Validity of the three apathy items of the Geriatric Depression Scale (GDS-3A) in measuring apathy in older persons

Apathy, gait slowness, and executive dysfunction (AGED) triad: opportunities to predict and delay dementia onset

This study investigates whether older adults diagnosed with the apathy, gait impairment, and executive dysfunction (AGED) triad, frequently associated with cerebrovascular disease and confounded with depression, have earlier dementia onset. We followed 322 community-dwelling older individuals (mean age 72.0 ± 6.4 years; 58.3% women) free of dementia at baseline for up to 9 years. The AGED triad was identified when gait slowness (< 1 m/s), apathy (assessed by Geriatric Depression Scale-3A with ≥ 2 items), and executive dysfunction (assessed by the 75th percentile of Trail Making Test-part B by age range) were simultaneously present. Incident dementia was diagnosed using the clinical dementia rating scale. Over the 9-year follow-up (mean 45.1 ± 28.6 months), 44 participants (13.6%) converted to dementia. Sixteen participants (5.0%) were diagnosed with AGED triad + and showed a significantly higher risk of earlier conversion to dementia compared with AGED triad- (hazard ratio = 5.08, 95%CI 2.16-11.97; p = 0.0001), as well as to those with only one AGED factor or fewer AGED factors. Hypertension and diabetes were 2 and 3 times more prevalent, respectively, in individuals with AGED triad + . These findings suggest that the AGED triad serves as a simplified and effective behavioral marker for accelerated progression to dementia.

SEND-PD in Parkinsonian Syndromes: Results of a Monocentric Cross-Sectional Study

Introduction

Neuropsychiatric symptoms in particular impair health-related quality of life (QoL) of patients with Parkinson's disease and atypical Parkinsonian syndromes. For this reason, various scales have been developed for detection of neuropsychiatric symptoms, such as the Scale for evaluation of neuropsychiatric disorders in Parkinson's disease (SEND-PD).

Objective

First, the objective of this study was to explore the interrelation between the SEND-PD and clinical parameters in patients with Parkinson's disease and thus confirm its validity. In addition, the applicability in a well-defined cohort of patients with atypical Parkinsonian syndromes was investigated for the very first time.

Methods

A clinically well-defined cohort of 122 patients with Parkinson's disease (PD), 55 patients with Progressive Supranuclear Palsy (PSP) and 33 patients with Multiple System Atrophy (MSA) were analyzed. First, the SEND-PD was correlated with established disease-specific scores in patients with PD. Next, the results of the SEND-PD were compared between the different Parkinsonian syndromes.

Results

The SEND-PD showed a strong significant correlation with several scores, especially the UPDRS I (Rho = 0.655) and GDS-15 (Rho = 0.645). Depressive burden was significantly higher in MSA patients in comparison to the PD patient cohort (PD, 3.8 ± 3.3; MSA, 5.45 ± 3.87), while PSP patients showed significantly less psychotic (PD 1.6 ± 2.1; PSP 0.6 ± 0.9) and impulse control disorders (PD 0.3 ± 1.0; PSP 0.02 ± 0.1).

Conclusion

The SEND-PD is a useful, brief and highly applicable screening tool for neuropsychiatric symptoms in PD, but not in atypical Parkinsonism, as their unique neuropsychiatric symptom composition is not fully captured.

Temporal dynamics of depressive symptoms and cognitive decline in the oldest old: dynamic time warp analysis of the Leiden 85-plus study

BACKGROUND

The prevalence of depressive symptoms and cognitive decline increases with age. We investigated their temporal dynamics in individuals aged 85 and older across a 5-year follow-up period.

METHODS

Participants were selected from the Leiden 85-plus study and were eligible if at least three follow-up measurements were available (325 of 599 participants). Depressive symptoms were assessed at baseline and at yearly assessments during a follow-up period of up to 5 years, using the 15-item Geriatric Depression Scale (GDS-15). Cognitive decline was measured through various tests, including the Mini Mental State Exam, Stroop test, Letter Digit Coding test and immediate and delayed recall. A novel method, dynamic time warping analysis, was employed to model their temporal dynamics within individuals, in undirected and directed time-lag analyses, to ascertain whether depressive symptoms precede cognitive decline in group-level aggregated results or vice versa.

RESULTS

The 325 participants were all 85 years of age at baseline; 68% were female, and 45% received intermediate to higher education. Depressive symptoms and cognitive functioning significantly covaried in time, and directed analyses showed that depressive symptoms preceded most of the constituents of cognitive impairment in the oldest old. Of the GDS-15 symptoms, those with the strongest outstrength, indicating changes in these symptoms preceded subsequent changes in other symptoms, were worthlessness, hopelessness, low happiness, dropping activities/interests, and low satisfaction with life (all P's < 0.01).

CONCLUSION

Depressive symptoms preceded cognitive impairment in a population based sample of the oldest old.

Dissociable effects of dopaminergic medications on depression symptom dimensions in Parkinson disease

Depression in Parkinson disease (PD) is common, is disabling and responds poorly to standard antidepressants. Motivational symptoms of depression are particularly prevalent in PD and emerge with loss of dopaminergic innervation of the striatum. Optimizing dopaminergic treatment for PD can improve depressive symptoms. However, the differential effect of antiparkinsonian medication on symptom dimensions of depression is not known. Using data from a large (n = 412) longitudinal study of patients with newly diagnosed PD followed over 5 years, we investigated whether there are dissociable effects of dopaminergic medications on different depression symptom dimensions in PD. Previously validated 'motivation' and 'depression' dimensions were derived from the 15-item geriatric depression scale. Dopaminergic neurodegeneration was measured using repeated striatal dopamine transporter imaging. We identified dissociable associations between dopaminergic medications and different dimensions of depression in PD. Dopamine agonists were shown to be effective for treatment of motivational symptoms of depression. In contrast, monoamine oxidase-B inhibitors improved both depressive and motivation symptoms, albeit the latter effect is attenuated in patients with more severe striatal dopaminergic neurodegeneration.

Depressive symptoms in the entire spectrum of cognitive ageing in Greece: evidence from the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD)

OBJECTIVES

To study (i) the prevalence of mild and moderate-to-severe depressive symptoms in the entire spectrum of cognitive ageing in Greece and (ii) the relationship between these symptoms and demographic and clinical data.

METHODS

The study was based on the randomly selected cohort of the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD). Depressive symptoms were assessed with the 15-item version of the Geriatric Depression Scale. Participants also received a comprehensive neuropsychological assessment, while the clinical diagnoses of dementia and mild cognitive impairment were established according to international diagnostic criteria. Statistical analyses relied on comparison tests and a logistic (proportional odds) ordinal regression model.

RESULTS

Depressive symptoms were detected in 19.5% of the 1936 study participants, while 11.3% of both people with MCI and dementia had moderate-to-severe depressive symptoms. The regression model revealed that older adults with more severe depressive symptoms were more likely female, cognitively impaired, less educated, were treated with psychotropic medication and lived in Attica versus Thessaly.

CONCLUSIONS

Since depressive symptoms were detected in almost one in five older adults, healthcare professionals in Greece should safeguard the timely detection and effective treatment of such symptoms and the post-diagnostic care of older adults with depression.

Apathy Symptoms, Physical and Cognitive Function, Health-Related Quality of Life, and Mortality in Older Patients With CKD: A Longitudinal Observational Study

RATIONALE & OBJECTIVE

Apathy reflects diminished motivation, goal-directed behavior, and emotions, as well as less engagement in social interactions. Apathy overlaps with depression and is associated with cognitive decline. In the older individuals with chronic kidney disease (CKD), both depression and cognitive impairments are common, but apathy symptoms have been underreported. We investigated the occurrence of apathy symptoms and their associations with physical and cognitive functioning, health-related quality of life (HRQoL), and mortality in older patients with CKD.

STUDY DESIGN

Prospective observational cohort study.

SETTING & PARTICIPANTS

180 outpatients aged≥65 years with estimated glomerular filtration rate≤20mL/min/1.73m2 from 5 Dutch nephrology centers.

EXPOSURE

Apathy symptoms at baseline were considered present when a Geriatric Depression Scale's 3-item apathy subscale score was≥2 points.

OUTCOME

Physical and cognitive functioning, HRQoL (assessed in annual geriatric assessments), and 4-year mortality.

ANALYTICAL APPROACH

Linear regression for cross-sectional associations, linear regression models for longitudinal associations, and Cox regression models for mortality over 4 years of observation.

RESULTS

Apathy symptoms were present in 64 patients (36%; 67% men; median age 75.5 years), of whom 32 (50%) had no depressive symptoms. At baseline, the presence of apathy symptoms was associated with significantly more frailty, more functional dependence, less physical capacity, lower visuoconstructive performance, worse delayed recall, and lower HRQoL scores. The presence of apathy symptoms at baseline was also associated with a higher mortality risk (hazard ratio, 2.3 [95% CI, 1.3-4.2], P=0.005 adjusted for age, sex, and high education level), but not with changes in physical and cognitive functioning or HRQoL during the follow-up period.

LIMITATIONS

Risk of selection bias and residual confounding.

CONCLUSIONS

Apathy symptoms were highly prevalent and associated with concurrent lower physical and cognitive status, lower HRQoL, and increased mortality. These findings highlight apathy as a potentially important clinical phenotype in older CKD patients.

PLAIN-LANGUAGE SUMMARY

We observed that older kidney patients often present apathy symptoms, such as less motivation, fewer goal-directed behaviors, fewer emotions, and less social engagement. Prior research has not extensively described apathy in kidney disease. We investigated the link between apathy symptoms and poor outcomes. We measured physical functioning, cognitive functioning, and quality of life. We learned that one-third of our older kidney patients showed symptoms of apathy, only half of whom had symptoms of depression. Patients with apathy symptoms showed lower quality of life and lower physical and cognitive performance. They also had a higher risk of death. These findings highlight the need for awareness of apathy symptoms in older kidney patients.

Apathy as a determinant of health behaviors in older adults: Implications for dementia risk reduction

INTRODUCTION

Long-term improvements in physical inactivity and other behavioral risk factors are integral to dementia risk reduction; however, sustained behavior change is challenging. Apathy, depression, and fatigue may impact engagement in health behaviors, but their presentation overlaps. This study investigates whether these symptoms are differentially associated with multiple health behaviors.

METHODS

In 1037 community-dwelling older adults without dementia (aged 70-90, 55% women), regression analyses examined apathy, depression, and fatigue as predictors of health behaviors (physical activity, diet, alcohol, smoking) and a behavioral risk index.

RESULTS

Apathy was associated with reduced physical activity and alcohol use, and one or multiple behavioral risk factors. No or inconsistent relations were found between depression or fatigue and health behaviors.

DISCUSSION

Apathy is relevant to multiple health behaviors and should be considered when designing health promotion for older adults, including interventions for dementia risk reduction. Findings highlight the importance of distinguishing apathy from comorbid symptoms.

Highlights

Novel theory-based perspective on behavioural risk factors for dementia.Higher apathy predicted less physical activity and alcohol use, and increased odds of lifestyle risk factors.Depressive symptoms were not associated with any health behavior.Apathy may be a determinant of multiple health behaviors in older adults, distinct from depression and fatigue.Considering apathy in precision prevention of dementia appears warranted.

Longitudinal decline in striatal dopamine transporter binding in Parkinson's disease: associations with apathy and anhedonia

BACKGROUND

Motivational symptoms such as apathy and anhedonia are common in Parkinson's disease (PD), respond poorly to treatment, and are hypothesised to share underlying neural mechanisms. Striatal dopaminergic dysfunction is considered central to motivational symptoms in PD but the association has never been examined longitudinally. We investigated whether progression of dopaminergic dysfunction was associated with emergent apathy and anhedonia symptoms in PD.

METHODS

Longitudinal cohort study of 412 newly diagnosed patients with PD followed over 5 years as part of the Parkinson's Progression Markers Initiative cohort.Apathy and anhedonia were measured using a composite score derived from relevant items of the 15-item Geriatric Depression Scale (GDS-15) and part I of the MDS-Unified Parkinson's Disease Rating Scale. Dopaminergic neurodegeneration was measured using repeated striatal dopamine transporter (DAT) imaging.

RESULTS

Linear mixed-effects modelling across all contemporaneous data points identified a significant negative relationship between striatal DAT specific binding ratio (SBR) and apathy/anhedonia symptoms, which emerged as PD progressed (interaction:β=-0.09, 95% CI (-0.15 to -0.03), p=0.002). Appearance and subsequent worsening of apathy/anhedonia symptoms began on average 2 years after diagnosis and below a threshold striatal DAT SBR level. The interaction between striatal DAT SBR and time was specific to apathy/anhedonia symptoms, with no evidence of a similar interaction for general depressive symptoms from the GDS-15 (excluding apathy/anhedonia items) (β=-0.06, 95% CI (-0.13 to 0.01)) or motor symptoms (β=0.20, 95% CI (-0.25 to 0.65)).

CONCLUSIONS

Our findings support a central role for dopaminergic dysfunction in motivational symptoms in PD. Striatal DAT imaging may be a useful indicator of apathy/anhedonia risk that could inform intervention strategies.

Epidemiology of Motoric Cognitive Risk Syndrome in the Kerala Einstein Study: Protocol for a Prospective Cohort Study

BACKGROUND

The southern India state of Kerala has among the highest proportion of older adults in its population in the country. An increase in chronic age-related diseases such as dementia is expected in the older Kerala population. Identifying older individuals early in the course of cognitive decline offers the best hope of introducing preventive measures early and planning management. However, the epidemiology and pathogenesis of predementia syndromes at the early stages of cognitive decline in older adults are not well established in India.

OBJECTIVE

The Kerala Einstein Study (KES) is a community-based cohort study that was established in 2008 and is based in the Kozhikode district in Kerala state. KES aims to establish risk factors and brain substrates of motoric cognitive risk syndrome (MCR), a predementia syndrome characterized by the presence of slow gait and subjective cognitive concerns in individuals without dementia or disability. This protocol describes the study design and procedures for this KES project.

METHODS

KES is proposing to enroll a sample of 1000 adults ≥60 years old from urban and rural areas in the Kozhikode district of Kerala state: 200 recruited in the previous phase of KES and 800 new participants to be recruited in this project. MCR is the cognitive phenotype of primary interest. The associations between previously established risk factors for dementia as well as novel risk factors (apathy and traumatic brain injury) and MCR will be examined in KES. Risk factor profiles for MCR will be compared between urban and rural residents as well as with individuals who meet the criteria for mild cognitive impairment (MCI). Cognitive and physical function, medical history and medications, sociodemographic characteristics, lifestyle patterns, and activities of daily living will be evaluated. Participants will also undergo magnetic resonance imaging and electrocardiogram investigations. Longitudinal follow-up is planned in a subset of participants as a prelude to future longitudinal studies.

RESULTS

KES (2R01AG039330-07) was funded by the US National Institutes of Health in September 2019 and received approval from the Indian Medical Council of Research to start the study in June 2021. We had recruited 433 new participants from urban and rural sites in Kozhikode as of May 2023: 41.1% (178/433) women, 67.7% (293/433) rural residents, and 13.4% (58/433) MCR cases. Enrollment is actively ongoing at all the KES recruitment sites.

CONCLUSIONS

KES will provide new insights into risk factors and brain substrates associated with MCR in India and will help guide future development of regionally specific preventive interventions for dementia.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49933.

Dissociable effects of dopaminergic medications on depression symptom dimensions in Parkinson's disease

Background

Depression in Parkinson's disease (PD) is common, disabling and responds poorly to standard antidepressant medication. Motivational symptoms of depression, such as apathy and anhedonia, are particularly prevalent in depression in PD and predict poor response to antidepressant treatment. Loss of dopaminergic innervation of the striatum is associated with emergence of motivational symptoms in PD, and mood fluctuations correlate with dopamine availability. Accordingly, optimising dopaminergic treatment for PD can improve depressive symptoms, and dopamine agonists have shown promising effects in improving apathy. However, the differential effect of antiparkinsonian medication on symptom dimensions of depression is not known.

Aims

We hypothesised that there would be dissociable effects of dopaminergic medications on different depression symptom dimensions. We predicted that dopaminergic medication would specifically improve motivational symptoms, but not other symptoms, of depression. We also hypothesised that antidepressant effects of dopaminergic medications with mechanisms of action reliant on pre-synaptic dopamine neuron integrity would attenuate as pre-synaptic dopaminergic neurodegeneration progresses.

Methods

We analysed data from a longitudinal study of 412 newly diagnosed PD patients followed over five years in the Parkinson's Progression Markers Initiative cohort. Medication state for individual classes of Parkinson's medications was recorded annually. Previously validated "motivation" and "depression" dimensions were derived from the 15-item geriatric depression scale. Dopaminergic neurodegeneration was measured using repeated striatal dopamine transporter (DAT) imaging.

Results

Linear mixed-effects modelling was performed across all simultaneously acquired data points. Dopamine agonist use was associated with relatively fewer motivation symptoms as time progressed (interaction: β=-0.07, 95%CI [-0.13,-0.01], p=0.015) but had no effect on the depression symptom dimension (p=0.6). In contrast, monoamine oxidase-B (MAO-B) inhibitor use was associated with relatively fewer depression symptoms across all years (β=-0.41, 95%CI [-0.81,-0.01], p=0.047). No associations were observed between either depression or motivation symptoms and levodopa or amantadine use. There was a significant interaction between striatal DAT binding and MAO-B inhibitor use on motivation symptoms: MAO-B inhibitor use was associated with lower motivation symptoms in patients with higher striatal DAT binding (interaction: β=-0.24, 95%CI [-0.43, -0.05], p=0.012). No other medication effects were moderated by striatal DAT binding measures.

Conclusions

We identified dissociable associations between dopaminergic medications and different dimensions of depression in PD. Dopamine agonists may be effective for treatment of motivational symptoms of depression. In contrast, MAO-B inhibitors may improve both depressive and motivation symptoms, albeit the latter effect appears to be attenuated in patients with more severe striatal dopaminergic neurodegeneration, which may be a consequence of dependence on pre-synaptic dopaminergic neuron integrity.

Strengths and Weaknesses of the Vascular Apathy Hypothesis: A Narrative Review

The vascular apathy hypothesis states that cerebral small vessel disease (CSVD) can cause apathy, even when no other symptoms of CSVD are present. In order to examine this hypothesis, the objectives of this narrative review are to evaluate the evidence for a pathophysiological mechanism linking CSVD to apathy and to examine whether CSVD can be a sole cause of apathy. The nature of the CSVD-apathy relationship was evaluated using the Bradford Hill criteria as a method for research on the distinction between association and causation. Pathological, neuroimaging, and behavioral studies show that CSVD can cause lesions in the reward network, which causes an apathy syndrome. Studies in healthy older individuals, stroke patients and cognitively impaired persons consistently show an association between CSVD markers and apathy, although studies in older persons suffering from depression are inconclusive. A biological gradient is confirmed, as well as a temporal relationship, although the evidence for the latter is still weak. The specificity of this causal relationship is low given there often are other contributing factors in CSVD patients with apathy, particularly depression and cognitive deterioration. Differentiating between vascular apathy and other apathy syndromes on the basis of clinical features is not yet possible, while in-depth knowledge about differences in the prognosis and efficacy of treatment options for apathy caused by CSVD and other apathy syndromes is lacking. Since we cannot differentiate between etiologically different apathy syndromes as yet, it is premature to use the term vascular apathy which would suggest a distinct clinical apathy syndrome.

Does fluoxetine reduce apathetic and depressive symptoms after stroke? An analysis of the Efficacy oF Fluoxetine-a randomized Controlled Trial in Stroke trial data set

OBJECTIVE

Apathy is a common and disabling symptom after stroke with no proven treatments. Selective serotonin reuptake inhibitors are widely used to treat depressive symptoms post-stroke but whether they reduce apathetic symptoms is unknown. We determined the effect of fluoxetine on post-stroke apathy in a post hoc analysis of the EFFECTS (Efficacy oF Fluoxetine-a randomized Controlled Trial in Stroke) trial.

METHODS

EFFECTS enrolled patients ⩾18 years between 2 and 15 days after stroke onset. Participants were randomly assigned to receive oral fluoxetine 20 mg once daily or matching placebo for 6 months. The Montgomery-Åsberg Depression Rating Scale (MADRS) was administered at baseline and 6 months. Individual items on this scale were divided into those reflecting symptoms of apathy and depression. Symptoms were compared between fluoxetine and placebo groups.

RESULTS

Of 1500 participants enrolled, complete MADRS data were available for 1369. The modified intention-to-treat population included 681 patients in the fluoxetine group and 688 in the placebo group. Confirmatory factor analysis revealed that apathetic, depressive, and anhedonic symptoms were dissociable. Apathy scores increased in both fluoxetine and placebo groups (both p ⩽ 0.00001). In contrast, fluoxetine was associated with a reduction in depressive scores (p = 0.002).

CONCLUSION

Post-stroke apathetic and depressive symptoms respond differently to fluoxetine treatment. Our analysis suggests fluoxetine is ineffective in preventing post-stroke apathy.

Relationship between grave visitation and apathy among community-dwelling older adults

BACKGROUND

It has been shown that involvement in religious activities has a positive impact on psychological aspects. In this study, the relationship between grave visitation, a standard religious activity in Japan, and depression and apathy symptoms was investigated among older adults in Japan.

METHODS

A total of 638 older adults who participated in a community-based health check survey (Tarumizu Study 2019) were interviewed regarding the presence or absence of grave visitation, frequency, travel time, means of transportation, and flower offerings. Apathy and depressive symptoms were measured using the 15-item Geriatric Depression Scale (GDS-15). The participants were categorised into three grave visitation groups, namely, frequent (more than once per week), occasional (less than once per week), and non-visiting. Outcomes were compared between the frequency groups, and Poisson regression analysis was used to investigate the relationship between grave visitation frequency and apathy and depression.

RESULTS

Of the participants, 91.8% reported regular grave visitation. The non-visiting group had a significantly higher prevalence of apathy symptoms (44.2%) than the visiting groups. Furthermore, using the frequent group as the reference, Poisson regression analysis adjusted for potential covariates demonstrated that no grave visitation was significantly related to apathy (prevalence ratio, 1.43; 95% confidence interval, 1.00-2.05, P = 0.049).

CONCLUSIONS

Not practising grave visitation was significantly related to apathy among older adults. Helping older adults to visit graves may prevent apathy by facilitating motivation and increasing activity.

The Kesennuma Study in Miyagi, Japan: Study Design and Baseline Profiles of Participants

BACKGROUND

To clarify the association between psychosocial problems and frailty in the areas affected by the Great East Japan Earthquake, and to develop strategies for preventive long-term care in the community, we launched the Kesennuma Study in 2019. This report describes the study design and the participants' profiles at baseline.

METHODS

The prospective study comprised 9,754 people (4,548 men and 5,206 women) randomly selected from community-dwelling independent adults aged 65 to 84 who were living in Kesennuma City, Miyagi. The baseline survey was conducted in October 2019. It included information on general health, socio-economic status, frailty, lifestyle, psychological factors (eg, personality, depressive moods), and social factors (eg, social isolation, social capital). A follow-up questionnaire survey is planned. Mortality, incident disability, and long-term care insurance certifications will also be collected.

RESULTS

A total of 8,150 questionnaires were returned (83.6% response rate), and 7,845 were included in the analysis (80.4%; mean age 73.6 [standard deviation, 5.5] years; 44.7% male). About 23.5% were considered frail. Regarding psychological and social functions, 42.7% had depressive moods, 29.1% were socially isolated, and only 37.0% participated in social activities at least once a month. However, 82.5% trusted their neighbors.

CONCLUSION

While local ties were strong, low social activity and poor mental health were revealed as issues in the affected area. Focusing on the association between psychological and social factors and frailty, we aim to delay the need for long-term care for as long as possible, through exercise, nutrition, social participation, and improvement of mental health.

Vascular disease and apathy symptoms in the very old: A cross-sectional and longitudinal meta-analysis of individual participant data

OBJECTIVES

Previous findings suggest a vascular foundation underlying apathy, but transdiagnostic and prospective evidence on vascular apathy is scarce. This study examines the association between vascular disease and the presence and development of apathy symptoms in the very old.

METHODS

Four cohorts of the Towards Understanding Longitudinal International older People Studies (TULIPS)-consortium were included in a two-staged, individual participant data meta-analysis using generalized linear mixed models. Vascular disease was defined as a history of any clinical atherosclerotic pathology (angina pectoris, myocardial infarction, intermittent claudication, transient ischemic attack, stroke or related surgeries) and was related to apathy symptoms as repeatedly measured by the Geriatric Depression Scale (GDS-3A ≥2) over a maximum of 5 years.

RESULTS

Of all 1868 participants (median age 85 years old), 53.9% had vascular disease and 44.3% experienced apathy symptoms. Participants with vascular disease had a 76% higher risk of apathy symptoms at baseline (odds ratio (OR) 1.76, 95% confidence interval (CI) 1.32-2.35), irrespective of depressive symptoms and only partially explained by stroke. Conversely, there was no association of vascular disease with the occurrence of apathy symptoms longitudinally, both in those with apathy at baseline (OR 1.00, 95% CI 0.84-1.20) and without (OR 0.96, 95% CI 0.84-1.09).

CONCLUSIONS

Vascular disease in the very old is associated with apathy symptoms cross-sectionally, but not proven longitudinally, independent of depressive symptoms. These findings query a vascular cause underlying apathy symptoms. However, the consistency of our cross-sectional findings in direction and magnitude across the TULIPS-consortium do emphasize international relevance of the interplay of vascular factors and apathy in advanced age, which meaning needs further unravelling.

Depressive symptoms homophily among community-dwelling older adults in japan: A social networks analysis

Late-life depression is one of the most common mental illnesses that cause serious consequences, but the majority do not reach out for mental health services and relapses are common. The present study investigated profiled similarity of older adults' social networks in terms of depressive symptoms. In 2017, we distributed questionnaires inquiring about confidants in the community, depressive symptoms based on the 15-item Geriatric Depression Scale (GDS-15), and demographic and functional characteristics to all the community-dwelling older adults under the national insurance system in Wakuya City (Miyagi prefecture, Japan). Applying the Exponential Random Graph Model, we estimated the likelihood of a confidant relational tie by the similarity of overall and specific depressive symptoms within 217,470 potential ties among 660 respondents eligible for analysis. The overall depressive symptom homophily was marginally significant (p < 0.10), indicating that the likelihood of a confidant relational tie between two community-dwelling older adults was decreased by 5%, with one point increase in their difference in the total number of depressive symptoms (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.90-1). Focusing on specific domains of depressive symptoms, we found significant apathy homophily (p < 0.05) but no significant suicidal ideation of homophily. The results indicated that there is a 19% decrease in the likelihood of a confidant relational tie between two community-dwelling older adults by one point increase in their difference in the total number of apathy symptoms (OR, 0.81; 95%CI, 0.67-0.98) but no change by increasing the difference in their total number of suicidal ideation symptoms (OR, 1; 95%CI, 0.87-1.14). These findings suggest depressive symptom homophily, particularly with respect to apathy domains, in confidant social networks of community-dwelling older adults, and the importance of network intervention in preventing late-life depression.

The apathy, gait impairment, and executive dysfunction (AGED) triad vascular variant

Apathy, gait disturbances, and executive dysfunction (AGED) often occur together. Although they can arise independently, the presence of one might portend another. This recognition suggests the possible etiology. We focus on the most common, the vascular. We explain the AGED vascular mechanism through the ambibaric brain concept. The brain contains two complementary blood pressure systems: One high in the primitive brain (brainstem, basal ganglia, and thalamus) and a low-pressure system in the Homo sapiens brain (cerebral hemispheres). Hypertension inflicts the most damage on the primitive brain. The frontal systems connect to the basal ganglia, then the thalamus and back to the cortex. Many connections converge on the primitive brain where they are damaged by vascular disease. We need methods of determining optimal, individual blood pressures. Although the AGED triad can result from other causes, it should first signal a vascular etiology, the most prevalent, treatable, and preventable one.

The 3-Item "Apathy" Subscale Within the GDS-15 Is Not Supported in De Novo Parkinson's Disease Patients: Analysis of the PPMI Cohort

This study examined individual components of the Geriatric Depression Scale-15 (GDS-15) to determine whether the 3-item Withdrawal-Apathy-Lack of Vigor (WAV) subscale, which has been validated in older adults and advanced Parkinson's disease (PD), was applicable to newly diagnosed patients with PD. Baseline Parkinson's Progression Markers Initiative (PPMI) data (n = 345), including GDS-15 and Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) depression, apathy, and anxiety scores, were examined. Data reduction techniques (i.e., principal components, confirmatory factor analyses) were used. Model fit was poor for the previously identified GDS-15 factor structures. Via principal components analysis, 5 components were identified, none of which reflected the 3-item WAV subscale previously reported in the literature. Internal consistency of the GDS-15 was acceptable, as was the internal consistency for the largest component (labeled "Dysphoria"). All 5 components significantly correlated with the MDS-UPDRS depression, apathy, and anxiety items. Model fit was fair for the "Dysphoria" factor only. Overall, the 3-item WAV factor reported in previous literature was not supported in this sample of de novo PD patients.

Meaningful Activities and Psychosomatic Functions in Japanese Older Adults after Driving Cessation

The purpose of this cross-sectional study was to analyse the differences in meaningful activities and psychosomatic function depending on the driving status of community-dwelling older adults. Data from 594 older adults were obtained, including activities meaningful to individuals and psychosomatic functions, such as grip strength, depression, cognitive function, and ability of activity. Participants were divided into active driving (n = 549) and after driving cessation (n = 45) groups. In addition, the active driving group was operationally divided into three groups: high-frequency group (n = 387), medium group (n = 119), and infrequent group (n = 42). In the after driving cessation group, grip strength, and Japan Science and Technology Agency Index of Competence scores were significantly lower. Furthermore, the proportion of apathy and physical and social frailty was significantly higher in the after driving cessation group. Regarding meaningful activity, domestic life scores in the after driving cessation group were significantly higher than those of the active driving group. Decreased driving frequency in the active driving group was associated with weak muscle strength, lack of interest, and low activity. This study demonstrated that meaningful activity differed based on the driving status. Hence, we should support the activities of older adults who are considering driving cessation.

Apathy Measures in Older Adults and People with Dementia: A Systematic Review of Measurement Properties Using the COSMIN Methodology

BACKGROUND

Apathy is highly prevalent in dementia and is also seen in mild cognitive impairment and the general population. Apathy contributes to failure to undertake daily activities and can lead to health problems or crises. It is therefore important to assess apathy. However, there is currently no gold standard measure of apathy. A comprehensive systematic review of the measurement properties of apathy scales is required.

METHODS

A systematic review was registered with PROSPERO (ID: CRD42018094390). MEDLINE, Embase, PsycINFO, and CINAHL were searched for studies that aimed to develop or assess the validity or reliability of an apathy scale in participants over 65 years, living in the community. A systematic review was conducted in line with the COnsensus-based Standards for the selection of health Measurement INstruments procedure for reviewing patient-reported outcome measures. The studies' risk of bias was assessed, and all relevant measurement properties were assessed for quality. Results were pooled and rated using a modified Grading of Recommendations Assessment, Development, and Evaluation procedure.

RESULTS

Fifty-seven publications regarding 18 measures and 39 variations met the eligibility criteria. The methodological quality of individual studies ranged from inadequate to very good and measurement properties ranged from insufficient to sufficient. Similarly, the overall evidence for measurement properties ranged from very low to high quality. The Apathy Evaluation Scale (AES) and Lille Apathy Rating Scale (LARS) had sufficient content validity, reliability, construct validity, and where applicable, structural validity and internal consistency.

CONCLUSION

Numerous scales are available to assess apathy, with varying psychometric properties. The AES and LARS are recommended for measuring apathy in older adults and people living with dementia. The apathy dimension of the commonly used Neuropsychiatric Inventory should be limited to screening for apathy.

Association between apathy and satisfaction with meaningful activities in older adults with mild cognitive impairment: A population-based cross-sectional study

OBJECTIVES

This cross-sectional study aimed to clarify the relationship between apathy, meaningful activities, and satisfaction with such activities of older adults with mild cognitive impairment (MCI).

METHODS

We analyzed 235 older adults with MCI (≥65 years, mean age: 76.9 ± 6.4 years, women: 63.4%) who participated in a community-based health check survey (Tarumizu Study 2018). MCI was defined as at least 1.5 SD below the reference threshold (age- and education-adjusted score) on one or more of the computerized cognitive test including memory, attention, executive functions, and processing speed. Apathy symptoms were assessed using three of the 15 items of Geriatric Depression Scale. Participants selected meaningful activities from the 95 activities of the Aid for Decision-Making in Occupation Choice and evaluated their satisfaction and performance.

RESULTS

Apathy in MCI was prevalent by 23.8%. The categories of meaningful activities revealed no difference, with, or without apathy. Logistic regression analysis showed that activity satisfaction was significantly associated with apathy after adjusting for age, sex, education, instrumental activities of daily living, depressive symptoms, and MCI subtype (OR, 0.62; 95% CI, 0.44-0.88, p = 0.008).

CONCLUSIONS

Satisfaction with the activities that are deemed meaningful is associated with apathy among community-dwelling older adults with MCI.

Apathy symptoms increase the risk of dementia conversion: a case-matching cohort study on patients with post-stroke mild cognitive impairment in China

BACKGROUND

Apathy is a neuropsychiatric symptom frequently observed in patients with cognitive impairment. It has been found to be a predictor of conversion from mild cognitive impairment (MCI) to dementia of Alzheimer disease type. However, this association between apathy and dementia conversion has not yet been confirmed in vascular MCI, especially post-stroke MCI. The aim of this study was to evaluate whether apathy would increase the risk of dementia conversion in patients with post-stroke MCI after 6 months.

METHOD

A prospective multi-centre cohort study was performed in 14 clinics in seven provinces and cities of China. A total of 989 subjects were included 2 weeks to 6 months after stroke, and met the diagnostic criteria of International Working Group for MCI. Symptoms of apathy were assessed using the apathy subscale of Geriatric Depression Scale. Subjects were divided into an apathy group (n = 128) and a non-apathy group (n = 861). The primary outcome was the dementia conversion after 6 months. To eliminate potential biases, subjects were chosen from 861 non-apathy patients with similarity in seven potential predictors of cognitive impairment to match with the apathy group (n = 128) at a 1:1 ratio, as a matched non-apathy group (n = 128). The dementia conversion rate was compared between the apathy group (n = 128) and its correspondingly matched non-apathy group (n = 128), and the relative risk (RR) was calculated.

RESULTS

The prevalence of apathy in post-stroke MCI was 12.9%. After 6 months, 5.2% of patients with post-stroke MCI converted to dementia. The dementia conversion rate of the apathy group was significantly higher than that of the non-apathy group before case-matching (17.2% vs 3.4%, P < 0.001), and also after case-matching (17.2% vs 6.3%, P < 0.001). Symptoms of apathy increased the risk of conversion from MCI to dementia (RR 2.75, 95% CI 1.272-5.947, P < 0.001).

CONCLUSIONS

For patients with post-stroke MCI, apathy symptoms increase the risk of conversion from MCI to dementia.

Specific Dimensions of Depression Have Different Associations With Cognitive Decline in Older Adults With Type 2 Diabetes

OBJECTIVE

Depression is highly frequent in older adults with type 2 diabetes and is associated with cognitive impairment, yet little is known about how various depression dimensions differentially affect cognition. We investigated longitudinal associations of specific depression dimensions with cognitive decline.

RESEARCH DESIGN AND METHODS

Participants (N = 1,002) were from the Israel Diabetes and Cognitive Decline study, were ≥65 years of age, had type 2 diabetes, and were not experiencing dementia at baseline. Participants underwent a comprehensive neuropsychological battery at baseline and every 18 months thereafter, including domains of episodic memory, attention/working memory, semantic categorization/language, and executive function, and Z-scores of each domain were averaged and further normalized to calculate global cognition. Depression items from the 15-item Geriatric Depression Scale were measured at each visit and subcategorized into five dimensions: dysphoric mood, withdrawal-apathy-vigor (entitled apathy), anxiety, hopelessness, and memory complaint. Random coefficients models examined the association of depression dimensions with baseline and longitudinal cognitive functioning, adjusting for sociodemographics and baseline characteristics, including cardiovascular risk factors, physical activity, and use of diabetes medications.

RESULTS

In the fully adjusted model at baseline, all dimensions of depression, except for anxiety, were associated with some aspect of cognition (P values from 0.01 to <0.001). Longitudinally, greater apathy scores were associated with faster decline in executive function (P = 0.004), a result that withstood adjustment for multiple comparisons. Associations of other depression dimensions with cognitive decline were not significant (P > 0.01).

CONCLUSIONS

Apathy was associated with a faster cognitive decline in executive function. These findings highlight the heterogeneity of depression as a clinical construct rather than as a single entity and point to apathy as a specific risk factor for cognitive decline among older adults with type 2 diabetes.

Apathy and the Risk of Predementia Syndromes in Community-Dwelling Older Adults

Objectives

Apathy is a potential predictor of dementia in older adults, but this investigation has been limited to older adults with a preexisting neurological illness like mild cognitive impairment (MCI), stroke or Parkinson’s disease. The objective of this study was to investigate the association between apathy at baseline and incident predementia syndromes, including MCI and motoric cognitive risk syndrome (MCR), subjective cognitive complaints and slow gait, in community-dwelling older adults.

Method

We prospectively studied the association between apathy (using the 3-item subscale of the Geriatric Depression Scale [GDS3A]) and incident cognitive disorders in 542 community-dwelling older adults enrolled in the Central Control of Mobility in Aging study using Cox proportional hazard models. Associations were reported as hazard ratio (HR) with 95% confidence intervals (CIs), adjusting for age, education, baseline cognitive performance, and depressive symptoms.

Results

Apathy was associated with incident MCR (HR 2.39, 95% CI: 1.10–5.20), but not predementia syndromes overall nor MCI. In sensitivity analyses of MCI subtypes, apathy was associated with nonamnestic MCI (HR 2.44, 95% CI: 1.14–5.22), but not amnestic MCI. Our study was limited by a short follow-up time (median 13.6 months; interquartile range 29.8) and a brief subscale measurement of apathy, GDS3A.

Discussion

In our study, apathy predicted MCR but not MCI in community-dwelling older adults. These results and the current literature suggest that apathy is an early risk factor for dementia. Additionally, apathy may be a novel treatment target that could forestall the disability of dementia.

The association between apathy and frailty in older adults: a new investigation using data from the Mapt study

INTRODUCTION

Apathy is a behavioral syndrome that has been suggested to share similar neuro-physiological pathways with frailty.

OBJECTIVE

To investigate the cross-sectional association between apathy and frailty using original data from dementia-free, community-dwelling older adults.

METHOD

A cross-sectional analysis was performed to test the association between frailty (according to Fried's frailty phenotype) and apathy (defined by three items from Geriatric Depression Scale) using data from MAPT, a 3-year, randomized, multicenter, placebo-controlled trial among community-dwelling, dementia-free participants (1.679 individuals with mean age of 75 years).

RESULTS

The ordinal logistic regression showed that apathetic individuals had a two-fold more probability to be rated as frail (OR 2.20, 95% CI 1.7-2.9), when adjusting for confounders. Apathetic individuals display a two-fold more likelihood to be rated as pre-frail (RRR 2.1; 95% CI 1.5-2.8) and a three-fold higher probability to be rated as frail (RRR 3.5, 95% CI 1.8-6.9) compared to robust participants.

CONCLUSION

Although data on the associations between apathy and frailty are scarce, these conditions potentially shares physiological mechanisms and were found to be closely associated. Temporal association between frailty and apathy deserve to be further investigated.

Factors Associated with Step Numbers in Acutely Hospitalized Older Adults: The Hospital-Activities of Daily Living Study

OBJECTIVES

To determine the number of steps taken by older patients in hospital and 1 week after discharge; to identify factors associated with step numbers after discharge; and to examine the association between functional decline and step numbers after discharge.

DESIGN

Prospective observational cohort study conducted in 2015-2017.

SETTING AND PARTICIPANTS

Older adults (≥70 years of age) acutely hospitalized for at least 48 hours at internal, cardiology, or geriatric wards in 6 Dutch hospitals.

METHODS

Steps were counted using the Fitbit Flex accelerometer during hospitalization and 1 week after discharge. Demographic, somatic, physical, and psychosocial factors were assessed during hospitalization. Functional decline was determined 1 month after discharge using the Katz activities of daily living index.

RESULTS

The analytic sample included 188 participants [mean age (standard deviation) 79.1 (6.7)]. One month postdischarge, 33 out of 174 participants (19%) experienced functional decline. The median number of steps was 656 [interquartile range (IQR), 250-1146] at the last day of hospitalization. This increased to 1750 (IQR 675-4114) steps 1 day postdischarge, and to 1997 (IQR 938-4098) steps 7 days postdischarge. Age [β = -57.93; 95% confidence interval (CI) -111.15 to -4.71], physical performance (β = 224.95; 95% CI 117.79-332.11), and steps in hospital (β = 0.76; 95% CI 0.46-1.06) were associated with steps postdischarge. There was a significant association between step numbers after discharge and functional decline 1 month after discharge (β = -1400; 95% CI -2380 to -420; P = .005).

CONCLUSIONS AND IMPLICATIONS

Among acutely hospitalized older adults, step numbers double 1 day postdischarge, indicating that their capacity is underutilized during hospitalization. Physical performance and physical activity during hospitalization are key to increasing the number of steps postdischarge. The number of steps 1 week after discharge is a promising indicator of functional decline 1 month after discharge.

Lower Blood Pressure, Small-Vessel Disease, and Apathy in Older Persons With Mild Cognitive Deficits

BACKGROUND

In older persons, both high and low blood pressure (BP) levels are associated with symptoms of apathy. Population characteristics, such as burden of cerebral small-vessel disease (CSVD), may underlie these apparently contradictory findings. We aimed to explore, in older persons, whether the burden of CSVD affects the association between BP and apathy.

DESIGN

Cross-sectional study.

SETTING

Primary care setting, the Netherlands.

PARTICIPANTS

Community-dwelling older persons (mean age = 80.7 years; SD = 4.1 years) with mild cognitive deficits and using antihypertensive treatment, participating in the baseline measurement of the magnetic resonance imaging substudy (n = 210) of the Discontinuation of Antihypertensive Treatment in the Elderly Study Leiden.

MEASUREMENTS

During home visits, BP was measured in a standardized way and apathy was assessed with the Apathy Scale (range = 0-42). Stratified linear regression analyses were performed according to the burden of CSVD. A higher burden of CSVD was defined as 2 or more points on a compound CSVD score (range = 0-3 points), defined as presence of white matter hyperintensities (greater than median), any lacunar infarct, and/or two or more microbleeds.

RESULTS

In the entire population, those with a lower systolic and those with a lower diastolic BP had more symptoms of apathy (β = -.35 [P = .01] and β = -.66 [P = .02], respectively). In older persons with a higher burden of CSVD (n = 50 [24%]), both lower systolic BP (β = -.64, P = .02) and lower diastolic BP (β = -1.6, P = .01) were associated with more symptoms of apathy, whereas no significant association was found between BP and symptoms of apathy in older persons with a lower burden of CSVD (n = 160).

CONCLUSIONS

Particularly in older persons with a higher burden of CSVD, lower BP was associated with more symptoms of apathy. Adequate BP levels for optimal psychological functioning may vary across older populations with a different burden of CSVD. J Am Geriatr Soc 68:1811-1817, 2020.

Empirical support for the vascular apathy hypothesis: A structured review

OBJECTIVES

A systematic review of the relationship between subclinical small vessel disease (SSVD) in the general population and apathy to examine the hypothesis that apathy has a vascular basis.

METHODS

We searched for studies on associations between apathy and SSVD, operationalized as white matter hyperintensities (WMH) or white matter diffusivity changes, lacunar infarcts, cerebral microbleeds, decreasing cortical thickness, and perivascular spaces, while also peripheral proxies for SSVD were considered, operationalized as ankle brachial pressure index (ABI), intima media thickness, arterial stiffness, cardio-femoral pulse wave velocity, hypertension, or cardiovascular disease. Only eligible retrospective and prospective observational studies conducted in the general population were included.

RESULTS

The 14 studies eligible for review examined the associations between apathy and hypertension (3), ABI (1), arterial stiffness (1), cardiovascular disease (2), WMH (3), white matter diffusivity (2), cerebral microbleeds (1), or cortical thickness (3). Arterial stiffness and white matter diffusivity were not related to apathy, while the associations with cortical thickness were contradictory. Cross-sectional studies in the general population did find evidence of apathy being associated with WMH, CM, cardiovascular disease, hypertension, and ABI, and cardiovascular disease was prospectively associated with apathy. The methodologies of the studies reviewed were too heterogeneous to perform meta-analyses.

CONCLUSIONS

Although more prospective evidence is needed and vascular depression needs to be controlled for, cardiovascular disease, hypertension, and ABI as proxies for SSVD, and WMH and cerebral microbleeds as direct measures of SSVD have been found to be associated with apathy in the general population, supporting the hypothesis of vascular apathy.

A network approach on the relation between apathy and depression symptoms with dementia and functional disability

BACKGROUND

Studies on the association between depression and dementia risk mostly use sum scores on depression questionnaires to model symptomatology severity. Since individual items may contribute differently to this association, this approach has limited validity.

METHODS

We used network analysis to investigate the functioning of individual Geriatric Depression Scale (GDS-15) items, of which, based on studies that used factor analysis, 3 are generally considered to measure apathy (GDS-3A) and 12 depression (GDS-12D). Functional disability and future dementia were also included in our analysis. Data were extracted from 3229 participants of the Prevention of Dementia by Intensive Vascular care trial (preDIVA), analyzed as a single cohort, yielding 20,542 person-years of observation. We estimated a sparse network by only including connections between variables that could not be accounted for by variance in other variables. For this, we used a repeated L1 regularized regression procedure.

RESULTS

This procedure resulted in a selection of 59/136 possible connections. GDS-3A items were strongly connected to each other and with varying strength to several GDS-12D items. Functional disability was connected to all three GDS-3A items and the GDS-12D items "helplessness" and "worthlessness". Future dementia was only connected to the GDS-12D item "memory problems", which was in turn connected to the GDS-12D items "unhappiness" and "helplessness" and all three GDS-3A items.

CONCLUSION

Network analysis reveals interesting relationships between GDS items, functional disability and dementia risk. We discuss what implications our results may have for (future) research on the associations between depression and/or apathy with dementia.

Apathy and depressive symptoms in older people and incident myocardial infarction, stroke, and mortality: a systematic review and meta-analysis of individual participant data

Background

Previous findings suggest that apathy symptoms independently of depressive symptoms measured using the Geriatric Depression Scale (GDS) are associated with cardiovascular disease (CVD) in older individuals.

Aims

To study whether apathy and depressive symptoms in older people are associated with future CVD, stroke, and mortality using individual patient-data meta-analysis.

Methods

Medline, Embase, and PsycInfo databases up to September 3, 2013, were systematically searched without language restrictions. We sought prospective studies with older (mean age ≥65 years) community-dwelling populations in which the GDS was employed and subsequent stroke and/or CVD were recorded to provide individual participant data. Apathy symptoms were defined as the three apathy-related subitems of the GDS, with depressive symptoms the remaining items. We used myocardial infarction (MI), stroke, and all-cause mortality as main outcomes. Analyses were adjusted for age, sex, and MI/stroke history. An adaptation of the Newcastle–Ottawa scale was used to evaluate bias. Hazard ratios were calculated using one-stage random-effect Cox regression models.

Results

Of the 52 eligible studies, 21 (40.4%) were included, comprising 47,625 older people (mean age [standard deviation] 74 [7.4] years), over a median follow-up of 8.8 years. Participants with apathy symptoms had a 21% higher risk of MI (95% confidence interval [CI] 1.08–1.36), a 37% higher risk of stroke (95% CI 1.18–1.59), and a 47% higher risk of all-cause mortality (95% CI 1.38–1.56). Participants with depressive symptoms had a comparably higher risk of stroke (HR 1.36, 95% CI 1.18–1.56) and all-cause mortality (HR 1.44, 95% CI 1.35–1.53), but not of MI (HR 1.08, 95% CI 0.91–1.29). Associations for isolated apathy and isolated depressive symptoms were comparable. Sensitivity analyses according to risk of bias yielded similar results.

Conclusion

Our findings stress the clinical importance of recognizing apathy independently of depressive symptoms, and could help physicians identify persons at increased risk of vascular disease.

Apathy is associated with incident dementia in community-dwelling older people

Objective

To assess whether apathy and depressive symptoms are independently associated with incident dementia during 6-year follow-up in a prospective observational population-based cohort study.

Methods

Participants were community-dwelling older people in the Prevention of Dementia by Intensive Vascular Care trial, aged 70–78 years, without dementia at baseline. Apathy and depressive symptoms were measured using the 15-item Geriatric Depression Scale (GDS-15). Dementia during follow-up was established by clinical diagnosis confirmed by an independent outcome adjudication committee. Hazard ratios (HRs) were calculated using Cox regression analyses. Given its potentially strong relation with incipient dementia, the GDS item referring to memory complaints was assessed separately.

Results

Dementia occurred in 232/3,427 (6.8%) participants. Apathy symptoms were associated with dementia (HR 1.28, 95% confidence interval [CI] 1.12–1.45; p < 0.001), also after adjustment for age, sex, Mini-Mental State Examination score, disability, and history of stroke or cardiovascular disease (HR 1.21, 95% CI 1.06–1.40; p = 0.007), and in participants without depressive symptoms (HR 1.26, 95% CI 1.06–1.49; p = 0.01). Depressive symptoms were associated with dementia (HR 1.12, 95% CI 1.05–1.19), also without apathy symptoms (HR 1.16, 95% CI 1.03–1.31; p = 0.015), but not after full adjustment or after removing the GDS item on memory complaints.

Conclusions

Apathy and depressive symptoms are independently associated with incident dementia in community-dwelling older people. Subjective memory complaints may play an important role in the association between depressive symptoms and dementia. Our findings suggest apathy symptoms may be prodromal to dementia and might be used in general practice to identify individuals without cognitive impairment at increased risk of dementia.