Time to Care About Apathy: A Practical Guide for General Psychiatrists

SPECIAL REPORT: GERIATRIC PSYCHIATRY

Apathy, defined as a quantitative reduction in goal-directed activity compared with a patient’s previous functioning, is highly prevalent and pervasive in patients with cognitive impairment. It significantly impacts treatment outcomes across psychiatric and neurological conditions.¹ Despite its prevalence and clinical significance, apathy as a syndrome remains underrecognized and undertreated in general psychiatric practice.² Recent advances in assessment tools, treatment approaches, and our understanding of apathy subtypes now provide evidence-based strategies for effective management.

The 2021 consensus criteria define apathy as persistent symptoms (≥ 4 weeks) affecting at least 2 of the following domains: diminished initiative, diminished interest, or diminished emotional expression/responsiveness.³ Unlike depression, apathy involves emotional blunting and indifference rather than persistent negative mood states (Table 1).⁴

Case Vignette 1: Late-Life Depression vs Apathy

“Gemma,” a retired teacher aged 73 years, presents with her daughter’s concerns about “giving up on everything” during the past 3 months. Gemma has stopped gardening, no longer calls her friends, and shows little interest in her grandchildren’s visits. She denies feeling sad, hopeless, or guilty, stating, “I just don’t see the point anymore.” She does not show any somatic preoccupation. Her daughter notes Gemma responds to direct requests but rarely initiates activities independently.

This presentation illustrates the distinction between apathy and depression, which often co-occur with neurocognitive disorders.⁴ Although both conditions involve reduced activity and interest, apathy is characterized by emotional neutrality rather than negative affect.² Gemma’s lack of dysphoria, guilt, or hopelessness, as well as somatic preoccupation combined with her responsiveness to external stimuli, suggests primary apathy rather than depression.

The 3 Subtypes of Apathy

Research has identified 3 neurobiologically distinct apathy subtypes, each requiring different therapeutic approaches⁵:

1. Executive apathy (cognitive).

• Difficulty planning and organizing goals
• Problems with sustained attention and task completion
• Associated with dorsolateral prefrontal cortex dysfunction
• Best assessed with: Trail Making Test, Wisconsin Card Sorting Test

2. Emotional apathy (affective).

• Reduced emotional reactivity and empathy
• Diminished response to positive/negative events
• Linked to orbitofrontal and ventromedial prefrontal circuits
• Key observations: flat affect, reduced facial expression

3. Initiation apathy (auto-activation).

• Lack of self-initiated behavior despite preserved response to prompts
• Difficulty generating thoughts or actions spontaneously
• Associated with anterior cingulate and basal ganglia dysfunction
• Key observations: preserved ability when externally prompted

The Patient and Caregiver Experience

Recent qualitative research by Burgon et al reveals that patients and caregivers did not recognize apathy as a manifestation of neurocognitive decline but rather as an understandable response to everyday struggles with cognitive and physical decline.⁶ Clinicians can reframe apathy for families as a neurobiological symptom rather than a behavioral choice. This reduces caregiver distress and guilt while promoting therapeutic engagement.

Key themes from patient and caregiver interviews include the following⁶:

• Identity preservation. Patients withdraw to protect their remaining sense of self.
• Effort-outcome imbalance. Activities require increased effort for diminished reward.
• Environmental barriers. Lack of support and opportunities exacerbates symptoms.
• Misunderstanding. Families often interpret apathy as a willful lack of cooperation.

Assessment Algorithm

To best assess for apathy, screen all patients 65 years or older with the Brief Dimensional Apathy Scale (b-DAS) as part of routine visits or the comprehensive Apathy Motivation Index (AMI) assessment (Table 2). Clinicians can then identify predominant subtype(s) for targeted intervention and evaluate environmental and social contextual factors.⁶ It is also important to rule out depression, cognitive impairment, and potential medication effects during assessment. Lastly, it is imperative to support any potential caregiver burnout. The following tools can be used during this process.

For quick screening (2-3 minutes)…

b-DAS⁷: There are 9 items assessing all 3 subtypes with a clinical cutoff for significant apathy for each.

• Executive (clinical cutoff > 4 points): “When doing a demanding task, does the patient have difficulty working out what they have to do?”
• Emotional (clinical cutoff > 5 points): “Is the patient indifferent to what is going on around them?”
• Initiation (clinical cutoff > 6 points): “Does the patient think of new things to do during the day?”

For comprehensive assessment (10-15 minutes)…

AMI⁸: There are 18 items with excellent psychometric properties.

• Behavioral activation (6 items): “I make decisions firmly and without hesitation.”
• Social motivation (6 items): “I suggest activities for me and my friends to do.”
• Emotional sensitivity (6 items): “I feel awful if I say something insensitive.”
• Cutoff: Above 1.91 for moderate apathy and above 2.38 for severe apathy.

Assessment should tackle not just symptom severity but also environmental factors and caregiver dynamics that influence the presentation of apathy. Consider and document social support availability, environmental considerations, impediments to engagement, caregiver understanding, and cultural factors (as expression of motivation varies across cultural backgrounds) in your assessment.⁶

Etiology-Specific Interventions

Alzheimer Disease

Initiate donepezil or galantamine if the patient is not already receiving it for Alzheimer dementia.⁹ Add-on methylphenidate. The landmark ADMET 2 trial established methylphenidate 20 mg daily as the first evidence-based treatment for apathy in Alzheimer disease. Over 6 months, 27% of treated participants achieved complete remission vs 14% with placebo.¹⁰

Dosing Strategy:

• Start: 5 mg twice daily with breakfast and lunch.
• Titrate: Increase by 5 mg every 3 to 4 days.
• Target: 10 mg twice daily (most effective dose).
• Monitor: Blood pressure, weight, appetite (especially if combined with acetylcholinesterase inhibitors), and sleep. Mind interactions and contraindications (uncontrolled hypertension, recent myocardial infarction, arrhythmia).
• Maintain for 6 months.

Parkinson Disease

Dopamine agonists are the preferred first-line treatment. Network meta-analysis demonstrates efficacy of dopaminergic agonists but found them to be comparable in efficacy to other medication classes (cholinesterase inhibitors and antidepressants).¹¹ Dopaminergic medications are especially helpful for apathy in early Parkinson disease.¹²

Treatment Hierarchy Based on Quality of Evidence⁹:

1. Rotigotine patch: 2 to 8 mg/d (if not already on a dopamine agonist)
2. Pramipexole: 0.125 mg 3 times a day
3. Piribedil: 50 mg 3 times a day
4. Monitor for impulse control disorders with all dopamine agonists

Late-Life Depression

Address selective serotonin reuptake inhibitor (SSRI)–induced apathy. Ranges of 20% to 92% of patients on SSRIs develop treatment-emergent apathy.¹³ Recent evidence supports switching strategies rather than augmentation.

Management Algorithm:

1. Dose reduction of SSRI and monitor response.
2. Switch to another antidepressant class, such as bupropion XL 300 mg daily (dopaminergic activity) or vortioxetine.
3. Augmentation: Methylphenidate 5 to 10 mg twice a day if switching ineffective

Case Vignette 2: Alzheimer Disease With Apathy

“Robert,” a man aged 78 years, has mild Alzheimer disease, which was diagnosed approximately 18 months ago. His wife now reports that he has stopped his woodworking hobby, rarely speaks during family dinners, and needs prompting for basic hygiene. Donepezil has helped his memory but has not addressed the motivational decline. Mini-Mental State Exam: 24/30; AMI score: 2.1 (predominantly initiation apathy).

After 8 weeks of treatment with methylphenidate 5 mg twice a day, titrated to 10 mg twice daily over 2 weeks, Robert resumed simple woodworking projects and was more conversational at follow-up. His wife noted he now initiates some daily activities independently sometimes.

Pharmacological Interventions

Based on the 3 subtypes of apathy mechanisms^4,9:

Cognitive Processing Deficits (Dorsolateral PFC-Caudate):

• First-line: Cholinesterase inhibitors (donepezil, galantamine)
• Second-line: Methylphenidate

Emotional-Affective Processing Deficits (Orbital-medial PFC):

• Consider: Agomelatine
• Avoid: SSRIs

Auto-Activation Deficits (Basal Ganglia Output):

• Dopamine agonists (piribedil, rotigotine)
• Cholinesterase inhibitors (rivastigmine)

Nonpharmacological Interventions

Executive Apathy

Several behavioral activation interventions can be used to target executive apathy, including structured and predictable activity scheduling with graded task assignment, breaking complex activities into manageable steps, using external prompts and reminders, and focusing on previously enjoyed activities with high potential for reward.

Emotional Apathy

Interventions for emotional apathy can focus on social engagement. This can include group activities that target interpersonal connection. Music therapy has shown evidence in Parkinson disease,14 whereas virtual reality environments have shown promise in socially isolated patients.15

Environmental Modification for Initiation Apathy

Patients with initiation apathy may respond best to environmental modifications. Whenever possible, clinicians should help patients reduce decision-making demands, help provide or plan clear daily structure and routines, use visual cues and prompts, and train caregivers in prompting techniques.

Future Directions

Both repetitive transcranial magnetic stimulation (rTMS) and digital monitoring have shown promise in addressing apathy. High-frequency rTMS protocols targeting dorsolateral prefrontal cortex show efficacy in Alzheimer disease,¹⁶ and wearable devices may present an opportunity to screen for apathy through activity patterns, potentially enabling early detection and treatment response monitoring.

Concluding Thoughts

Apathy is a pervasive and treatment-resistant syndrome requiring systematic assessment and targeted intervention. By using validated screening tools for routine apathy detection, understanding apathy subtypes, and applying condition-specific, evidence-based pharmacological and behavioral treatment algorithms, psychiatrists can improve the quality of life of patients and their families.

Dr Fahed is an associate professor of psychiatry at the University of Connecticut School of Medicine in Farmington and an adjunct faculty member at the Yale School of Medicine in New Haven, Connecticut. He is board certified in geriatric psychiatry and adult psychiatry.

References

1. Robert P, Lanctôt KL, Agüera-Ortiz L, et al. Is it time to revise the diagnostic criteria for apathy in brain disorders? the 2018 international consensus group. Eur Psychiatry. 2018;54:71-76.

2. Steffens DC, Fahed M, Manning KJ, Wang L. The neurobiology of apathy in depression and neurocognitive impairment in older adults: a review of epidemiological, clinical, neuropsychological and biological research. Transl Psychiatry. 2022;12:525.

3. Miller DS, Robert P, Ereshefsky L, et al. Diagnostic criteria for apathy in neurocognitive disorders. Alzheimers Dement. 2021;17(12):1892-1904.

4. Lanctôt KL, Ismail Z, Bawa KK, et al. Distinguishing apathy from depression: a review differentiating the behavioral, neuroanatomic, and treatment-related aspects of apathy from depression in neurocognitive disorders. Int J Geriatr Psychiatry. 2023;38(2):e5882.

5. Levy R, Dubois B. Apathy and the functional anatomy of the prefrontal cortex-basal ganglia circuits. Cereb Cortex. 2006;16(7):916-928.

6. Burgon C, Goldberg S, van der Wardt V, Harwood RH. Experiences and understanding of apathy in people with neurocognitive disorders and their carers: a qualitative interview study. Age Ageing. 2023;52(3):afad031.

7. Radakovic R, McGrory S, Chandran S, et al. The brief Dimensional Apathy Scale: a short clinical assessment of apathy. Clin Neuropsychol. 2020;34(2):423-435.

8. Ang YS, Lockwood P, Apps MAJ, et al. Distinct subtypes of apathy revealed by the apathy Motivation Index. PLoS One. 2017;12(1):e0169938.

9. Theleritis C, Siarkos K, Politis A, et al. A systematic review of pharmacological interventions for apathy in aging neurocognitive disorders. Brain Sci. 2023;13(7):1061.

10. Mintzer J, Lanctôt KL, Scherer RW, et al; ADMET 2 Research Group. Effect of methylphenidate on apathy in patients with Alzheimer disease: the ADMET 2 randomized clinical trial. JAMA Neurol. 2021;78(11):1324-1332.

11. Mai AS, Lee YS, Yong JH, et al. Treatment of apathy in Parkinson’s disease: a bayesian network meta-analysis of randomised controlled trials. Heliyon. 2024;10(4):e26107.

12. Castrioto A, Schmitt E, Anheim M, et al. Improvement of apathy in early Parkinson’s disease. NPJ Parkinsons Dis. 2025;11(1):89.

13. Masdrakis VG, Markianos M, Baldwin DS. Apathy associated with antidepressant drugs: a systematic review. Acta Neuropsychiatr. 2023;35(4):189-204.

14. Shah-Zamora D, Anderson S, Barton B, Fleisher JE. Virtual group music therapy for apathy in Parkinson’s disease: a pilot study. J Geriatr Psychiatry Neurol. 2024;37(1):49-60.

15. Ho KY, Cheung PM, Cheng TW, et al. Virtual reality intervention for managing apathy in people with cognitive impairment: systematic review. JMIR Aging. 2022;5(2):e35224.

16. Jin Y, Li J, Xiao B. Efficacy and safety of neuromodulation for apathy in patients with Alzheimer’s disease: a systematic review and meta-analysis of randomized controlled trials. J Psychiatr Res. 2024;171:17-24.