Aspects Of Apathy Research Articles

Apathy, empathy and depression in Alzheimer’s disease and frontotemporal dementia: Examining the constructs and white matter correlates

AbstractBackgroundApathy and reduced empathy are commonly observed in Alzheimer’s disease (AD) and the core features of behavioural‐variant frontotemporal dementia (bvFTD). Depression is also prevalent in these syndromes. Recent work has proposed a multidimensional framework of apathy which includes three aspects of apathy: executive apathy (reduction of planning and organisation), emotional apathy (emotional indifference and decreased social engagement) and initiation apathy (reduced behaviour execution). These aspects can manifest as symptoms resembling empathy loss and/or depression. The extent to which these symptoms represent similar/divergent clinical dimensions, and their underpinning neural networks, remains unclear. This study investigated the interrelations between apathy, empathy loss and depression, and its white matter correlates, in AD and bvFTD.MethodThirty‐four AD and 51 bvFTD patients participated in the study. Items of the Dimensional Apathy Scale, Interpersonal Reactivity Index and Depression Anxiety Stress‐Depression Subscale were examined using Principal Component Analysis (PCA). White matter integrity and its associations with clinical components were measured via changes in fibre density and cross‐section using fixel‐based analysis.ResultThree components were identified through the PCA (Fig 1). Component 1 consisted of items assessing emotional apathy and empathy, while Component 2 included executive apathy items. Finally, all depression items loaded into Component 3. Regarding white matter correlates, Component 2 were strongly related to reduced white matter bundle density and cross‐section in fibres connecting the bilateral frontal lobe and subcortical structures (Fig 2), whereas Components 1 and 3 were associated with distributed white matter reductions.ConclusionThis study demonstrates that while emotional apathy and empathy loss share the underlying construct, executive apathy and depression are rather independent. White matter changes have strong implications for executive apathy, but not for emotional apathy, empathy and depression. Improved conceptualisation of these symptoms will be important for the development of personalised symptom‐specific therapies.

Multidimensional Apathy: The Utility of the Dimensional Apathy Scale in Huntington's Disease.

Apathy is a disorder of motivation common to Huntington's disease (HD). Recent conceptual frameworks suggest that apathy is not unitary but consists of discrete subtypes ("dimensions"). Which of the proposed dimensions are preferentially affected in HD, and how these dimensions evolve with disease progression is unknown. The Dimensional Apathy Scale (DAS) separates apathy into Executive, Initiation and Emotional subscales. Using the DAS, we aimed to: 1) Determine the apathy subtypes prevalent in HD; 2) Compare the DAS against a unitary measure of apathy (Apathy Evaluation Scale, AES); 3) Assess the reliability of self- and observer-ratings; and 4) Determine the relationship between the DAS, and disease burden, total functional capacity (TFC) and the AES. Fifty pre-manifest, 51 manifest-HD, 87 controls, and 50 HD-observers completed the DAS, AES, and TFC. Manifest-HD participants had the highest levels of apathy across all dimensions (30.4% on Executive subscale, 34.8% on Initiation subscale, and 15.2% on Emotional subscale), relative to pre-manifest and control participants. Self- and observer-ratings on the DAS did not differ. Hierarchical regressions across the entire gene-expanded sample showed that scores on the Initiation subscale correlated with AES scores; higher Executive subscale scores were related to higher disease burden; and Emotional subscale scores with lower total functional capacity. In this first study of the DAS in HD, manifest-HD participants were more apathetic than pre-manifest and control participants across all apathy subtypes. The DAS may be a useful tool for measuring different aspects of apathy in people with HD.

Differential impact of behavioral, social, and emotional apathy on Parkinson's disease.

Apathy is highly prevalent in Parkinson's disease. New findings suggest the syndrome is multifaceted. Here, we investigate whether all aspects of apathy are equally affected in Parkinson's disease and whether different dimensions of apathy were associated with depression and anhedonia. On the Apathy Motivation Index, while behavioral apathy and social apathy were elevated, emotional motivation was relatively preserved in Parkinson's disease, although a few patients did show impaired emotional sensitivity. Behavioral and social, but not emotional, apathy was associated with depression and anhedonia. These findings suggest aspects of motivation can be selectively impaired in Parkinson's disease and may have implications for guiding treatment.

Association between altered neurochemical metabolites and apathy in patients with Alzheimer's disease

Apathy was assessed through the Apathy Evaluation Scale (AES). 1H MRS was performed to measure neurochemical metabolite levels in the anterior cingulate region and right orbitofrontal region. Associations between neurochemical metabolites and the total score and subscores of each domain of the AES were analyzed. Altogether, 36 patients completed the study. Patients with lower N-acetylaspartate/creatine ratios (NAA/Cr) in the anterior cingulate region demonstrated higher total apathy scores (β = -0.56, p = 0.003) with adjustments for age, gender, educational level, dementia severity, and depression severity. In a further analysis, a lower NAA/Cr in the anterior cingulate region was associated with all subdomains of apathy, including cognition (β = -0.43, p = 0.028), behavior (β = -0.55, p = 0.002), and emotion (β = -0.50, p = 0.005). No statistically significant associations were discovered in the right orbitofrontal region. Our results suggest that apathy, in each of its cognitive, behavioral, or emotional subdomains is associated with brain neurochemical alterations in the anterior cingulate region. Abnormal neuronal integrity over the anterior cingulate cortex may exhibit a central role in causing all aspects of apathy in patients with AD.

Apathy in amyotrophic lateral sclerosis: insights from Dimensional Apathy Scale

Objectives: Apathy is associated with cognitive decline and worse survival in amyotrophic lateral sclerosis (ALS); an accurate evaluation of this aspect is relevant in clinical settings. The aims of this study are to evaluate the prevalence of apathy in a large ALS sample, using published diagnostic criteria, and to explore the psychometric properties, the sensitivity and the specificity of the Dimensional Apathy Scale (DAS) as a screening tool for apathy.Methods: One hundred and thirty-one patients underwent clinical interview based on diagnostic criteria for apathy, DAS, Apathy Evaluation Scale, and assessment of depression, global cognitive functioning, and non-verbal intelligence.Results: According to diagnostic criteria, apathy occurred in 28.2% of the patients. The DAS showed high consistency, convergent, and discriminant validities. Apathetic and non-apathetic patients significantly differed on total DAS and executive and Behavioral/Cognitive Initiation subscales, indicating good criterion validity. Receiver operating characteristics analysis, considering diagnostic criteria for apathy as gold standard, revealed that a score of 26/27 was an optimal cut-off score for the identification of apathy.Conclusions: The DAS is a valid screening tool for apathy and its aspects in ALS through limiting the impact of physical disability. Executive and behavioral/cognitive aspects of apathy, rather than emotional aspects, are more frequent in ALS.

Apathy is more severe in vascular than amnestic mild cognitive impairment in a community: The Kurihara Project

The aim of this study was to estimate the prevalence of apathy, and to compare vascular mild cognitive impairment (vMCI), amnestic MCI (amMCI), and other type using Clinical Assessment for Spontaneity (CAS). Agreement to take part in the study was obtained from 590 community dwellers, aged ≥75 years living in Kurihara, Japan. Of the 590 subjects, 221 had a clinical dementia rating (CDR) of 0 (normal); 295 had CDR 0.5 (mild cognitive impairment; MCI); and 74 had CDR 1+ (dementia). The CDR 0.5 subjects were divided into three groups: 55 with vMCI (Erkinjuntti et al. criteria), 91 with amMCI and 149 with other type. To evaluate the various aspects of apathy, we used the three CAS subscales: clinical interview (CAS1), self-evaluation (CAS2), and caregiver assessment (CAS3). Three analyses were then performed to determine: (i) the validity of CAS; (ii) the prevalence rate of apathy in CDR 0 versus CDR 0.5 versus CDR 1+; and (iii) the prevalence rate of apathy in normal versus vMCI versus amMCI versus other type. CAS was validated with the Apathy Evaluation Scale. There were significant differences among the three CDR groups in CAS1, CAS2 and CAS3 (P < 0.001). The prevalence rate of apathy in each CAS in the CDR 1+ group was higher than the CDR 0.5 group, which was higher than the CDR 0 group. There was a significant difference in CAS3 score between the four groups (the normal and the three subgroups; P < 0.001). Apathy in vMCI was more severe than in the other three groups (P < 0.05) on CAS3 score. vMCI subjects have more severe apathy compared with amMCI subjects on caregiver assessment.

Apathy in the Elderly: From Assessment to Treatment

In a clinical context, the term “apathy” refers to a clustering of behavioural and emotional symptoms that manifests as diminished interest and involvement in normal purposeful behaviour, diminished emotional responsiveness, and a lack of initiation and drives to complete nonroutine activities. Apathy may be one of the most common behavioural symptoms of neurodegenerative and other brain disorders yet it is one of the most underrecognised, underdiagnosed, and poorly managed aspects of these diseases. It is therefore gratifying that we have been able to produce a special issue on the topic of apathy covering aspects of significant interest to the practicing clinician. The papers in this issue encompass a broad spectrum of clinical aspects of apathy with a clear overarching theme of apathy as an important behavioural syndrome which warrants careful study of its features, diagnosis and management. The specific topics represented by the papers range from an exploration of the phenomenology of apathy and the manifestation of apathy in different neurodegenerative conditions, the overlap between apathy and depression, and the application of new technologies in the management of apathy in the nursing home settings. Behavioural syndromes such as apathy may inform diagnostic aspects of different types of dementia. In the paper by D. Quaranta et al., apathy-related items on the Neuropsychiatric Inventory [1] were compared in frontotemporal dementia and Alzheimer disease. Their findings suggest that the different anatomical substrates of the respective dementia types may drive the different clinical expression of apathy, which may, in turn, inform the diagnosis of the dementia type. The link between apathy and depression as well as apathy and impulsivity was explored in two contributions. D. Ahearn et al. found that in Parkinson's disease, apathy and impulsivity might overlap and that specific phenomenological profiles within the behavioural syndromes were associated with particular clinical phenotypes. P. Njomboro and S. Deb found that in a sample of patients with acquired brain injury, the degree of overlap between depression and apathy was dependent on the method of assessment of apathy. The assessment and measurement of apathy continue to be refined as new instruments to be developed and validated. Here, item response theory [2] was used as a basis to explore a possible early screening tool for apathy in elderly people. The management of apathy has long been a challenge and the evidence base for pharmacological interventions is very limited. It is therefore heartening to read that other approaches have been adopted. The paper by A. Leone et al. outlines a nonpharmacological intervention incorporating the use of novel technologies in the assessment and delivery of a tailored activity in nursing home residents. Further studies of interventions along these lines would be welcomed by the field. Finally, this set of five informative papers may well become a standard feature in the reference lists of future studies in what we can now see as a pivotal topic in the overall understanding of dementia. Iracema Leroi Philippe H. Robert

Apathy and Its Nonpharmacological Treatment in Dementia

Apathy is the most common behavioral symptom in Alzheimer’s disease. Apathy has been defined as a state characterized by simultaneous diminution in the overt behavioral, cognitive, and emotional concomitants of goal-directed behavior. In that sense, apathy refers to impairments in motor, cognitive, and emotional functions. To date, there is little empirical foundation for how these three levels interact in patients suffering from apathy. We describe here neurobiological foundations as well as clinical correlations between the severity of apathy and impairments in motor, cognitive, and emotional functions. Furthermore, we present a literature review of the nonpharmacological treatment options of apathy in dementia. We suggest that focusing on the motor, cognitive, and emotional aspects of apathy may help to implement successful treatment strategies. Multimodal, individualized approaches, including the use of physical activation and biography-based information to motivate dementia patients, seem to be of high relevance.

Brain perfusion correlates of the apathy inventory dimensions of Alzheimer's disease.

Apathy is defined as a lack of motivation in behavior, cognition and affect. This syndrome is frequent in various neuropsychiatric diseases but little is known about its pathophysiology. The aim of this study was to investigate the metabolic correlates of the behavioral, cognitive and emotional, aspects of apathy in Alzheimer's disease (AD). Thirty AD patients were included. Lack of initiative, lack of interest and of emotional blunting were assessed with the Apathy Inventory (IA), a tool designed to provide a separate assessment of the behavioral, cognitive and emotional, aspects of apathy. Brain perfusion was measured by (99m)Tc-labeled bicisate (ECD) single photon emission tomography. The Statistical Parametric Mapping software provides negative correlation between IA total score and brain perfusion in left and right superior orbito-frontal gyrus, and to a lesser extent in left middle frontal gyrus (BA10). Lack of initiative score was negatively correlated with perfusion in right anterior cingulate cortex. Lack of interest score was negatively correlated with perfusion in right middle orbitofrontal gyrus). Emotional blunting score correlated negatively with in left superior dorsolateral prefrontal cortex activity. These results underline that the cognitive, behavioral and affective components of motivation are mediated by different fronto-sub-cortical circuits and are differently lateralized. In particular, left prefrontal hypoperfusion is involved in emotional blunting, as it was often demonstrated in depressive disorders. These distinct components of apathy may be targeted by different therapeutic means, in which dopaminergic enhancement might play a major role.