Apathy

Primer

Apathy is a distinct neuropsychiatric syndrome that has various clinical definitions, which makes it difficult to study and examine clinically. It can be thought of as diminished cognitive plus emotional goal-directed behaviour.[1] Apathy is not the same as depression.[2]

Pathophysiology

Abulia

Abulia (from Greek, meaning “non-will”) is considered a more severe type of apathy, but its definition varies across providers and clinical utility remains unclear.[4] It is characterized by a lack of drive and initiative, no spontaneity, apathy, slowness of thought, blunted emotional responses and lack of response to external stimuli.

Diagnostic Criteria

There is no consensus diagnostic criteria for apathy as a syndrome. Apathy is mostly defined as a disorder of motivation, and where there is diminished goal-oriented behaviour and cognition.[5]

Proposed Diagnostic Criteria for Apathy

Adapted from: Starkstein, S., and Leentjens, A. F. (2008). The nosological position of apathy in clinical practice. JNNP. 79(10), 1088-1092
(A) Lack of motivation relative to the patient’s previous level of functioning or the standards of his or her age and culture as indicated either by subjective account or observation by others.
(B) Presence for at least 4 weeks during most of the day, of at least 1 symptom belonging to each of the following 3 domains:
1. Diminished goal directed behaviour
• Lack of effort or energy to perform everyday activities.
• Dependency on prompts from others to structure everyday activities.
2. Diminished goal directed cognition
• Lack of interest in learning new things, or in new experiences.
• Lack of concern about one’s personal problems.
3. Diminished concomitants of goal directed behaviour
• Unchanging or flat affect
• Lack of emotional responsivity to positive or negative events.
(C) The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
(D) The symptoms are not due to diminished level of consciousness or the direct physiological effects of a substance.

Treatment

  • Methylphenidate has been shown to be useful in the treatment of apathy specifically in Alzheimer's disease.[6]
    • Individuals who are not anxious or agitated, younger, already on an acetylcholinesterase inhibitor, have optimal diastolic blood pressure control (73-80 mm Hg), or more impaired function are more likely to benefit from treatment. [7]

Resources

For Providers

References

1) Marin, R. S., & Wilkosz, P. A. (2005). Disorders of diminished motivation. The Journal of head trauma rehabilitation, 20(4), 377-388.
2) Levy, M. L., Cummings, J. L., Fairbanks, L. A., Masterman, D., Miller, B. L., Craig, A. H., ... & Litvan, I. (1998). Apathy is not depression. The Journal of neuropsychiatry and clinical neurosciences, 10(3), 314-319.
3) Le Heron, C., Holroyd, C. B., Salamone, J., & Husain, M. (2019). Brain mechanisms underlying apathy. Journal of Neurology, Neurosurgery & Psychiatry, 90(3), 302-312.
4) Starkstein, S. E., & Leentjens, A. F. (2008). The nosological position of apathy in clinical practice. Journal of Neurology, Neurosurgery & Psychiatry, 79(10), 1088-1092.
5) Starkstein, S. E., Leentjens, A. F. (2008). The nosological position of apathy in clinical practice. Journal of Neurology, Neurosurgery Psychiatry, 79(10), 1088-1092.
6) Mintzer, J., Lanctôt, K. L., Scherer, R. W., Rosenberg, P. B., Herrmann, N., Van Dyck, C. H., ... & ADMET 2 Research Group. (2021). Effect of Methylphenidate on Apathy in Patients With Alzheimer Disease: The ADMET 2 Randomized Clinical Trial. JAMA neurology.
7) Lanctôt, K. L., Rivet, L., Tumati, S., Perin, J., Sankhe, K., Vieira, D., ... & Herrmann, N. (2023). Heterogeneity of response to methylphenidate in apathetic patients in the ADMET 2 Trial. The American Journal of Geriatric Psychiatry.