expected not to see an interaction possible with the experts. Table 6 shows the corresponding
effect. contingency cross tabulation, from which we calculated an

Table 5 Criterion related validity, sensitivity, and specificity indices and cut off values for
the AES and LARS scales, with respect to dichotomous expert judgments of apathy
Scale Cut off scores Accuracy k Sensitivity Specificity

LARS >217 0.89 0.76 0.94 0.87

>216 0.91 0.79 0.89 0.92
>215 0.91 0.79 0.87 0.93
AES .20 0.85 0.65 0.81 0.87
.21 0.86 0.65 0.77 0.89
.22 0.84 0.61 0.68 0.91

AES, apathy evaluation scale; LARS, Lille Apathy Rating Scale.

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LARS: validation study 583

Table 6 Cross tabulation table showing the proportion of patients (per cent) in each of
the four apathy severity classes, according to the LARS global score and the expert’s
judgement
Expert judgement

No Slight Moderate Severe Total

LARS No 48.4 1.2 0 0 49.68

Slight 6.3 8.8 3.1 0 18.24
Moderate 3.1 2.5 6.3 4.4 16.35
Severe 0 0 0 15.7 15.72
Total 57.86 12.58 9.43 20.13 100

LARS, Lille Apathy Rating Scale.

accuracy index of 0.81 with a k of 0.74. These data clearly of apathy (behavioural, cognitive, and emotional) and our
argue in favour of use of the LARS for optimally distinguish- results agree with and reinforce these suggestions, as these
ing between different degrees of severity in apathy syn- same three realms emerged from our analysis. Nevertheless,
dromes. our data also generated a fourth factor, representing a
reduction in self awareness and impaired behavioural
DISCUSSION adjustment to social life. This factor seemed to emerge in
This new Lille Apathy Rating Scale (LARS) was built on the relation to certain specific characteristics of patients with
conceptual basis of Marin’s apathy evaluation scale (AES) cognitive decline.
but sought to remove various practical difficulties in using Discriminating between depression and apathy has always
the latter. In particular, we have noticed first, a lack of been a tricky issue. Nevertheless, some studies have
standardisation in the administration and scoring procedures addressed this problem. For instance, Marin et al19 evaluated
(because of the semistructured nature of the AES); second, apathy and depression in patients with either Alzheimer’s
variations in interpretation owing to multiple sources of disease, stroke, or major depression. Although apathy and
informants; and third, possible sources of error because of depression generally correlated within the groups, absolute
fluctuation in the positive/negative orientation of questions. scores varied considerably (and independently) between
Moreover, we have also noticed a heterogeneous weighting of groups. Levy et al20 found the same disease specific relation
the items in relation to the main psychological domains. In using the NPI and concluded that the presence of one
order to enhance standardisation, improve stability, and condition did not predict the presence of the other. Pluck and
reduce subjective interpretations during scoring, we adopted Brown3 drew very similar conclusions: although the symp-
a dichotomous scale. Moreover, the nine domains of interest toms can dissociate within individual patients, comorbid
were equally weighted in the final score, enabling the depression and apathy appeared to have an additive effect on
generation of subject profiles. Question by question exam- symptoms such as cognitive dysfunction. Our data seem to be
ination did not reveal floor or ceiling effects or extremely low compatible with published reports: the correlation between
or high inter-item correlations that would indicate incon- LARS and MADRS scores is clearly explained by the latter’s
gruence or redundancy. This internal consistency was dysphoric apathy subscale, which covaries with the LARS IC
reinforced by relatively high reliability coefficients, suggest- dimension (and, to a lesser extent, with AI). Moreover, the
ing that the scale indeed deals with a single, coherent simultaneous presence of these two symptoms indicated the
construct. Parkinson’s disease patients with the worst scores on the
In addition to the global assessment of apathy, the LARS LARS. In practical terms, distinguishing apathy from depres-
also revealed a structure whose factors were interpreted as sion implies that one should consider both the LARS and the
representing intellectual curiosity, action initiation, emotion, MADRS scores: extremely low scores on both scales indicate
and self awareness. In fact, several studies2 4 6 17 18 have patients with little suspicion of either condition; extremely
proposed definitions which incorporate distinct components high scores on both scales indicate patients with a high
suspicion of both conditions; depressed patients should
present a relatively high MADRS score with a relative low
20 LARS score, whereas a relatively low MADRS score and a
18
relatively high LARS score predict the presence of apathy in
Parkinson's disease
the absence of depression.
16 Healthy controls
The main goal of this study was to provide a useful tool
14 (meeting the usual psychometric prerequisites) for the
Number of cases

assessment of apathy. We demonstrated that the LARS has

12 very satisfactory inter-rater and test–retest reliability.
10 Moreover, the establishment of excellent concurrent and
criterion related validity was a major step in proving the value
8
of LARS as a screening test. Furthermore, we proposed
6 several cut off scores with good specificity and sensitivity. The
comparison with Marin’s AES criterion related validity was
4
arduous, because we found several proposed AES cut off
2 values.3 21 22 However, by opting for a cut off value corre-
sponding to the mean AES score for the normal control group
0
–36 –32 –28 –24 –20 –16 –12 –8 –4 0 4 8 12 minus 2.5 SD, our sensitivity and specificity values showed
Apathy score (LARS) that the LARS provided slightly more reliable validity. Finally,
the four-class severity system may provide greater sensitivity
Figure 1 The distribution of LARS apathy scores for patients with by enabling precise measurements in treatment efficacy
Parkinson’s disease and for healthy controls. studies or, more generally, during patient follow up.

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584 Sockeel, Dujardin, Devos, et al

In the current version of the LARS, all input information is 3 Pluck GC, Brown RG. Apathy in Parkinson’s disease. J Neurol Neurosurg
Psychiatry 2002;73:636–42.
obtained from the patient. In patients with anosognosia (who 4 Marin RS, Biedrzycki RC, Firinciogullari S. Reliability and validity of the
may thus underrate their symptoms), this may constitute a apathy evaluation scale. Psychiatry Res 1991;38:143–62.
limitation. It is useful to obtain information from an 5 Cummings JL, Mega M, Gray K, et al. The neuropsychiatric inventory:
comprehensive assessment of psychopathology in dementia.
informant in such cases, and we are currently working on Neuropsychology 1994;44:2308–14.
an informant version of the LARS. 6 Robert PH, Clairet S, Benoit M, et al. The apathy inventory: assessment of
Our results showed that apathy is frequent in Parkinson’s apathy and awareness in Alzheimer’s disease, Parkinson’s disease and mild
cognitive impairment. Int J Geriatr Psychiatry 2002;17:1099–105.
disease and that higher apathy levels are observed in patients 7 Starkstein SE, Mayberg HS, Preziosi TJ, et al. Reliability, validity, and clinical
with cognitive complications. The observed prevalence of 29% correlates of apathy in Parkinson’s disease. J Neuropsychiatry Clin Neurosci
was within the range of previously reported values.3 7 8 1992;4:134–9.
8 Aarsland D, Larsen JP, Lim NG, et al. Range of neuropsychiatric disturbances
in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry
Conclusion 1999;67:492–6.
9 Litvan I, Mega MS, Cummings JL, et al. Neuropsychiatric aspects of
The LARS is a reliable and practical instrument for assessing progressive supranuclear palsy. Neurology 1996;47:1184–9.
the multiple dimensions of apathetic syndrome. Its psycho- 10 Gibb WR, Lees AJ. The relevance of the Lewy body to the pathogenesis of
metric qualities appear to make it particularly suitable for idiopathic Parkinson’s disease. J Neurol Neurosurg Psychiatry
1988;51:745–52.
assessing changes in the manifestations of apathy: in the 11 Fahn S, Elton RL, and the members of the UPDRS Development Committee. The
future, the scale could thus constitute an interesting outcome Unified Parkinson’s disease rating scale. In:Fahn S, Marsden CD, Calne DB,
variable for evaluating the efficacy of potential apathy Goldstein M, editors.Recent developments in Parkinson’s disease, vol 2.
Florham Park, NJ: Macmillan Healthcare, 1987:153–63.
treatments. Further studies will have to demonstrate the 12 Montgomery SA, Asberg M. A new depression scale designed to be sensitive
ability of the LARS to specify the apathy profile of different to change. Br J Psychiatry 1979;134:382–9.
patient groups in relation to a given disease aetiology or 13 Parker RD, Flint EP, Bosworth HB, et al. A three-factor analytic model of the
MADRS in geriatric depression. Int J Geriatr Psychiatry 2003;18:73–7.
severity level. 14 Mattis S. Mental status examination for organic mental syndrome in the
elderly patient. In:Bellak L, Karasy TE, editors. Geriatric psychiatry. New York:
..................... Grune and Stratton, 1976:77–121.
Authors’ affiliations 15 Nunally JC. Psychometric theory, 2nd edition. New York, NY: McGraw-Hill,
P Sockeel, K Dujardin, Psychology Department, Charles De Gaulle 1978.
16 Landis JR, Koch GG. The measurement of observer agreement for categorical
University, Lille, France data. Biometrics 1977;33:159–74.
D Devos, C Denève, A Destée, L Defebvre, Neurology and Movement 17 Marin RS. Apathy: concept, syndrome, neural mechanism and treatment.
Disorders Unit, EA2683, Faculty of Medicine and Lille University Semin Clin Neuropsychiatry 1996;1:304–14.
Hospital, Lille 18 Starkstein SE, Petracca G, Chemerinski E, et al. Syndromic validity of apathy
in Alzheimer’s disease. Am J Psychiatry 2001;158:872–7.
Competing interests: none declared 19 Marin RS, Firinciogullari S, Biedrzycki RC. Group differences in the
relationship between apathy and depression. J Nerv Ment Dis
1994;182:235–9.
20 Levy ML, Cummings JL, Fairbanks LA, et al. Apathy is not depression.
REFERENCES J Neuropsychiatr Clin Neurosci 1998;10:314–19.
1 Marin RS. Differential diagnosis and classification of apathy. Am J Psychiatry 21 Andersson S, Krogstad JM, Finset A. Apathy and depressed mood in acquired
1990;147:22–30. brain damage: relationship to lesion localization and psychophysiological
2 Stuss DT, Van Reekum R, Murphy KJ. Differentiation of states and causes of reactivity. Psychol Med 1999;29:447–56.
apathy. In:Borod J, editor. The neuropsychology of emotion. New York: 22 Kant R, Duffy JD, Pivovarnik A. Prevalence of apathy following head injury.
Oxford University Press, 2000:340–63. Brain Injury 1998;12:87–92.

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The Lille apathy rating scale (LARS), a new

instrument for detecting and quantifying
apathy: validation in Parkinson's disease
P Sockeel, K Dujardin, D Devos, C Denève, A Destée and L Defebvre

J Neurol Neurosurg Psychiatry 2006 77: 579-584

doi: 10.1136/jnnp.2005.075929

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