Persistent Feelings of Apathy May Be Linked to Higher Dementia Risk

Apathy—feelings of indifference and lack of interest and motivation—is an important harbinger of dementia In people who go on to develop Alzheimer’s disease (AD) and other dementias, emotional and behavioral changes that reflect this growing loss of interest may be the first signal of cognitive problems.

“Apathy is a strong clinical marker in AD,” says Gad Marshall, MD, a neurologist at Massachusetts General Hospital (MGH) and associate medical director of clinical trials at the Center for Alzheimer Research and Treatment at Brigham and Women’s Hospital in Boston. “Individuals with dementia-related apathy are not unhappy or sad—as are people with depression—but just detached. They are often capable of performing activities, but they don’t have the drive to do so. On the other hand, these individuals often will take part in events and enjoy themselves when someone else provides the motivation.”

Addressing Symptoms

Persistent apathy in an older adult definitely warrants a closer look, Dr. Marshall says, especially when it represents a change from previous behavior. (See the Apathy Evaluation Scale below.) Since apathy is also a symptom of depression, and can co-occur with depression—which can be treated effectively—it’s important to seek a professional evaluation to determine what may be causing the neurobehavioral symptoms.

Symptoms of dementia-related apathy include:

▶ Greater difficulty initiating and completing tasks

▶ Lack of interest in ongoing events, little curiosity or insight

▶ Indifference; blunted emotional response

▶ Diminishing social engagement

▶ Diminishing engagement in usual activities

▶ Low energy

“The individual with dementia-related apathy may recognize his or her mood changes at first, but awareness usually fades over time as the neurodegenerative process advances, even as the apathy increases,” Dr. Marshall says. “Depression is also common in people with AD, and the two conditions often overlap but can be distinguished from one another.”

There are few treatments for dementia-related apathy. What treatments do exist have not been studied extensively, and it is unknown how long their benefit may last. Most commonly, health-care providers prescribe off-label stimulants, such as methalphenidate (Ritalin, Concerta, and Daytrana), modafinil (Provigil), and brom dextroamphetamine (Adderall), as well as cholinesterase inhibitors, such as donepezil (Aricept), which is approved for the treatment of AD.

“Friends and family members can act as external motivators and encourage apathetic individuals to participate in activities they enjoy,” Dr. Marshall says. “With their help, the individual can more easily overcome feelings of apathy to take part in events that provide benefits such as mental and physical stimulation and social interaction.”

Shrinking Brain

As interest in apathy as a marker for incipient brain disease is increasing, so are the number of studies designed to understand what is happening to the brain when apathy develops. Findings to date suggest that people with apathy may have experienced significant changes to their brain structure.

“Regions typically affected early in the AD disease process are affected in individuals who show early signs of dementia-related apathy,” says Dr. Marshall. “Our research has linked apathy with a thinning of the inferior temporal cortex, a region of the brain associated with early symptoms of AD.”

Other research in individuals in the later stages of dementia who have apathy has revealed shrinkage of the brain’s frontal lobe, which is involved in attention, thinking, planning, self-monitoring, and the reward system. The shrinkage involves both the brain’s gray matter, which contains nerve cells responsible for higher thinking abilities, and its white matter, which enables communication among brain cells.

Scientists have also linked apathy with decreased activity in certain brain regions, a reduction in connections within the brain, and a buildup of the toxic proteins tau and beta amyloid, which are hallmarks of AD.

“The problem of apathy does not get as much attention as some other symptoms of dementia, but it’s important,” says Dr. Marshall.

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