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Apathy Evaluation Scale (AES)

Last Updated: Monday, February 16, 2009

Apathy Evaluation Scale (AES Form)

Apathy is a common problem following traumatic brain injury (TBI). The Apathy Evaluation Scale (AES) was developed by Marin (1991) as a method for measuring apathy resulting from brain-related pathology. He defined apathy as lack of motivation not attributable to diminished level of consciousness, cognitive impairment, or emotional distress. (Marin, 1991). He also relates an operational definition: a state characterized by simultaneous diminution in the overt behavioral, cognitive, and emotional concomitants of goal-directed behavior. (Marin et al, 1991) Stemming from this definition, Marin described three domains of apathy:

Deficits in goal-directed behavior A decrement in goal-related thought content Emotional indifference with flat affect (Marin, 1996)

Although it was originally used in people with stroke, Alzheimers disease, and depression, Kant et al. (1998) used the AES to study people with traumatic brain injury (TBI). He found that 85% of those who were apathetic according to AES also met their criteria for depression using the Beck Depression Inventory-II. Because this study implies that the AES may not distinguish the apathy of depression from neurologically-based apathy, Glenn et al. (2002) modified Marins definition of apathy, deleting the exclusion due to "emotional distress" and adding some other clarifications as well: "lack of motivation not attributable to diminished level of consciousness, cognitive impairment, or motor dysfunction; and manifested by decreased initiative, akinesia, emotional indifference, and flat affect. (adapted from Marin, 1991). Stuss et al (2000) have questioned whether apathy is a single construct.

Rater

For the AES-S and AES-I, the person filling out the scale is instructed: For each question, circle the answer that best describes your (his/her) thoughts, feelings, and actions during the past 4 weeks. (Marin, 1991) There are additional instructions for the interview done for the AES-C:

Instructions to patient: I am going to ask you a series of questions about your thoughts, feelings, and activities. Base your answers on the last 4 weeks. To begin, tell me about your current interests. Tell me about anything that is of interest to you. For example, hobbies or work; activities you are involved in or that you would like to do; interest within the home or outside; with otheer people or alone; interests that you may be unable to pursue, but which are of interest to youfor example, swimming even though its winter.

Intervieweer then notes: (1) Number of interests reported; (2) degree of detail reported for each interest; (3) affective aspects of expression (verbal and nonverbal).

Interviewer then states: Now Id like you to tell me about your average day. Start from the time you wake up and go to the time you go to sleep. How the patient deals with this (and all other) questions is assumed to provide information about how other activities are dealt with (e.g., with initiative, exuberance, and energy). Therefore, prompting is indicated only if the subject seems not to understand what information is being sought or has forgotten the question.

Interviewer notes number of activities, degree of detail, intensity and duration of involvement, and affect associated with presentation of data.

Each item is now presented using the wording of the item itself. Additional information may be requested to clarify responses. Item 15, Accurate understanding of problems, is rated by appraising subjects awareness and understanding of personal or, if present, clinical problems. Simple bridges between items may be used to preserve a conversational quality to the interview. Items are rated as they are presented using all information acquired. The response recorded is the clinicians assessment of the subjects response. Thus, if a subject states a lot but the clinician judges somewhat, the latter is used. The only exceptions are the self-evaluation (SE) items in [the interview] (#3, #8, #13, #16). For these items, the subject specifies which response code to use (e.g., Not at All, Slightly); the clinician raters appraisal is not considered for SE items.

All items are coded as follows: 1. Not at all characteristic. 2. Slightly characteristic (trivial, questionable, minimal). 3. Somewhat characteristic (moderate, definite). 4. Very characteristic (a great deal, strongly). Requires verbal or nonverbal evidence of intensity. Note: Very characteristic is the level obtained by normal individuals.

The criteria for applying these codes are quantified for several items (#1, #2, #4, #5, #12). These quantifiable items (labeled Q in [the rating scale]) are rated by counting the number of instances cited by the subject for a particular item (e.g., number of interests, number of friends): 1. Not at all: 0 items 2. Slightly: 1-2 items 3. Somewhat: 2-3 items 4. Very: 3 or more

When there is difficulty in choosing between ratings, the following guidelines are used: 1. In general, rate toward the more apathetic score. 2. Consider the degree of differentiation of responses. For example, rate Interest in things as Slightly if a subject simply specifies reading and television as interest, but Somewhat if specific books or television programs can be specified. Similarly, if a subject is interested only in reading, but provides multiple examples of reading materias, rate Somewhat or Very, based on the number of examples given. 3. Consider the presence of verbal and nonberbal evidence of affect. For example, rate toward lower apathy if subject uses phrases such as very much or tremendously, or uses facial expression, gesture, or vocal intonation to suggest affect. 4. If still in doubt, ask the patient whether, for example, Somewhat or Very is the more appropriate descriptor. (Marin, 1991)

Items for the AES-I and AES-S are rated as follows: Not at all true=1 Slightly true=1 Somewhat true=3 Very true=4 (Marin, 1991; Marin,1996) Some items have positive and some have negative syntax. After the form is filled out, scoring is arranged so that greater apathy results in higher scores