Apathy in People with Dementia


The term “apathy” is derived from the Greek word for passion: “pathos”. A-pathy describes a lack of passion. We’re all apathetic sometimes, but chronic apathy can be classified as a psychological/medical disorder. It’s like depression in that respect, and indeed depression and apathy often happen together and apathy is often mistaken for depression. But there is a distinction. Some say depression is a “disorder of emotion”, while apathy is a “disorder of motivation”.

Why should we want to treat apathy? Well, it diminishes quality of life for the patient and the caregiver. It can disable the patient, at least functionally, from some activities and capabilities. While medicines should never be administered without thought and while the elderly typically take many pills already, pharmacological treatment of apathy is viable.

Apathy is certainly a secondary condition - that is a symptom of other diseases and illnesses. Whether it is also a primary disease that should be attacked directly - that’s a matter of debate. Traumatic brain injuries and strokes often result in apathy. Neurological diseases such as dementia can also produce apathy.

Recognition of Apathy

Apathy symptoms include lack of motivation, not taking initiatives, and general indifference about life. It's not so much that the person has low subjective wellbeing; it's that the person has no opinion about his or her wellbeing at all.

Apathy is perhaps underappreciated as a medical problem partly because people do not approach doctors and nurses with complaints about it. People with apathy don’t mention it at the doctor’s office (Why would they? They’re apathetic.) And caregivers often don’t mention it as they think it is normal.

Further, when the symptoms are recognized, the condition is often classified as depression by doctors and lay people. There is a technical distinction between these two conditions although they share some symptoms and are often treated similarly.

A widely referenced scientific paper lists these diagnostic criteria.

  • Diminished goal-directed behavior
  • Diminished goal-directed cognition
  • Diminished emotion

Medicine, and especially psychiatry, is full of scales. There is an Apathy Evaluation Scale. Although we are not sure how widely it is used or whether psychiatrists take it seriously.

Dementia and Apathy

Dementia results in both apathy and depression. Frontotemporal dementia tends to be more on the apathy side, while Alzheimer’s is more on the depression side. This is consistent with the observation that brain injuries that affect the prefrontal cortex (and basal ganglia) are correlated with high rates of apathy.

Apathy is also frequently a problem for those with other chronic neurological disorders.

Many doctors start treatment of apathy with a cholinesterase inhibitor, especially if the patient has not been on one before. If symptoms do not improve dopamine agonists and/or stimulants are used.

Treatment

Because apathy resembles subcortical dementia in some ways, doctors often choose to treat it with dopamine receptor agonists.

The types of drugs used to treat depression are sometimes used. While the widely used SSRI medicines are not prescribed for apathy, dopamine agonists often are given. (SSRI antidepressants sometimes make apathy worse in elderly patients.) Also stimulants and cholinesterase inhibitors (widely used in treatment of Alzheimer’s) can be employed. The atypical antipsychotics used to manage schizophrenia have been reported to be useful for treating apathy in patients with dementias. Methylphenidate, also called Ritalin, is often prescribed, sometimes in combination with an antidepressant.

Italian scientists report use of Rivastigmine can help alleviate neuropsychiatric symptoms, including Apathy to some extent, in patients with Parkinson’s Disease Dementia. They admit they are “more circumspect” about the influence of Rivastigmine on apathy than on on some other symptoms.

Counters to Apathy

  • Involvement with other people
  • Involvement with community and wider world
  • Hobbies
  • Write a book - not a book about your memories, but an explanatory book about something. Make yourself into an expert and write it. Exercise
  • Read/Learn
  • Seek variety / Move locations
  • Avoid “shows” - tv addiction
  • Play chess, bridge, mah jong, etc.
  • Write poetry, short stories
  • Paint - not for commercial purposes, but for fun.

man and woman

Percepción Errónea o Malentendido

Apatía

"Old age is the most unexpected of all things that happens to man" - Leon Trotsky