Effect of domiciliary oxygen therapy on exercise capacity and quality of life in patients with pulmonary arterial or chronic thromboembolic pulmonary hypertension: a randomised, placebo-controlled trial.

STUDY QUESTION: We investigated whether domiciliary oxygen therapy (DOXT) increases exercise capacity and quality of life in patients with pulmonary arterial or distal chronic thromboembolic pulmonary hypertension (PAH/CTEPH) presenting with mild resting hypoxaemia and exercise-induced oxygen desaturation. MATERIALS AND METHODS: 30 patients with PAH/CTEPH, mean±sd age 60±15 years, pulmonary artery pressure 39±11 mmHg, resting arterial oxygen saturation measured by pulse oximetry (S pO2 ) ≥90%, S pO2 drop during a 6-min walk test ≥4%, on pulmonary hypertension-targeted medication, were randomised in a double-blind crossover protocol to DOXT and placebo (ambient air) treatment, each over 5 weeks, at 3 L·min-1 via nasal cannula overnight and when resting during the day. Treatment periods were separated by 2 weeks of washout. Co-primary outcomes were changes in 6-min walk distance (6MWD, breathing ambient air) and physical functioning scale of the 36-item short-form medical outcome questionnaire during treatment periods. RESULTS: DOXT increased the 6MWD from baseline 478±113 m by a mean (95% CI) of 19 (6-32) m, and physical functioning from 52±29 by 4 (0-8) points. Corresponding changes with placebo were 1 (-11-13) m in 6MWD and -2 (-6-2) points in physical functioning. Between-treatment differences in changes were 6MWD 18 (1-35) m (p=0.042) and physical functioning 6 (1-11) points (p=0.029). DOXT significantly improved the New York Heart Association functional class versus placebo. ANSWER TO THE QUESTION: This first randomised trial in PAH/CTEPH patients with exercise-induced hypoxaemia demonstrates that DOXT improves exercise capacity, quality of life and functional class. The results support large long-term randomised trials of DOXT in PAH/CTEPH.

Quality of life in patients with chronic thromboembolic pulmonary hypertension.

Patients with chronic thromboembolic pulmonary hypertension (CTEPH) experience debilitating symptoms that have a negative impact on their quality of life (QoL) in terms of physical capability, psychological wellbeing and social relationships. The use of QoL measurement tools is important in the assessment of treatment efficacy and in guiding treatment decisions. However, despite the importance of QoL, particularly to the patient, it remains under-reported in clinical studies of CTEPH therapy. CTEPH is unique in pulmonary hypertension in that it is potentially curable by surgery; however, a proportion of patients either have residual PH following surgery or are not operable. Although some patients with CTEPH have been treated off-label with pulmonary arterial hypertension-specific therapies, there have been few randomised controlled trials of these therapies in patients with CTEPH. Moreover, in these trials QoL outcomes are variably assessed, and there is little consistency in the tools used. Here we review the assessment of QoL in patients with CTEPH and the tools that have been used. We also discuss the effect of surgical intervention and medical therapies on QoL. We conclude that further studies of QoL in patients with CTEPH are needed to further validate the optimal QoL tools.

Patients' attitude and knowledge about oral anticoagulation therapy: results of a self-assessment survey in patients with atrial fibrillation conducted by the European Heart Rhythm Association.

The purpose of this European Heart Rhythm Association survey was to assess the attitude, level of education, and knowledge concerning oral anticoagulants (OACs) among patients with atrial fibrillation (AF) taking vitamin K antagonists (VKAs), non-VKA oral anticoagulants (NOACs) or antiplatelets. A total of 1147 patients with AF [mean age 66 ± 13 years, 529 (45%) women] from 8 selected European countries responded to this survey. The overall use of OACs and antiplatelets was 77 and 15.3%, respectively. Of the patients taking OACs, 67% were on VKAs, 33% on NOACs, and 17.9% on a combination of OACs and antiplatelets. Among patients on VKAs, 91% correctly stated the target international normalized ratio (INR) level. The proportion of patients on VKA medication who were aware that monthly INR monitoring was required for this treatment and the proportion of patients on NOAC who knew that renal function monitoring at least annually was mandatory for NOACs was 76 and 21%, respectively. An indirect estimation of compliance indicated that 14.5% of patients temporarily discontinued the treatment, and 26.5% of patients reported having missed at least one dose. The survey shows that there is room for improvement regarding education and adherence of patients taking OACs, particularly regarding monitoring requirements for NOACs.

[Development of a questionnaire to identify patients' preference for a conventional or a direct oral anticoagulant]. / Entwicklung eines Fragebogens zur Identifikation der Präferenz von Patienten für ein konventionelles oder ein direktes orales Antikoagulanz.

BACKGROUND: Oral anticoagulant therapy is currently performed using vitamin K-dependent (VKA) or novel, non-vitamin-K-dependent (NOAC) anticoagulants. Patients can thus be involved into the decision process which type of anticoagulants to use. Preference of patients for a specific type of anticoagulants is included in several international guidelines for prophylaxis of embolic events in patients with atrial fibrillation. METHOD: Description of the development of a short questionnaire to identify this preference in patients treated with VKA. RESULTS: Using the questionnaires Freiburger personality inventory (FPI-R), health survey SF-12, State-Trait Anxiety Inventory (STAI) and a self-developed questionnaire on anticoagulant therapy, multiple regression analysis identified 7 items for the willingness of patients to change anticoagulation from VKA to NOAC with a probability of about 90%. CONCLUSION: Further investigations have to be performed to identify the preference of patients for anticoagulation with VKA using this short questionnaire.

Practical management approaches to anticoagulation non-compliance, health literacy, and limited English proficiency in the outpatient clinic setting.

Warfarin is a widely used oral anticoagulant. It is highly efficacious for the treatment and prevention of thromboembolic disorders despite its narrow therapeutic window. Poor compliance with warfarin is common and a major contributor to poor anticoagulation control. A number of psychosocial issues (e.g. depressive symptoms, attitudinal and behavioral factors, cognitive function, lack of social support, limited English proficiency, health illiteracy) have been associated with warfarin non-compliance among patients in anticoagulation clinics. Patient-specific features, such as these, are important to identify in order to develop appropriate and practical interventions. Health literacy and limited English proficiency are the extension of issues related to culture, language, and ethnicity. A better understanding of patients' functioning level and health utilization factors may help to develop and target interventions for high risk patients and reduce complications from suboptimal therapy and poor warfarin management due to non-compliance. Four patient case scenarios will be used to illustrate these issues and identify potential interventions to optimize warfarin therapy.

Awareness and Perception of Thromboembolism and Thromboprophylaxis among Hospitalized Patients in Jordan.

BACKGROUND AND OBJECTIVE: Despite the established importance of thromboprophylaxis in patients with Venous Thromboembolism (VTE), a limited number of studies have assessed the awareness of VTE and thromboprophylaxis therapy among the affected patients. The aim of the current study was to assess awareness and to explore variables associated with awareness about VTE and its thromboprophylaxis. METHODS: A cross-sectional study was conducted on hospitalized patients who received thromboprophylaxis (5000 units of heparin subcutaneously (SC) q8-12h, or 30-40 mg of enoxaparin SC once daily). In addition to the sociodemographic variables, awareness and perception of VTE and its thromboprophylaxis were assessed using a validated questionnaire. Multiple logistic regressions were conducted to build a model of variables significantly associated with VTE awareness. RESULTS: A total of 225 patients participated in the study, with only 38.2% and 22.2% of the participants being aware of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) respectively. Logistic regression showed that the participants with low educational level had 3.046 value, with the odds being not aware of DVT or PE compared with participants with high educational level. Participants without a personal history of VTE had 7.374 value, with the odds being not aware of DVT or PE compared with those who had a personal history of VTE. Participants who had a negative perception of VTE had 2.582 value, with the odds being not aware of DVT or PE compared with participants who had a positive perception and those who did not have any information about DVT or PE had 13.727 value, with the odds being not aware of DVT or PE. CONCLUSION: The findings reveal that there is a lack of awareness about VTE and its thromboprophylaxis among the study participants. Patients with lower educational level and those with no history of previous VTE need awareness improvement about VTE and its thromboprophylaxis. Clinical Pharmacists need to focus on providing information about VTE and improving patients' perception about VTE and its thromboprophylaxis with the aim of improving the awareness about VTE, and hence the better health outcome.

The emotional impact of genetic testing and aspects of counseling prior to prescription of oral contraceptives.

BACKGROUND: Oral contraceptives increase the thrombotic risk in women with factor V Leiden. Emotional aspects of genetic testing prior to the prescription of oral contraceptives (OC), aspects of counseling and referral patterns are widely unknown. STUDY DESIGN: Two hundred forty-seven women with and 132 women without factor V Leiden were interviewed by questionnaire. RESULTS: One hundred sixty-one women (65%) with factor V Leiden and 63 (48%) with wild-type factor V responded. One hundred seventy-one women (76%) reported being emotionally disturbed by genetic testing. Eighty percent of women with factor V Leiden and 16% of women with wild-type factor V were discouraged from OC use. Three percent of women with factor V Leiden were encouraged to take OC. Forty-one percent of women with factor V Leiden used at least one hormone contraceptive method after diagnosis. Only 46 women (29%) with factor V Leiden were counseled about the relevance of the mutation in case of pregnancy. CONCLUSIONS: Testing for factor V Leiden has considerable emotional impact. Recommendations after testing are not consistently driven by the test result.

The management of oral anticoagulant therapy: the patient's point of view.

The aims of this study were to investigate on the general adhesion of the patients to oral anticoagulant therapy, and particularly on the quality of life of our patients, the doctor-patient relationship and the Centre-patient relationship. For this purpose we administered a questionnaire containing 17 main questions each with a maximum of 4 secondary questions. The questionnaire was administered to two groups of 127 and 137 oral anticoagulated patients (127 males and 137 females, mean age 55 +/- 19 years), followed at two Anticoagulation Clinics, in two Italian cities, Cagliari (Sardinia) and Padua (North East Italy). The cities differed in the number of patients monitored and the management modalities of anticoagulation. The results show that oral anticoagulant therapy does not limit the life-style of the patients. Only 11% of the patients complain of limitations to their daily life. Fifty-two percent believe their health has improved, and 87% are not afraid of negative consequences. The doctor-patient relationship is considered very important by 96% of patients. Seventy-eight percent refer to the Anticoagulation Clinic also for other health problems, 93% consider it important to be assessed by the doctor at the Anticoagulation Clinic, while 83% believe the doctor should always hand out the results personally. We conclude that in general oral anticoagulant therapy is accepted by the majority of patients, in spite of the need for periodic monitoring. The doctor-patient relationship should be taken into account, even in the case of a monitored, computer-assisted method of dose-adjustment.

A comparison of 3 valuation methods for temporary health states in patients treated with oral anticoagulants.

BACKGROUND: The application of the time tradeoff (TTO) method in temporary health states may lead to less valid results because an unrealistic scenario is presented to patients. The chained TTO has been proposed to solve this problem. OBJECTIVES: To compare a chained TTO method with a conventional TTO method in the valuation of temporary health states, in terms of consistency and reliability. To compare both TTO methods with direct rating. PATIENTS AND METHODS: Eighty-four patients treated with oral anticoagulants were interviewed twice. During the 1st interview, values for 5 temporary health states were obtained with a rank ordering procedure, direct rating, and the chained TTO method. During the 2nd interview, either the 1st interview was repeated (n = 30) or health state values were obtained with the conventional TTO method (n = 54). Consistency was assessed by comparing the 3 valuation methods with the rank ordering procedure. Generalizability theory was used to assess reliability. RESULTS: The 3 methods produced significantly different valuations of health states. Chained TTO values were higher than values obtained with direct rating and the conventional TTO. Consistency and reliability did not differ across the 3 methods. CONCLUSION: The authors found no evidence for a difference in consistency and reliability between the chained TTO method and the conventional TTO method in the valuation of temporary health states. As direct rating is simpler to administer than both TTO methods, one could consider using direct ratings for the valuation of temporary health states. Biases associated with the conventional and the chained TTO method are discussed.

Telephone versus office-based management of warfarin: impact on international normalized ratios and outcomes.

Studies have concluded that telephone-based management of warfarin is an effective alternative to in-office management. High rates of patient and physician satisfaction have been reported with telephone-based monitoring. Proposed benefits of telephone-based monitoring include time- and cost savings for patients and healthcare providers alike as well as increased access to care for those patients who have difficulty making in-office appointments. This study aimed to evaluate the impact of telephone versus office-based management of warfarin on extreme INR values. A retrospective cohort study was conducted to assess outcomes of patients receiving warfarin managed either by telephone or in-office appointments. The primary endpoint of the study was the frequency of extreme INR values, defined as an INR ≤1.5 or ≥4.5. A total of 110 patients were evaluated; subjects were distributed 2:1 between the in-office and telephone groups. Baseline characteristics were similar between groups. Subjects followed via telephone had a twofold increase in the incidence of extreme INR values compared to the patients followed in-office (15.18 vs. 7.98 %; p < 0.0001). Overall TTR was similar between groups (85.39 vs. 80.38 %, p = 0.1171). There was no difference between the two groups in the incidence of major bleeding events (2.67 vs. 0 %, p = 1.00), thromboembolic events (8 vs. 0 %, p = 0.1740), or hospitalizations related to anticoagulation therapy (6.67 vs. 0 %, p = 0.1758). Patients monitored via telephone had a higher incidence of extreme INR values than patients followed in-office, which may lead to an increased incidence of adverse outcomes in the long-term. Well-designed, prospective studies are needed to confirm such findings.

Lexical learning in mild aphasia: gesture benefit depends on patholinguistic profile and lesion pattern.

Gestures accompany speech and enrich human communication. When aphasia interferes with verbal abilities, gestures become even more relevant, compensating for and/or facilitating verbal communication. However, small-scale clinical studies yielded diverging results with regard to a therapeutic gesture benefit for lexical retrieval. Based on recent functional neuroimaging results, delineating a speech-gesture integration network for lexical learning in healthy adults, we hypothesized that the commonly observed variability may stem from differential patholinguistic profiles in turn depending on lesion pattern. Therefore we used a controlled novel word learning paradigm to probe the impact of gestures on lexical learning, in the lesioned language network. Fourteen patients with chronic left hemispheric lesions and mild residual aphasia learned 30 novel words for manipulable objects over four days. Half of the words were trained with gestures while the other half were trained purely verbally. For the gesture condition, rootwords were visually presented (e.g., Klavier, [piano]), followed by videos of the corresponding gestures and the auditory presentation of the novel words (e.g., /krulo/). Participants had to repeat pseudowords and simultaneously reproduce gestures. In the verbal condition no gesture-video was shown and participants only repeated pseudowords orally. Correlational analyses confirmed that gesture benefit depends on the patholinguistic profile: lesser lexico-semantic impairment correlated with better gesture-enhanced learning. Conversely largely preserved segmental-phonological capabilities correlated with better purely verbal learning. Moreover, structural MRI-analysis disclosed differential lesion patterns, most interestingly suggesting that integrity of the left anterior temporal pole predicted gesture benefit. Thus largely preserved semantic capabilities and relative integrity of a semantic integration network are prerequisites for successful use of the multimodal learning strategy, in which gestures may cause a deeper semantic rooting of the novel word-form. The results tap into theoretical accounts of gestures in lexical learning and suggest an explanation for the diverging effect in therapeutical studies advocating gestures in aphasia rehabilitation.

Self-management of oral anticoagulation in elderly patients - effects on treatment-related quality of life.

UNLABELLED: BACKGROUND - RATIONALE FOR STUDY: In elderly patients, long-term self-management of oral anticoagulation has been shown to reduce the number of major thromboembolic and bleeding complications and improve the quality of oral anticoagulation (OAC) control compared to routine care for a mean follow-up period of three years. This article presents the results of the predefined secondary endpoint treatment-related quality of life (QoL). METHODS AND RESULTS: The effect of self-management on five aspects of QoL was evaluated in comparison with routine care. A validated questionnaire specifically designed for patients receiving OAC was used. The evaluation was possible for 141 patients, comprising 90% of surviving patients on OAC. At baseline, all patients had high scores for the following QoL-aspects: general treatment satisfaction, self-efficacy, daily hassles and strained social network. A high proportion of patients in both groups explicitly reported high distress, indicating that general psychological distress seems to be of particular concern in this population. After about 3 years of follow-up, patients performing self-management showed a significantly greater improvement in general treatment satisfaction than controls (median score increase [25th percentile, 75th percentile]: 0.9 [0.0, 1.6] vs. 0.0 [-0.2, 0.6], p=0.002; scale 1-6). Changes in general psychological distress, self-efficacy, daily hassles and strained social network were not significant. CONCLUSION: Treatment related quality of life in elderly patients performing self-management of OAC was similar as for patients in routine care setting, with a tendency of higher general treatment satisfaction, after three years of follow up.

Health care use in depressed, elderly, cardiac patients and the effect of antidepressant use.

PURPOSE: The association between a diagnosis of depression after a thromboembolic event (TEE) and an increase in acute health care use was examined. METHODS: A cohort of Medicare beneficiaries who were 65 years of age and older, who resided in the community, and who also experienced a TEE was constructed from the 1997-2001 Medicare Current Beneficiary Survey. Beneficiaries were assessed for TEEs and depression using the International Classification of Diseases, 9th Revision, Clinical Modification codes listed on Medicare claims. Time to first emergency department (ED) visit, inpatient hospitalization, and outpatient hospital visit were assessed using Cox-proportional hazard models. Counts of offices visits were assessed using negative binomial-regression models. RESULTS: Of the 7051 elderly patients included in the analysis, the total number with a claim for depression within 6 months of having a TEE was 380 (5.4%), including 259 antidepressant users (68.2% of depressed elders) and 198 selective serotonin-reuptake inhibitor (SSRI) users (76.4% of antidepressant users). Over half of elders with a depression claim (52.4%) had an inpatient hospitalization within 12 months of having a TEE compared to one third of the entire study sample (36.4%). Depressed elders had a 51% greater risk of hospitalization, a 56% greater risk of ED visits, and a 19% greater risk of outpatient visits. Antidepressant use did not affect the findings and was not found to be associated with health care use. CONCLUSION: A claim for depression by Medicare patients was associated with the increased use of acute health care services, including hospitalizations and ED visits, in the 12 months following a TEE. Neither antidepressant use nor SSRI use was associated with an increase or reduction in risk of using such services.

Acceptability of low molecular weight heparin thromboprophylaxis for inpatients receiving palliative care: qualitative study.

OBJECTIVE: To find out what inpatients with advanced cancer who are receiving palliative care think about the effect of thromoprophylaxis on overall quality of life. DESIGN: Qualitative study using audiotaping of semistructured interviews. SETTING: Regional cancer centre in Wales. PARTICIPANTS: 28 inpatients with advanced metastatic cancer receiving palliative care and low molecular weight heparin. MAIN OUTCOME MEASURES: Recurring themes on the effect of thromboprophylaxis on overall quality of life. RESULTS: Major emerging themes showed that patients knew about the risks of venous thromboembolism and the purpose of treatment with heparin. Media coverage had raised awareness about venous thromboembolism, and many had previous experience of thromboprophylaxis. All found low molecular weight heparin an acceptable intervention, and many said that it improved their quality of life by giving them a feeling of safety and reassurance. Antiembolic stockings were considered uncomfortable and had a negative impact on quality of life. Patients were concerned that because they had advanced disease they might not be eligible for thromboprophylaxis. CONCLUSION: Low molecular weight heparin is acceptable to inpatients with advanced cancer receiving palliative care and has a positive impact on overall quality of life. Antiembolic stockings are an unacceptable intervention in this patient group. Guidelines on thromboprophylaxis are urgently needed for palliative care inpatient units and hospices.

Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis.

OBJECTIVES: To quantify the influence of physicians' experiences of adverse events in patients with atrial fibrillation who were taking warfarin. DESIGN: Population based, matched pair before and after analysis. SETTING: Database study in Ontario, Canada. PARTICIPANTS: The physicians of patients with atrial fibrillation admitted to hospital for adverse events (major haemorrhage while taking warfarin and thromboembolic strokes while not taking warfarin). Pairs of other patients with atrial fibrillation treated by the same physicians were selected. MAIN OUTCOME MEASURES: Odds of receiving warfarin by matched pairs of a given physician's patients (one treated after and one treated before the event) were compared, with adjustment for stroke and bleeding risk factors that might also influence warfarin use. The odds of prescriptions for angiotensin converting enzyme (ACE) inhibitor before and after the event was assessed as a neutral control. RESULTS: For the 530 physicians who had a patient with an adverse bleeding event (exposure) and who treated other patients with atrial fibrillation during the 90 days before and the 90 days after the exposure, the odds of prescribing warfarin was 21% lower for patients after the exposure (adjusted odds ratio 0.79, 95% confidence interval 0.62 to 1.00). Greater reductions in warfarin prescribing were found in analyses with patients for whom more time had elapsed between the physician's exposure and the patient's treatment. There were no significant changes in warfarin prescribing after a physician had a patient who had a stroke while not on warfarin or in the prescribing of ACE inhibitors by physicians who had patients with either bleeding events or strokes. CONCLUSIONS: A physician's experience with bleeding events associated with warfarin can influence prescribing warfarin. Adverse events that are possibly associated with underuse of warfarin may not affect subsequent prescribing.

Predictors of cognitive dysfunction in patients with systemic lupus erythematosus.

OBJECTIVE: To evaluate predictors of cognitive dysfunction in patients with systemic lupus erythematosus (SLE). METHODS: The authors evaluated 123 patients enrolled in the San Antonio Lupus Study of Neuropsychiatric Disease (SALUD) who had completed at least 3 years of follow-up. Study visits occurred every 4 months and included a standard medical history, physical examination, and cognitive testing. Blood was obtained at each study visit for autoantibody testing. RESULTS: There were 116 (94.3%) women and 7 (5.7%) men (mean age = 41.5 [+/-12.0] years). Patients had the following vascular risk factors: hypercholesterolemia (17.1%), diabetes (21.1%), and hypertension (48.0%). Consistent medication use included aspirin (21.1%), prednisone (65.0%), nonsteroidal anti-inflammatories (42.3%), and hydroxychloroquine (58.5%). The numbers of patients with consistently positive autoantibody levels were as follows: antiphospholipid, 54%; anti-beta-2-glycoprotein 1, 73%; and anti-ribosomal P, 17%. Factors significantly associated with declining cognitive function were consistently positive antiphospholipid antibodies, consistent prednisone use, diabetes, higher depression scores, and less education. The association of prednisone and poorer cognitive function was seen primarily in the middle age group and could not be totally explained by SLE-associated disease activity. Consistent aspirin use was associated with improved cognitive function, primarily in the oldest age group, especially if diabetes was also present. CONCLUSIONS: Regular aspirin use is associated with improved cognitive function in older patients with systemic lupus erythematosus (SLE) in conjunction with the presence of other vascular risk factors. Regular prednisone use is associated with decreased cognitive functioning in middle-aged patients with SLE. Although this prednisone effect was independent of measures of SLE-associated disease activity, the authors cannot exclude the possibility that consistent prednisone use is a surrogate for more severe disease.

Attitudes to the use of prophylaxis for thrombo-embolism in neurosurgical patients.

Neurosurgical patients are at significant risk of thromboembolic complications. A survey of 58 consultant neurosurgeons in United Kingdom confirmed that 84.5% regularly used some form of prophylaxis. For all forms of neurosurgery, the most preferred method of prophylaxis was mechanical (graduated compression stockings-TEDS and intra-operative pneumatic calf compressors-IPC) or in the post-operative period a combination of mechanical methods and low molecular weight heparin (LMWH). LMWH was rarely administered in the perioperative period. The majority of neurosurgeons believed that TEDS and LMWH reduced post-operative DVT (79% and 90%, respectively) and PE (43% and 67%), but 29% associated LMWH with bleeding complications. A review of current literature revealed that TEDS, IPC, and LMWH are effective in reducing the incidence of DVT, but the evidence over the safety of heparin is inconclusive in neurosurgical patients. There is still room for improvement as a minority of neurosurgeons continue to ignore the importance of prophylaxis against thrombo-embolism in neurosurgery.

Apathy following cerebrovascular lesions.

BACKGROUND AND PURPOSE: Although apathy has been reported to constitute a frequent sequela of stroke lesions, there have been no prospective studies on the frequency and correlates of apathy after stroke lesions. In the present study, we examined the frequency and correlates of apathy in a consecutive series of 80 patients with cerebrovascular lesions. METHODS: We included patients within the first 10 days after a stroke lesion. Patients were examined with a comprehensive neuropsychiatric battery that included the Apathy Scale. RESULTS: Eighteen patients (22.5%) showed apathy, nine of whom were also depressed. On the other hand, 18 patients (22.5%) showed depression in the absence of apathy. Although depression and apathy may exist independent of one another, major depression (but not minor depression) was associated with an increased frequency of apathy. Apathy was also significantly associated with older age, cognitive impairments, and deficits in activities of daily living. Finally, apathy was significantly associated with lesions in the posterior limb of the internal capsule. CONCLUSIONS: These findings demonstrate that apathy is a frequent finding among patients with acute stroke lesions and may coexist with important emotional and cognitive poststroke disturbances.