Assessment of apathy in neurological patients using the Apathy Motivation Index caregiver version

Verena S Klar,Patricia Lockwood,Sarosh R Irani,Daniel Drew,Elitsa Slavkova,Rhea Zambellas,Sofia Toniolo,Annika Kienast,Yuen‐Siang Ang,Shannon Dickson,Olivia Plant,Bahaaeddin Attaallah,Masud Husain,Maria R Maio

doi:10.1111/jnp.12262

Abstract

Apathy is a common, disabling neuropsychiatric syndrome that occurs across many brain disorders and may be associated with diminished motivation in behavioural, cognitive, emotional and social domains. Assessment is complicated by the variability of symptoms across apathy domains and self‐report from patients, which can be misleading due to their lack of insight. Independent evaluation by clinicians also has limitations though if it has to be performed with limited time. Caregiver reports are a viable alternative, but current assessments for them either do not distinguish between different apathy domains or are interview‐based and take long to administer. In this study, we developed a brief caregiver questionnaire version of the recently developed Apathy Motivation Index (AMI), which is a self‐report tool. We confirmed three apathy factors in this new caregiver measure (AMI‐CG) that were also present in the AMI: Behavioural Activation, Emotional Sensitivity and Social Motivation. Furthermore, we validated the scores against more extensive caregiver interviews using the established Lillle apathy rating scale as well as patient self‐reports of apathy, measures of depression, anhedonia, cognition, activities of daily living and caregiver burden across four different neurological conditions: Parkinson's disease, Alzheimer's disease, subjective cognitive impairment and limbic encephalitis. The AMI‐CG showed good internal reliability, external validity and diagnostic accuracy. It also uncovered cases of social apathy overlooked by traditional instruments. Crucially, patients who under‐rated their apathy compared to informants were more likely to have difficulties performing everyday activities and to be a greater burden to caregivers. The findings provide evidence for a multidimensional conceptualization of apathy and an instrument for efficient detection of apathy based on caregiver reports for use in clinical practice.

Highlights

Apathy is a common, disabling neuropsychiatric syndrome that occurs across many brain disorders and may be associated with diminished motivation in behavioural, cognitive, emotional and social domains
Prevalence rates of cognitive impairment, apathy, depression and anhedonia In order to assess prevalence rates of apathy and relevant neuropsychiatric features in our patient groups, we classified participants according to standard cut-off values
Patients were classified as apathetic if either the Apathy Motivation Index (AMI) or the LARS-CG indicated apathy, as depressed if either the Beck’s Depression Inventory (BDI) or the Geriatric Depression Scale (GDS) indicated depression, as anhedonic based on the Snaith–Hamilton Pleasure Scale (SHAPS), and cognitively impaired if the ACE

Summary

Introduction

Apathy is a common, disabling neuropsychiatric syndrome that occurs across many brain disorders and may be associated with diminished motivation in behavioural, cognitive, emotional and social domains. Apathy is increasingly recognized to be a common, disabling syndrome characterized by impairments of motivation and associated with poor prognosis (Husain & Roiser, 2018; Starkstein & Leentjens, 2008). It is considered a major neuropsychiatric manifestation of many brain disorders, including neurodegenerative and neuroinflammatory conditions, both common and rare. SCI can precede MCI, which in turn can progress to AD (Jessen et al, 2014, 2020; Reisberg et al, 2008; Slot et al, 2018) In these groups, the reported prevalence ranges from 2.2 to 75%, with apathy being associated with a two-fold increased risk of dementia (van Dalen et al, 2018). Should the assessment rely on self-report by the patient, the evaluation of a person who knows them well, such as a caregiver, or on independent interview of either the patient or the caregiver? All of these different types of assessment have been used with instruments that seek to dissociate different dimensions of the syndrome

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