Part II | Vascular risk factors for depression and apathy 133 7 Moreover, to our knowledge no studies have been performed that compared clinical symptoms of apathy in CSVD patients to clinical symptoms of apathy in other populations. And, given that currently there is no convincing evidence to suggest that vascular apathy is clinically distinct from apathy due to other causes both are diagnosed according to the same consensus criteria 1. Moreover, when CSVD is identified as the likely cause of apathy, this does not alter the treatment since no specific other options have been developed. Monitoring both systolic and diastolic blood pressure should be emphasized 84, while physical activity, occupational therapy and/or cognitive interventions are the non-pharmacological treatments of choice 85. The evidence for the efficacy of pharmacological interventions is still weak and confined to specific populations, and for CSVD related-apathy no such evidence exists 86 87. Further, often CSVD will not be the sole cause of apathy. According to the diagnostic criteria 1 sedative medication, physical impairment and important psychosocial changes that induce apathetic behavior should be ruled out before diagnosing an apathy syndrome, but even then, other causes of apathy, -in particular neurodegenerative processes and depression-, often co-occur with CSVD 72 79 48 . In conclusion, based on our review of the literature we can argue that the use of the term vascular apathy is justified by the evidence that CSVD is a cause of apathy. Furthermore, apathy in CSVD patients can often be distinguished from other clinical syndromes which are associated with CSVD. However, there are no data to support that vascular apathy is different from other apathy syndromes in clinical presentation or treatment options and it accordingly does not qualify as a distinct clinical syndrome. The term vascular apathy would at this moment merely refer to the probable cause of the apathy and not to a clinically different syndrome. Further, since CSVD may often not be the sole cause of apathy and in clinical practice one cannot always be certain about which of several contributing factors is the most important, we recommend using the non-specific term apathy syndrome for the time being. Limitations The Bradford-Hill criteria which were used to evaluate the causal relationship between CSVD and apathy were not intended as a “check-list” of criteria, but as criteria to consider when distinguishing between association or causation 16. We aimed to stay true to this way of thinking. In our opinion, a narrative review better suited this purpose than a structured review or meta-analysis would, since in a narrative review a broader scope of evidence and arguments can be presented and more emphasis is put on the process of weighing of evidence and arguments.
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