"People are getting excited about apathy now
because it may be a behavioral marker for a
more rapidly progressing dementia," said
Prasad Padala, MD, assistant professor of
psychiatry at the University of Nebraska
Medical Center in Omaha.
A recent 4-year study linked apathy to a hastened decline in persons with Alzheimer disease (AD).1 Another recent study found that persons with mild cognitive impairment (MCI) were more likely to convert to AD a year later if they also had apathy.2
Another factor that has increased interest in apathy is the growing understanding of physical changes in the brain. For example, an autopsy study found that among persons with AD, those who had chronic apathy tended to have more neurofibrillary tangles than those without apathy.3 Clinically apathetic persons with dementia may even have a different genetic makeup than persons with dementia who are not apathetic. A recent study showed that persons with AD were more likely to be carriers of the ApoE e4 allele if they also had apathy.4
Apathy traditionally has received less attention than other neuropsychiatric states in dementia, such as depression, agitation, aggression, and psychosis. This is slowly changing. Although researchers are becoming more knowledgeable about the condition, treating it remains difficult. "There aren't many medications or other treatments that have shown efficacy in treating apathy," said Tiffany Chow, MD, assistant professor of neurology and geriatric psychiatry at the University of Toronto. But given the new interest in the condition, researchers expect full-scale randomized controlled trials to follow.
COMMON BEHAVIORAL PROBLEM
Apathy, which refers to a loss of motivation, is marked by such characteristics as diminished initiation, poor persistence, lack of interest, indifference, low social engagement, blunted emotional re- sponse, and lack of insight.5 It is the most common behavioral disturbance in dementia. Prevalence rates are as high as 80% in clinic samples of patients with primary dementia and range from 27% to 36% in community samples.6 An analysis of 3 European studies produced a mean of about 56%.7 The incidence of apathy increases with the severity of the dementia.
"In the beginning stages of dementia, people may withdraw from activities because they're aware of what's going on and want to avoid making themselves look bad," said Chow. "Then in the moderate to severe stages, they do shut down and are not able to initiate their own activities."
Apathy has a dramatic effect on persons with dementia and their families. First, the condition leads to decreased function. In one study, persons with apathy were nearly 3 times more likely than those without apathy to be impaired in dressing, bathing, transferring from bed to chair, using the toilet, walking, or eating and more than 3 times more likely to be impaired in all 6 activities.8
Second, apathy is linked to executive cognitive dysfunction. For example, a study of 184 patients with probable AD found that apathetic patients had significantly poorer performance in naming, word-list learning, verbal fluency, and set-shifting than those without apathy.9 "Without interest or initiative, it's difficult for these patients to use their remaining cognitive function," said Philippe Robert, MD, director of the Memory Center for Care and Research at Nice University Hospital in France.
Third, apathy makes persons less likely to comply with treatment. This can lead to setbacks in treatment not only for dementia but also for concomitant health conditions. Finally, the extreme burden on caregivers created by these deficits tends to increase caregiver distress. "People with apathy tend to depend a lot more on caregivers, even for things they can do on their own," said Padala. Although it has not been proved in studies, patients with apathy may require hired home care and institutional care earlier than other patients with dementia.
Apathy may pack an additional punch for caregivers who are family members because it chips away at the patient's personality. "The caregiver sees the person withdrawing and shutting down, and it seems like they're fading into the distance right before their eyes," said Chow. "A lot of family members say that they prefer someone doing obsessive-compulsive things to just being apathetic," she added.
The situation may be different in a nursing home, where apathetic patients who sit quietly and do not cause disturbances might be viewed as easy to care for. "If I were working in a nursing home, I would probably not be perturbed by apathetic patients as much as by someone who is having active hallucinations," said Padala. This may be one reason why apathy research has traditionally received less funding than research on problems such as agitation and psychosis.
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