Abstract
Importance: Given the importance of apathy for stroke, we felt it was time to scrutinize the psychometric properties of the commonly used Starkstein Apathy Scale (SAS) for this purpose.Objectives: The objectives were to: (i) estimate the extent to which the SAS items fit a hierarchical continuum of the Rasch Model; and (ii) estimate the strength of the relationships between the Rasch analyzed SAS and converging constructs related to stroke outcomes.Methods: Data was from a clinical trial of a community-based intervention targeting participation. A total of 857 SAS questionnaires were completed by 238 people with stroke from up to 5 time points. SAS has 14 items, rated on a 4-point scale with higher values indicating more apathy. Psychometric properties were tested using Rasch partial-credit model, correlation, and regression. Items were rescored so higher scores are interpreted as lower apathy levels.Results: Rasch analysis indicated that the response options were disordered for 8/14 items, pointing to unreliability in the interpretation of the response options; they were consequently reduced from 4 to 3. Only 9/14 items fit the Rasch model and therefore suitable for creating a total score. The new rSAS was deemed unidimensional (residual correlations: < 0.3), reasonably reliable (person separation index: 0.74), with item-locations uniform across time, age, sex, and education. However, 30% of scores were > 2 SD above the standardized mean but only 2/9 items covered this range (construct mistargeting). Apathy (rSAS/SAS) was correlated weakly with anxiety/depression and uncorrelated with physical capacity. Regression showed that the effect of apathy on participation and health perception was similar for rSAS/SAS versions: R2 participation measures ranged from 0.11 to 0.29; R2 for health perception was ∼0.25. When placed on the same scale (0–42), rSAS value was 6.5 units lower than SAS value with minimal floor/ceiling effects. Estimated change over time was identical (0.12 units/month) which was not substantial (1.44 units/year) but greater than expected assuming no change (t: 3.6 and 2.4).Conclusion: The retained items of the rSAS targeted domains of behaviors more than beliefs and results support the rSAS as a robust measure of apathy in people with chronic stroke.
Highlights
Apathy is a defining feature in many common neurological conditions, including Parkinson’s Disease, Alzheimer’s Disease, and stroke (Robert et al, 2018; Le Heron et al, 2019)
This study found that 9 of the original 14 items of the Starkstein Apathy Scale (SAS) fit a linear hierarchy suitable for measuring apathy in people with stroke
The results of the Rasch analysis on the original four-point ordinal scale showed that these thresholds were not used in a manner consistent with endorsing more positive response option with decreasing apathy
Summary
Apathy is a defining feature in many common neurological conditions, including Parkinson’s Disease, Alzheimer’s Disease, and stroke (Robert et al, 2018; Le Heron et al, 2019). Mayo et al (2009) estimated from an inception cohort that 20% of patients had apathy, as reported by a close companion, at some point in the first year post-stroke. The 2018 consensus group largely echoed Marin’s description, defining apathy as a quantitative reduction of goal-directed activity either in behavioral, cognitive, emotional, or social dimensions in comparison to the patient’s previous level of functioning in these areas. They indicated that these changes may be reported by patients themselves or be based on the observations of others
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