1
|
Parrotta I, Cacciatore S, D'Andrea F, D'Anna M, Giancaterino G, Lazzaro G, Arcara G, Manzo N. Prevalence, treatment, and neural correlates of apathy in different forms of dementia: a narrative review. Neurol Sci 2024; 45:1343-1376. [PMID: 38015288 PMCID: PMC10942903 DOI: 10.1007/s10072-023-07197-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES The aim of this review is to provide an overview on prevalence and clinical tools for the diagnosis of apathy, as well as on neurophysiological and neuroimaging findings obtained from studies in patients with apathy in different forms of dementia, including Alzheimer's disease (AD), vascular (VaD) and mixed dementia, frontotemporal dementia (FTD), and Parkinson's disease dementia (PDD). METHODS Randomized controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series from four databases (WebOfScience, Scopus, Pubmed, and PsycINFO) addressing apathy in adults or older people aged over 65 years of age affected by dementia were included. RESULTS The prevalence of apathy was 26-82% for AD, 28.6-91.7 for VaD, 29-97.5% in PDD, and 54.8-88.0 in FTD. The assessment of apathy was not consistent in the reviewed studies. Methylphenidate was the most successful pharmacological treatment for apathy. Neurobiological studies highlighted the relationship between both structural and functional brain areas and the presence or severity of apathy. CONCLUSION Apathy is a very common disorder in all types of dementia, although it is often underdiagnosed and undertreated. Further studies are needed to investigate its diagnosis and management. A consensus on the different evaluation scales should be achieved.
Collapse
Affiliation(s)
- Ilaria Parrotta
- Movement Control and Neuroplasticity Research Group, Tervuursevest 101, 3001, Louvain, Belgium
- IRCCS San Camillo Hospital, Via Alberoni 70, 30126, Venice, Italy
- Young Epidemiologists of the Italian Society of Gerontology and Geriatrics (SIGG) (YES) Working Group, Italian Society of Gerontology and Geriatrics, Via Giulio Cesare Vanini 5, 50129, Florence, Italy
| | - Stefano Cacciatore
- Young Epidemiologists of the Italian Society of Gerontology and Geriatrics (SIGG) (YES) Working Group, Italian Society of Gerontology and Geriatrics, Via Giulio Cesare Vanini 5, 50129, Florence, Italy.
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, 00168, Rome, Italy.
| | - Flavio D'Andrea
- Department of Human Neuroscience, Sapienza University, Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Marianna D'Anna
- Department of Human Neuroscience, Sapienza University, Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Giulia Giancaterino
- Department of Human Neuroscience, Sapienza University, Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Giovanni Lazzaro
- IRCCS San Camillo Hospital, Via Alberoni 70, 30126, Venice, Italy
| | - Giorgio Arcara
- IRCCS San Camillo Hospital, Via Alberoni 70, 30126, Venice, Italy
| | - Nicoletta Manzo
- IRCCS San Camillo Hospital, Via Alberoni 70, 30126, Venice, Italy
| |
Collapse
|
2
|
Voorend CGN, van Buren M, Berkhout-Byrne NC, Kerckhoffs APM, van Oevelen M, Gussekloo J, Richard E, Bos WJW, Mooijaart SP. Apathy Symptoms, Physical and Cognitive Function, Health-Related Quality of Life, and Mortality in Older Patients With CKD: A Longitudinal Observational Study. Am J Kidney Dis 2024; 83:162-172.e1. [PMID: 37741610 DOI: 10.1053/j.ajkd.2023.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 09/25/2023]
Abstract
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.
Collapse
Affiliation(s)
- Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands.
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands
| | - Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands
| | - Angèle P M Kerckhoffs
- Department of Internal Medicine and Geriatrics, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Mathijs van Oevelen
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands
| | - Jacobijn Gussekloo
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
3
|
Zhu CW, Grossman HT, Elder GA, Rosen H, Sano M. Apathy in Lewy body disease and its effects on functional impairment over time. Front Neurol 2024; 15:1339190. [PMID: 38313558 PMCID: PMC10835801 DOI: 10.3389/fneur.2024.1339190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Background and objectives Apathy strongly affects function in Alzheimer's disease and frontotemporal dementia, however its effect on function in Lewy Body Disease (LBD) has not been well-described. This study aims to (1) examine the prevalence and persistence of apathy in a large, national cohort of well-characterized patients with LBD, and (2) estimate the effect of apathy on function over time. Methods Study included 676 participants with mild cognitive impairment (MCI) or dementia in the National Alzheimer's Coordinating Center Uniform Data Set. Participants were followed for an average of 3.4 ± 1.7 years and consistently had a primary diagnosis of LBD. Apathy was defined by clinician judgment, categorized into four mutually exclusive profiles: (1) never apathetic across all visits, (2) at least one but <50% of visits with apathy (intermittent apathy), (3) ≥50% but not all visits with apathy (persistent apathy), and (4) always apathy across all visits. Dementia severity was measured by baseline Clinical Dementia Rating score. Parkinsonism was defined by the presence of bradykinesia, resting tremor, rigidity, gait, and postural instability. Functional impairment was assessed using the Functional Assessment Questionnaire (FAQ). Results Baseline characteristics of the sample were: average age = 72.9 ± 6.9, years of education = 15.6 ± 3.4, Mini Mental State Exam (MMSE) = 24.4 ± 5.4, Geriatric Depression Scale (GDS) = 3.8 ± 3.2, FAQ = 12.0 ± 9.1. 78.8% were male and 89% were non-Hispanic white. Prevalence of apathy increased from 54.4% at baseline to 65.5% in year 4. 77% of participants had apathy at some point during follow-up. Independent of cognitive status and parkinsonian features, FAQ was significantly higher in participants with intermittent/persistent and always apathetic than never apathetic. Annual rate of decline in FAQ was faster in participants who were always apathetic than never apathy. Discussion In this large national longitudinal cohort of LBD patients with cognitive impairment, apathy was strongly associated with greater functional impairment at baseline and faster rate of decline over time. The magnitude of these effects were clinically important and were observed beyond the effects on function from participants' cognitive status and parkinsonism, highlighting the importance of specifically assessing for apathy in LBD.
Collapse
Affiliation(s)
- Carolyn W. Zhu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- James J. Peters VA Medical Center, Bronx, NY, United States
- Department of Psychiatry, Alzheimer Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Hillel T. Grossman
- James J. Peters VA Medical Center, Bronx, NY, United States
- Department of Psychiatry, Alzheimer Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Gregory A. Elder
- James J. Peters VA Medical Center, Bronx, NY, United States
- Department of Psychiatry, Alzheimer Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Howie Rosen
- Department of Neurology, Memory and Aging Center, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Mary Sano
- James J. Peters VA Medical Center, Bronx, NY, United States
- Department of Psychiatry, Alzheimer Disease Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| |
Collapse
|
4
|
Gharat R, Dixit G, Khambete M, Prabhu A. Targets, trials and tribulations in Alzheimer therapeutics. Eur J Pharmacol 2024; 962:176230. [PMID: 38042464 DOI: 10.1016/j.ejphar.2023.176230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 12/04/2023]
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by abnormal accumulation of extracellular amyloid beta senile plaques and intracellular neurofibrillary tangles in the parts of the brain responsible for cognition. The therapeutic burden for the management of AD relies solely on cholinesterase inhibitors that provide only symptomatic relief. The urgent need for disease-modifying drugs has resulted in intensive research in this domain, which has led to better understanding of the disease pathology and identification of a plethora of new pathological targets. Currently, there are over a hundred and seventy clinical trials exploring disease modification, cognitive enhancement, and reduction of neuro-psychiatric complications. However, the path to developing safe and efficacious AD therapeutics has not been without challenges. Several clinical trials have been terminated in advanced stages due to lack of therapeutic translation or increased incidence of adverse events. This review presents an in-depth look at the various therapeutic targets of AD and the lessons learnt during their clinical assessment. Comprehensive understanding of the implication of modulating various aspects of Alzheimer brain pathology is crucial for development of drugs with potential to halt disease progression in Alzheimer therapeutics.
Collapse
Affiliation(s)
- Ruchita Gharat
- SVKM's Dr. Bhanuben Nanavati College of Pharmacy, VM Road, Vile Parle (West), Mumbai, 400056, Maharashtra, India
| | - Gargi Dixit
- SVKM's Dr. Bhanuben Nanavati College of Pharmacy, VM Road, Vile Parle (West), Mumbai, 400056, Maharashtra, India
| | - Mihir Khambete
- Department of Chemistry, Yale University, New Haven, CT, USA
| | - Arati Prabhu
- SVKM's Dr. Bhanuben Nanavati College of Pharmacy, VM Road, Vile Parle (West), Mumbai, 400056, Maharashtra, India.
| |
Collapse
|
5
|
Njomboro P, Lekhutlile T. The Effect of Apathy and Depressive Syndromes on Functional Outcomes in Alzheimer's Disease. J Alzheimers Dis 2024; 98:579-591. [PMID: 38427474 DOI: 10.3233/jad-230426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Background Alzheimer's disease (AD) is the most common cause of dementia. Its initially characterized by progressive short-term memory loss followed by cross-domain cognitive decline in later stages resulting in significant functional deficits and loss of activities of daily living (ADLs) independence. Apathy and depression are frequent neuropsychiatric sequelae in AD, but their contribution to functional deficits is poorly understood. Objective We aimed to quantitatively investigate if apathy and depressive symptoms predict ADLs in AD. We also wanted to fractionate apathy dimensions by factor-analyzing the apathy evaluation scale (AES) and then investigate the dimensions' relation to ADLs. Methods We recruited a sample of 115 patients with probable or possible AD and assessed them for depression, apathy, and ADLs alongside other measures. We hypothesized that apathy and depressive symptoms would predict ADLs and that AES items will load into cognitive, behavioral, and affective factors that would differentially relate to ADLs. Results Our results indicated that apathy symptoms predict ADLs deficits. The AES items resolved into a three-factor solution but the manner of clustering diverged from that proposed by AES authors. When these factors were regressed simultaneously, only behavioral apathy predicted global ADLs. Distinguishing basic from instrumental ADLs showed that behavioral and cognitive apathy symptoms associate with ADLs deficits while affective symptoms do not. Conclusions Our results highlight the influence of apathy on ADLs in AD. This has important implications for patient care considering the high prevalence of apathy in AD and other dementing illnesses.
Collapse
Affiliation(s)
- Progress Njomboro
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | | |
Collapse
|
6
|
Nijsten JMH, Smalbrugge M, Plouvier AOA, Koopmans RTCM, Leontjevas R, Gerritsen DL. Identifying and managing apathy in people with dementia living in nursing homes: a qualitative study. BMC Geriatr 2023; 23:727. [PMID: 37946109 PMCID: PMC10636808 DOI: 10.1186/s12877-023-04422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 10/20/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Although apathy is common in people with dementia and has profound negative effects, it is rarely diagnosed nor specifically treated in nursing homes. The aim of this study is to explore experiences in identifying and managing apathy from the perspectives of people with dementia and apathy (PwA), family caregivers (FCs) and professional caregivers (PCs). METHODS Descriptive qualitative study with purposive sampling, comprising eleven semi-structured in-depth interviews with PwA, FCs or PCs and focus groups with twelve PCs in Dutch nursing homes. Seventeen additional in-depth interviews with caregivers were held, after signals of increasing apathy during the first Covid-19 lockdown. Using an inductive approach, data was analysed thematically to explore the experiences in identifying and managing apathy from the perspective of different stakeholders. RESULTS Three themes were identified: 1) the challenge to appraise signals, 2) the perceived impact on well-being, 3) applied strategies to manage apathy. Although participants described apathy in line with diagnostic criteria, they were unfamiliar with the term apathy and had difficulties in appraising signals of apathy. Also, the perceived impact of apathy varied per stakeholder. PwA had difficulties reflecting on their internal state. FCs and PCs experienced apathy as challenging when it reduced the well-being of PwA or when they themselves experienced ambiguity, frustration, insecurity, disappointment or turning away. Dealing with apathy required applying specific strategies that included stimulating meaningful contact, adjusting one's expectations, and appreciating little successes. CONCLUSIONS When addressing apathy in nursing homes, it is important to consider that a) all stakeholders experience that appraising signals of apathy is challenging; b) apathy negatively influences the well-being of people with dementia and especially their FCs and PCs; and c) FCs and PCs can successfully, albeit temporarily, manage apathy by using specific strategies.
Collapse
Affiliation(s)
- Johanna M H Nijsten
- Radboud University, Nijmegen, The Netherlands.
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands.
- Radboud Alzheimer Centre, Nijmegen, The Netherlands.
- Archipel, Landrijt Expertise Centre for Specialized Care, Eindhoven, The Netherlands.
| | - Martin Smalbrugge
- Department of Medicine for Older People, UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Aging & Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Annette O A Plouvier
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
- Radboud Alzheimer Centre, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
- Radboud Alzheimer Centre, Nijmegen, The Netherlands
- Waalboog, Joachim and Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
| | - Ruslan Leontjevas
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
- Radboud Alzheimer Centre, Nijmegen, The Netherlands
- Faculty of Psychology, Open University of the Netherlands, Heerlen, The Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community Care, Research Institute for Medical Innovation, Radboud University Medical Centre, Nijmegen, The Netherlands
- Radboud Alzheimer Centre, Nijmegen, The Netherlands
| |
Collapse
|
7
|
Connors MH, Teixeira-Pinto A, Ames D, Woodward M, Brodaty H. Apathy and depression in mild cognitive impairment: distinct longitudinal trajectories and clinical outcomes. Int Psychogeriatr 2023; 35:633-642. [PMID: 36715000 DOI: 10.1017/s1041610222001089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Apathy is a common symptom in mild cognitive impairment (MCI) and may predict progression to dementia. Little research, however, has investigated the longitudinal trajectory of apathy in patients with MCI or controlled for depression, which can mimic apathy, when examining its clinical correlates. The current study sought to address these issues. DESIGN A prospective longitudinal study was conducted over 3 years. SETTING Nine memory clinics around Australia. PARTICIPANTS One hundred and eighty-five patients with MCI at baseline. MEASUREMENTS Measures of cognition, function, neuropsychiatric symptoms, caregiver burden, and medication use were completed annually with additional assessments at 3 and 6 months. Patients were also assessed for dementia by expert clinicians at these time points. RESULTS Of 164 patients who completed measures of neuropsychiatric symptoms, 59 (36.0%) had apathy and 61 (37.2%) had depression. The proportion affected by apathy and overall apathy scores increased over time, in contrast to measures of depression, which remained relatively stable. Apathy was associated with incident dementia and worse cognition, function, neuropsychiatric symptoms, and caregiver burden independent of both depression and incident dementia. Depression was associated with worse function, albeit to lesser degree than apathy, and neuropsychiatric symptoms. CONCLUSIONS Apathy increases in MCI and is associated with worse clinical outcomes. These findings provide further evidence for apathy as a marker of clinical decline in older people and poorer outcomes across neurocognitive disorders.
Collapse
Affiliation(s)
| | | | - David Ames
- National Ageing Research Institute, Melbourne, Australia
- University of Melbourne Academic Unit for Psychiatry of Old Age, Melbourne, Australia
| | | | - Henry Brodaty
- Centre for Healthy Brain Ageing, UNSW Sydney, Sydney, Australia
| |
Collapse
|
8
|
Dolphin H, Dyer AH, McHale C, O'Dowd S, Kennelly SP. An Update on Apathy in Alzheimer's Disease. Geriatrics (Basel) 2023; 8:75. [PMID: 37489323 PMCID: PMC10366907 DOI: 10.3390/geriatrics8040075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023] Open
Abstract
Apathy is a complex multi-dimensional syndrome that affects up to 70% of individuals with Alzheimer's disease (AD). Whilst many frameworks to define apathy in AD exist, most include loss of motivation or goal-directed behaviour as the central feature. Apathy is associated with significant impact on persons living with AD and their caregivers and is also associated with accelerated cognitive decline across the AD spectrum. Neuroimaging studies have highlighted a key role of fronto-striatial circuitry including the anterior cingulate cortex (ACC), orbito-frontal cortex (OFC) and associated subcortical structures. Importantly, the presence and severity of apathy strongly correlates with AD stage and neuropathological biomarkers of amyloid and tau pathology. Following from neurochemistry studies demonstrating a central role of biogenic amine neurotransmission in apathy syndrome in AD, recent clinical trial data suggest that apathy symptoms may improve following treatment with agents such as methylphenidate-which may have an important role alongside emerging non-pharmacological treatment strategies. Here, we review the diagnostic criteria, rating scales, prevalence, and risk factors for apathy in AD. The underlying neurobiology, neuropsychology and associated neuroimaging findings are reviewed in detail. Finally, we discuss current treatment approaches and strategies aimed at targeting apathy syndrome in AD, highlighting areas for future research and clinical trials in patient cohorts.
Collapse
Affiliation(s)
- Helena Dolphin
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, D08W9RT Dublin, Ireland
| | - Adam H Dyer
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, D08W9RT Dublin, Ireland
| | - Cathy McHale
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
| | - Sean O'Dowd
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Department of Neurology, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Academic Unit of Neurology, Trinity College Dublin, D02R590 Dublin, Ireland
| | - Sean P Kennelly
- Tallaght Institute of Memory and Cognition, Tallaght University Hospital, D24NR0A Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, D08W9RT Dublin, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, D08W9RT Dublin, Ireland
| |
Collapse
|
9
|
Fidder H, Veenhuizen RB, Gerridzen IJ, van Wieringen WN, Smalbrugge M, Hertogh CMPM, van Loon AM. Impaired Awareness in People with Severe Alcohol-Related Cognitive Deficits Including Korskoff's Syndrome: A Network Analysis. J Clin Med 2023; 12:jcm12093139. [PMID: 37176580 PMCID: PMC10178999 DOI: 10.3390/jcm12093139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/13/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Impaired awareness of one's own functioning is highly common in people with Korsakoff's syndrome (KS). However, it is currently unclear how awareness relates to impairments in daily functioning and quality of life (QoL). METHODS We assessed how impaired awareness relates to cognitive, behavioral, physical, and social functioning and QoL by applying a network analysis. We used cross-sectional data from 215 patients with KS or other severe alcohol-related cognitive deficits living in Dutch long-term care facilities (LTCFs). RESULTS Apathy has the most central position in the network. Higher apathy scores relate positively to reduced cognition and to a greater decline in activities of daily living and negatively to social participation and the use of antipsychotic drugs. Impaired awareness is also a central node. It is positively related to a higher perceived QoL, reduced cognition and apathy, and negatively to social participation and length of stay in the LTCF. Mediated through apathy and social participation, impaired awareness is indirectly related to other neuropsychiatric symptoms. CONCLUSIONS Impaired awareness is closely related to other domains of daily functioning and QoL of people with KS or other severe alcohol-related cognitive deficits living in LTCFs. Apathy plays a central role. Network analysis offers interesting insights to evaluate the interconnection of different symptoms and impairments in brain disorders such as KS.
Collapse
Affiliation(s)
- Hester Fidder
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, De Boelelaan 1109, 1081 HV Amsterdam, The Netherlands
| | - Ruth B Veenhuizen
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, De Boelelaan 1109, 1081 HV Amsterdam, The Netherlands
- Atlant, Nursing Home Markenhof, Korsakoff Centre of Expertise, Kuiltjesweg 1, 7361 TC Beekbergen, The Netherlands
| | - Ineke J Gerridzen
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, De Boelelaan 1109, 1081 HV Amsterdam, The Netherlands
- Atlant, Nursing Home Markenhof, Korsakoff Centre of Expertise, Kuiltjesweg 1, 7361 TC Beekbergen, The Netherlands
| | - Wessel N van Wieringen
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, De Boelelaan 1081a, 1081 HV Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, De Boelelaan 1109, 1081 HV Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, De Boelelaan 1109, 1081 HV Amsterdam, The Netherlands
| | - Anouk M van Loon
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, De Boelelaan 1109, 1081 HV Amsterdam, The Netherlands
| |
Collapse
|
10
|
The importance of a multidimensional approach to the preclinical study of major depressive disorder and apathy. Emerg Top Life Sci 2022; 6:479-489. [PMID: 36413089 PMCID: PMC9788393 DOI: 10.1042/etls20220004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
Abstract
Both the neuropsychiatric syndrome of apathy and major depressive disorder comprise a heterogenous cluster of symptoms which span multiple behavioural domains. Despite this heterogeneity, there is a tendency in the preclinical literature to conclude a MDD or apathy-like phenotype from a single dimensional behavioural task used in isolation, which may lead to inaccurate phenotypic interpretation. This is significant, as apathy and major depressive disorder are clinically distinct with different underlying mechanisms and treatment approaches. At the clinical level, apathy and major depressive disorder can be dissociated in the negative valence (loss) domain of the Research Domain Criteria. Symptoms of MDD in the negative valence (loss) domain can include an exaggerated response to emotionally salient stimuli and low mood, while in contrast apathy is characterised by an emotionally blunted state. In this article, we highlight how using a single dimensional approach can limit psychiatric model interpretation. We discuss how integrating behavioural findings from both the positive and negative (loss) valence domains of the Research Domain Criteria can benefit interpretation of findings. We focus particularly on behaviours relating to the negative valence (loss) domain, which may be used to distinguish between apathy and major depressive disorder at the preclinical level. Finally, we consider how future approaches using home cage monitoring may offer a new opportunity to detect distinct behavioural profiles and benefit the overall translatability of findings.
Collapse
|
11
|
Asano T, Wang CW, Tsugaruya M, Ishikawa T. Effectiveness of life story book intervention on apathy and verbal fluency in people with dementia. Clin Gerontol 2022; 46:389-399. [PMID: 36409251 DOI: 10.1080/07317115.2022.2147887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study determined whether the individual intervention of using life story books (LSBs) improves apathy and verbal fluency in people with dementia (PWD). METHODS The intervention group (n = 43) underwent 3 interviews in the 10 weeks following an initial assessment. Based on the information obtained, LSBs were developed; participants received individual interventions weekly, five times for four weeks. They also received a final assessment 12 weeks after the end of the intervention. Primary outcome measures comprised the Categorical Verbal Fluency Test (CFT) and the Neuropsychiatric Inventory-Nursing Home Apathy sub-item. The control group (n = 32) underwent initial and final assessments at intervals of 28 weeks while receiving the best care services. RESULTS CFT scores for participants with mild to moderate dementia increased from 4.3 to 5.3 (P < .05) and the interaction effect of group and data collection timing was significant (p < .05). Apathy score for participants with severe dementia also improved from 4.5 to 2.5 (P < .05) immediately after the intervention period. CONCLUSIONS LSB is a comprehensive communication tool that encourages apathy and verbal fluency. CLINICAL IMPLICATIONS The use of LSB may allow caregivers to achieve intervention effects on apathy and verbal fluency in PWD.
Collapse
Affiliation(s)
- Tomoaki Asano
- Department of Occupational Therapy, Akita University, Graduate School of Health Science, Akita, Japan
| | - Chih-Wen Wang
- Department of Rehabilitation, Occupational Therapy Course, Faculty of Medical Science and Welfare, Tohoku Bunka Gakuen University, Sendai, Japan
| | - Megumi Tsugaruya
- Department of Occupational Therapy, Akita University, Graduate School of Health Science, Akita, Japan
| | - Takashi Ishikawa
- Department of Occupational Therapy, Akita University, Graduate School of Health Science, Akita, Japan
| |
Collapse
|
12
|
Beeri MS, Tirosh A, Lin H, Golan S, Boccara E, Sano M, Zhu CW. Stability in BMI over time is associated with a better cognitive trajectory in older adults. Alzheimers Dement 2022; 18:2131-2139. [PMID: 35049119 PMCID: PMC9296696 DOI: 10.1002/alz.12525] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Evidence on simultaneous changes in body mass index (BMI) and cognitive decline, which better reflect the natural course of both health phenomena, is limited. METHODS We capitalized on longitudinal data from 15,977 initially non-demented elderly from the Alzheimer's Disease Centers followed for 5 years on average. Changes in BMI were defined as (1) last minus first BMI, (2) mean of all follow-up BMIs minus first BMI, and (3) standard deviation of BMI change from baseline and all follow-up visits (representing variability). RESULTS Participants with significant changes in BMI (increase or decrease of ≥5%), or who had greater variability in BMI, had faster cognitive decline. This pattern was consistent irrespective of normal (BMI < 25; N = 5747), overweight (25 ≤ BMI < 30; N = 6302), or obese (BMI ≥ 30; N = 3928) BMI at baseline. CONCLUSIONS Stability in BMI predicts better cognitive trajectories suggesting clinical value in tracking BMI change, which is simple to measure, and may point to individuals whose cognition is declining.
Collapse
Affiliation(s)
- Michal Schnaider Beeri
- Department of PsychiatryThe Icahn School of Medicine at Mount SinaiNew YorkUSA,The Joseph Sagol Neuroscience CenterSheba Medical CenterRamat GanIsrael
| | - Amir Tirosh
- Division of EndocrinologyDiabetes and MetabolismSheba Medical CenterRamat GanIsrael
| | - Hung‐Mo Lin
- Department of Health Population Sciences and PolicyCenter of BiostatisticsIcahn School of MedicineMount SinaiUSA
| | - Sapir Golan
- The Joseph Sagol Neuroscience CenterSheba Medical CenterRamat GanIsrael
| | - Ethel Boccara
- The Joseph Sagol Neuroscience CenterSheba Medical CenterRamat GanIsrael
| | - Mary Sano
- Department of PsychiatryThe Icahn School of Medicine at Mount SinaiNew YorkUSA,GRECCJames J Peters VA Medical CenterBronxNew YorkUSA
| | - Carolyn W. Zhu
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of MedicineMount SinaiUSA,GRECCJames J Peters VA Medical CenterBronxNew YorkUSA
| |
Collapse
|
13
|
Connors MH, Teixeira-Pinto A, Ames D, Woodward M, Brodaty H. Distinguishing apathy and depression in dementia: A longitudinal study. Aust N Z J Psychiatry 2022; 57:884-894. [PMID: 35968798 DOI: 10.1177/00048674221114597] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Apathy is a common symptom in dementia, though can be difficult to distinguish from depression due to shared features and frequent co-occurrence. As such, a significant limitation of much previous research on apathy is the failure to control for depression. The current study sought to address this by examining the trajectory and clinical correlates of apathy after controlling for depression. METHODS Seven hundred and seventy-nine patients with dementia were recruited from nine memory clinics around Australia. Measures of dementia severity, cognition, functional ability, neuropsychiatric symptoms, caregiver burden and medication use were completed at baseline and at regular intervals over a 3-year period. Driving and institutionalisation data were obtained throughout the study. Mortality data were obtained from state registries 8 years after baseline. RESULTS Of the 662 patients with completed measures of neuropsychiatric symptoms, 342 (51.7%) had apathy and 332 (50.2%) had depression at baseline, while 212 (32.0%) had both. Whereas apathy increased over time, depression remained relatively stable. Apathy, but not depression, was associated with greater dementia severity, poorer cognition and function, driving cessation and mortality. Both apathy and depression were associated with greater neuropsychiatric symptoms, psychosis, caregiver burden and institutionalisation. CONCLUSIONS Apathy increases over the course of dementia and is associated with worse clinical outcomes independent of depression. Distinguishing apathy and depression appears important given their different implications for prognosis and management.
Collapse
Affiliation(s)
- Michael H Connors
- Centre for Healthy Brain Ageing (CHeBA), Discipline of Psychiatry and Mental Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - David Ames
- National Ageing Research Institute, Melbourne, VIC, Australia.,Academic Unit for Psychiatry of Old Age, The University of Melbourne, Melbourne, VIC, Australia
| | | | - Henry Brodaty
- Centre for Healthy Brain Ageing (CHeBA), Discipline of Psychiatry and Mental Health, UNSW Sydney, Sydney, NSW, Australia
| |
Collapse
|
14
|
Azocar I, Rapaport P, Burton A, Meisel G, Orgeta V. Risk factors for apathy in Alzheimer's disease: A systematic review of longitudinal evidence. Ageing Res Rev 2022; 79:101672. [PMID: 35714852 DOI: 10.1016/j.arr.2022.101672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/26/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Apathy is frequent and persistent in Alzheimer's disease (AD), associated with poor prognosis and carer distress; yet our knowledge of risk factors remains limited. AIMS To identify risk factors associated with apathy incidence and progression in AD over time. METHODS We systematically reviewed evidence based on longitudinal studies assessing risk factors for apathy in AD up to June 2021. Two authors independently assessed article eligibility and rated quality. RESULTS 13,280 articles were screened, of which 13 met inclusion criteria. Studies had a mean follow-up of 2.7 years reporting on a total of 2012 participants. Most findings were based on single studies of moderate quality evidence. Risk factors increasing apathy onset were: being a carrier of the T allele of the PRND gene polymorphism, and having high levels of the IL-6 and TNFα cytokines at baseline. Risk factors for apathy worsening were: reduced inferior-temporal cortical thickness, taking antidepressants, being an ApoE ε4 carrier, living longer with AD, lower cognitive test scores, higher baseline apathy, premorbid personality traits (lower agreeableness, higher neuroticism), and higher midlife motivational abilities. CONCLUSIONS Although results are limited by the small number of studies, this review identified specific genetic, neurobiological, AD specific, and dispositional factors that may increase risk of apathy onset and worsening in AD.
Collapse
Affiliation(s)
- Ignacia Azocar
- Division of Psychiatry, University College London, London, UK.
| | - Penny Rapaport
- Division of Psychiatry, University College London, London, UK
| | - Alexandra Burton
- Department of Behavioural Science and Health, University College London, London, UK
| | - Georgia Meisel
- Division of Psychiatry, University College London, London, UK
| | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| |
Collapse
|
15
|
Grossman HT, Sano M, Aloysi A, Elder GA, Neugroschl J, Schimming C, Soleimani L, Zhu CW. Prevalent, persistent, and impairing: Longitudinal course and impact of apathy in Alzheimer's disease. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2022; 13:e12169. [PMID: 35141391 PMCID: PMC8817116 DOI: 10.1002/dad2.12169] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/15/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Understanding of the natural history of apathy and its impact on patient function is limited. This study examines, in a large, national sample of Alzheimer's disease (AD) patients with long follow-ups: (1) prevalence, incidence, and persistence of apathy, and (2) impact of apathy on function across dementia severity. METHODS A longitudinal study of 9823 well-characterized AD patients in the National Alzheimer's Coordinating Center Uniform Data Set. RESULTS Apathy was highly prevalent across disease severity with cumulative prevalence of 48%, 74%, and 82% in Clinical Dementia Rating (CDR) 0.5, 1.0, and 2.0, respectively. Persistence of apathy from clinician judgment varied from visit to visit at earlier disease stages but remained high at moderate dementia. Independent of cognition, persistent apathy was strongly associated with accelerated rate of functional decline. DISCUSSION Findings point to important targets for the treatment and management of apathy, include functional outcomes, and study designs that account for variable persistence of the apathy syndrome.
Collapse
Affiliation(s)
- Hillel T. Grossman
- James J. Peters VA Medical CenterBronxNew YorkUSA
- Department of PsychiatryIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
| | - Mary Sano
- James J. Peters VA Medical CenterBronxNew YorkUSA
- Department of PsychiatryIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
| | - Amy Aloysi
- Department of PsychiatryIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
- Department of NeurologyIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
| | - Gregory A. Elder
- Department of PsychiatryIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
- Department of NeurologyIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
| | - Judith Neugroschl
- Department of PsychiatryIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
| | - Corbett Schimming
- James J. Peters VA Medical CenterBronxNew YorkUSA
- Department of PsychiatryIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
| | - Laili Soleimani
- Department of PsychiatryIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
| | - Carolyn W. Zhu
- James J. Peters VA Medical CenterBronxNew YorkUSA
- Department of PsychiatryIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiBronxNew YorkUSA
| |
Collapse
|
16
|
Chaudhary S, Zhornitsky S, Chao HH, van Dyck CH, Li CSR. Cerebral Volumetric Correlates of Apathy in Alzheimer's Disease and Cognitively Normal Older Adults: Meta-Analysis, Label-Based Review, and Study of an Independent Cohort. J Alzheimers Dis 2022; 85:1251-1265. [PMID: 34924392 PMCID: PMC9215906 DOI: 10.3233/jad-215316] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Affecting nearly half of the patients with Alzheimer's disease (AD), apathy is associated with higher morbidity and reduced quality of life. Basal ganglia and cortical atrophy have been implicated in apathy. However, the findings have varied across studies and left unclear whether subdomains of apathy may involve distinct neuroanatomical correlates. OBJECTIVE To identify neuroanatomical correlates of AD-associated apathy. METHODS We performed a meta-analysis and label-based review of the literature. Further, following published routines of voxel-based morphometry, we aimed to confirm the findings in an independent cohort of 19 patients with AD/mild cognitive impairment and 25 healthy controls assessed with the Apathy Evaluation Scale. RESULTS Meta-analysis of 167 AD and 56 healthy controls showed convergence toward smaller basal ganglia gray matter volume (GMV) in apathy. Label-based review showed anterior cingulate, putamen, insula, inferior frontal gyrus (IFG) and middle temporal gyrus (MTG) atrophy in AD apathy. In the independent cohort, with small-volume-correction, right putamen and MTG showed GMVs in negative correlation with Apathy Evaluation Scale total, behavioral, and emotional scores, and right IFG with emotional score (p < 0.05 family-wise error (FWE)-corrected), controlling for age, education, intracranial volume, and depression. With the Mini-Mental State Examination scores included as an additional covariate, the correlation of right putamen GMV with behavioral and emotional score, right MTG GMV with total and emotional score, and right IFG GMV with emotional score were significant. CONCLUSION The findings implicate putamen, MTG and IFG atrophy in AD associated apathy, potentially independent of cognitive impairment and depression, and suggest potentially distinct volumetric correlates of apathy.
Collapse
Affiliation(s)
- Shefali Chaudhary
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519
| | - Simon Zhornitsky
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519
| | - Herta H. Chao
- Comprehensive Cancer Center, Department of Medicine, Yale University School of Medicine, New Haven, CT 06519
| | - Christopher H. van Dyck
- Disease Research Center, Department of Psychiatry; Department of Neuroscience; Interdepartmental Neuroscience, Program, Yale University School of Medicine, New Haven, CT 06520
| | - Chiang-Shan R. Li
- Department of Psychiatry; Department of Neuroscience; Interdepartmental Neuroscience, Program, Wu Tsai Institute, Yale University, Yale University School of Medicine, New Haven, CT 06520
| |
Collapse
|
17
|
Gracia-García P, Modrego P, Lobo A. Apathy and neurocognitive correlates: review from the perspective of 'precision psychiatry'. Curr Opin Psychiatry 2021; 34:193-198. [PMID: 33395095 DOI: 10.1097/yco.0000000000000677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW From the perspective of motivated behaviour and the so-called 'precision psychiatry', we try to identify recent advances in the neurocognitive and biological correlates of apathy. RECENT FINDINGS New evidence supports the notion that apathy is a common transdiagnostic and heterogeneous clinical syndrome, now conceptualized as a reduction in 'goal-directed' activity. Similarly, abundant evidence has been found related to neurocognitive correlates of apathy and the associations between clinical apathy and the processes primarily responsible for mediating motivational drive and effort-based decision making.Notwithstanding that the neurobiological basis is still poorly understood, there is some agreement in recent articles about a common system-level mechanism underlying apathy, pointing at specific medial frontal cortex and subcortical structures, including anterior cingulate cortex, medial orbitofrontal cortex and ventral striatum and related circuitry. SUMMARY Although difficulties in interpreting the results of these studies are apparent, because of different concepts of apathy used and methodological shortcomings identified, we have found consistent advances in the neurocognitive and biological correlates of apathy, relevant for the deep phenotyping proposed by the 'precision psychiatry' approach. This framework may eventually facilitate the identification of predictive-risk models and new specific therapeutic targets in psychiatry.
Collapse
Affiliation(s)
- Patricia Gracia-García
- Hospital Universitario Miguel Servet
- Departamento de Medicina y Psiquiatría, Universidad de Zaragoza, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón [IIS Aragón]
- CIBERSAM, Instituto de Salud Carlos III, Zaragoza, Spain
| | - Pedro Modrego
- Hospital Universitario Miguel Servet
- Departamento de Medicina y Psiquiatría, Universidad de Zaragoza, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón [IIS Aragón]
- CIBERSAM, Instituto de Salud Carlos III, Zaragoza, Spain
| | - Antonio Lobo
- Departamento de Medicina y Psiquiatría, Universidad de Zaragoza, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón [IIS Aragón]
- CIBERSAM, Instituto de Salud Carlos III, Zaragoza, Spain
| |
Collapse
|
18
|
McCombie C, Cort E, Gould RL, Kiosses DN, Alexopoulos GS, Howard R, Lawrence VC. Adapting and Optimizing Problem Adaptation Therapy (PATH) for People With Mild-Moderate Dementia and Depression. Am J Geriatr Psychiatry 2021; 29:192-203. [PMID: 32600788 DOI: 10.1016/j.jagp.2020.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To adapt and optimize problem adaptation therapy for depression in dementia by grounding it in the lives of people with dementia, caregivers and clinicians. METHODS A person-centered qualitative approach was taken to elicit the unique cognitive, psychological and social needs of people with dementia relevant to the adaptation of the intervention. A two-stage design was used: the first involved interviews and focus groups to identify priorities and concerns surrounding depression in dementia, the second trialling of the adapted intervention. PARTICIPANTS Ten people with dementia and nine caregivers participated in individual interviews, 35 healthcare practitioners and clinical academics with experience of working with dementia participated in focus groups. RESULTS The findings highlight the importance of addressing key themes that typified the experience of depression among people with dementia including: a profound sense of isolation and role loss, the feeling of being both a burden and poorly understood, polarized thinking, interpersonal tensions, diverging views among carers and people with dementia about their capabilities, and changeability in cognitive ability and mood. These themes were used to inform adaptation of the intervention manual, ensuring that its content and delivery addressed the concerns of both people with depression and dementia and those who support them. CONCLUSION Implications for PATH included a focus on facilitating open communication, supporting the continuation of valued roles, and improving confidence.
Collapse
Affiliation(s)
- Catherine McCombie
- Department of Health Services and Population Research, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Elizabeth Cort
- Division of Psychiatry, University College London, London, United Kingdom
| | - Rebecca L Gould
- Division of Psychiatry, University College London, London, United Kingdom
| | | | | | - Robert Howard
- Division of Psychiatry, University College London, London, United Kingdom
| | - Vanessa C Lawrence
- Department of Health Services and Population Research, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom.
| |
Collapse
|
19
|
Cummings J. New approaches to symptomatic treatments for Alzheimer's disease. Mol Neurodegener 2021; 16:2. [PMID: 33441154 PMCID: PMC7805095 DOI: 10.1186/s13024-021-00424-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/02/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Successful development of agents that improve cognition and behavior in Alzheimer's disease (AD) is critical to improving the lives of patients manifesting the symptoms of this progressive disorder. DISCUSSION There have been no recent approvals of cognitive enhancing agents for AD. There are currently 6 cognitive enhancers in Phase 2 trials and 4 in phase 3. They represent a variety of novel mechanisms. There has been progress in developing new treatments for neuropsychiatric symptoms in AD with advances in treatment of insomnia, psychosis, apathy, and agitation in AD. There are currently 4 AD-related psychotropic agents in Phase 2 trials and 7 in Phase 3 trials. Many novel mechanisms are being explored for the treatment of cognitive and behavioral targets. Progress in trial designs, outcomes measures, and population definitions are improving trial conduct for symptomatic treatment of AD. CONCLUSIONS Advances in developing new agents for cognitive and behavioral symptoms of AD combined with enhanced trial methods promise to address the unmet needs of patients with AD for improved cognition and amelioration of neuropsychiatric symptoms.
Collapse
Affiliation(s)
- Jeffrey Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA.
| |
Collapse
|
20
|
Azocar I, Livingston G, Huntley J. The Association Between Impaired Awareness and Depression, Anxiety, and Apathy in Mild to Moderate Alzheimer's Disease: A Systematic Review. Front Psychiatry 2021; 12:633081. [PMID: 33613344 PMCID: PMC7889585 DOI: 10.3389/fpsyt.2021.633081] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/04/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives: Impaired awareness of cognitive and functional deficits is a common feature of Alzheimer's disease (AD). Although a lack of awareness has been suggested to be a protective factor against experiencing affective symptoms, such as depression, anxiety, and apathy which are common in AD, there is conflicting evidence about the links between them. This systematic review examines the evidence for an association between impaired awareness and depressive, anxiety, and apathy symptoms in mild to moderate AD. Method: We searched four databases (OvidMedline, Embase, PsycInfo, and PsycArticles) using terms encompassing awareness, apathy, depression, anxiety, and mild-moderate AD. We included studies that assessed the relationship between awareness and depressive symptoms, anxiety symptoms, or apathy. We assessed included papers for quality and report results using a narrative approach, prioritizing high quality studies. Results: We identified 1,544 articles, and twenty-seven studies fulfilled inclusion criteria (high-quality = 15; moderate-quality = 12). Most high-quality studies reported that impaired awareness in early-stage AD is cross-sectionally linked with fewer depressive symptoms and anxiety symptoms (correlation ranged from -0.3 to -0.7), but with more apathy. Conclusions: High-quality studies suggested that in people with early AD, impaired awareness is related to fewer depressive and anxiety symptoms and to more apathy. Future research should focus on elucidating causality among impaired awareness and these symptoms in AD.
Collapse
Affiliation(s)
- Ignacia Azocar
- Division of Psychiatry, University College London, London, United Kingdom
| | - Gill Livingston
- Division of Psychiatry, University College London, London, United Kingdom
| | - Jonathan Huntley
- Division of Psychiatry, University College London, London, United Kingdom
| |
Collapse
|
21
|
Lanctôt KL, Scherer RW, Li A, Vieira D, Coulibaly H, Rosenberg PB, Herrmann N, Lerner AJ, Padala PR, Brawman-Mintzer O, van Dyck CH, Porsteinsson AP, Craft S, Levey A, Burke WJ, Mintzer JE. Measuring Apathy in Alzheimer's Disease in the Apathy in Dementia Methylphenidate Trial 2 (ADMET 2): A Comparison of Instruments. Am J Geriatr Psychiatry 2021; 29:81-89. [PMID: 32565008 PMCID: PMC7704818 DOI: 10.1016/j.jagp.2020.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/10/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diagnostic criteria for apathy have been published but have yet to be evaluated in the context of clinical trials. The Apathy in Dementia Methylphenidate Trial 2 (ADMET 2) operationalized the diagnostic criteria for apathy (DCA) into a clinician-rated questionnaire informed by interviews with the patient and caregiver. OBJECTIVE The goal of the present study was to compare the classification of apathy using the DCA with that using the Neuropsychiatric Inventory-apathy (NPI-apathy) subscale in ADMET 2. Comparisons between NPI-Apathy and Dementia Apathy Interview Rating (DAIR) scale, and DCA and DAIR were also explored. METHODS ADMET 2 is a randomized, double-blind, placebo-controlled phase III trial examining the effects of 20 mg/day methylphenidate on symptoms of apathy over 6 months in patients with mild to moderate Alzheimer's disease (AD). Participants scoring at least 4 on the NPI-Apathy were recruited. This analysis focuses on cross-sectional correlations between baseline apathy scale scores using cross-tabulation. RESULTS Of 180 participants, the median age was 76.5 years and they were predominantly white (92.8%) and male (66.1%). The mean (±standard deviation) scores were 7.7 ± 2.4 on the NPI-apathy, and 1.9 ± 0.5 on the DAIR. Of those with NPI-defined apathy, 169 (93.9%, 95% confidence interval [CI] 89.3%-96.9%) met DCA diagnostic criteria. The DCA and DAIR overlapped on apathy diagnosis for 169 participants (93.9%, 95% CI 89.3%-96.9%). CONCLUSION The measurements used for the assessment of apathy in patients with AD had a high degree of overlap with the DCA. The NPI-apathy cut-off used to determine apathy in ADMET 2 selects those likely to meet DCA criteria.
Collapse
Affiliation(s)
| | - Roberta W. Scherer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. USA
| | - Abby Li
- Sunnybrook Research Institute, Toronto, ON, Canada
| | | | - Hamadou Coulibaly
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. USA
| | | | | | - Alan J Lerner
- University Hospital – Case Western Reserve University, Cleveland, OH, USA
| | - Prasad R Padala
- University of Arkansas for Medical Science, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Olga Brawman-Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | | | | | - Suzanne Craft
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Jacobo E. Mintzer
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| |
Collapse
|
22
|
Cai Y, Li L, Xu C, Wang Z. The Effectiveness of Non-Pharmacological Interventions on Apathy in Patients With Dementia: A Systematic Review of Systematic Reviews. Worldviews Evid Based Nurs 2020; 17:311-318. [PMID: 32767834 DOI: 10.1111/wvn.12459] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Apathy is one of the behavioral and psychological symptoms of dementia (BPSD), which is the most frequent and can accelerate the progress of dementia. AIMS To systematically review the evidence of effectiveness of non-pharmacological interventions on apathy in patients with dementia. METHODS Databases including the Cochrane Library, Joanna Briggs Institute (JBI) Library, PubMed, EMBASE, CINAHL, PsycINFO, Psychology and Behavioral Sciences Collection, CNKI, and Wan Fang Data were searched for systematic reviews of the effectiveness of non-pharmacological interventions on apathy in patients with dementia. AMSTAR 2 was applied to assess the methodological quality of reviews. RESULTS Nine systematic reviews were included. The average level of overall confidence for included systematic reviews was low. Among all the non-pharmacological interventions involved in this review, the effectiveness of multisensory stimulation, music therapy, cognitive stimulation, and pet therapy was relatively robust. The effects of reminiscence therapy, therapeutic conversation, progressive muscle relaxation, art therapy, exercise therapy, occupational therapy, dementia special care units, nursing staff education, and comprehensive interventions need to be validated further. Meanwhile, the current evidence failed to support the effects of psychomotor therapy and validation therapy on apathy. LINKING EVIDENCE TO ACTION Non-pharmacological interventions for apathy in patients with dementia are acceptable. In spite of requirements for adequate and high-quality original studies and quantitative systematic reviews to validate the efficacy of non-pharmacological interventions, multisensory stimulation, music therapy, cognitive stimulation, and pet therapy are deemed the most helpful according to evidences available.
Collapse
Affiliation(s)
- Yan Cai
- School of Nursing, Peking University, Beijing, China.,West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Liyu Li
- School of Nursing, Peking University, Beijing, China
| | - Chang Xu
- School of Nursing, Peking University, Beijing, China
| | - Zhiwen Wang
- School of Nursing, Peking University, Beijing, China
| |
Collapse
|
23
|
Saredakis D, Keage HA, Corlis M, Loetscher T. Using Virtual Reality to Improve Apathy in Residential Aged Care: Mixed Methods Study. J Med Internet Res 2020; 22:e17632. [PMID: 32469314 PMCID: PMC7380990 DOI: 10.2196/17632] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/26/2020] [Accepted: 04/08/2020] [Indexed: 12/17/2022] Open
Abstract
Background Apathy is a common symptom in neurological disorders, including dementia, and is associated with a faster rate of cognitive decline, reduced quality of life, and high caregiver burden. There is a lack of effective pharmacological treatments for apathy, and nonpharmacological interventions are a preferred first-line approach to treatment. Virtual reality (VR) using head-mounted displays (HMDs) is being successfully used in exposure- and distraction-based therapies; however, there is limited research on using HMDs for symptoms of neurological disorders. Objective This feasibility study aimed to assess whether VR using HMDs could be used to deliver tailored reminiscence therapy and examine the willingness to participate, response rates to measures, time taken to create tailored content, and technical problems. In addition, this study aimed to explore the immediate effects between verbal fluency and apathy after exposure to VR. Methods A mixed methods study was conducted in a sample of older adults residing in aged care, and 17 participants were recruited. Apathy was measured using the Apathy Evaluation Scale (AES), and verbal fluency was used as a proxy measure of improvements in apathy and debriefing interviews to assess feedback from participants. Side effects that can occur from using HMDs were also measured. Results We recruited participants from a high socioeconomic status setting with a high education level, and the participation rate was 85% (17/20); most responses to measures were positive. Access to a wide range of freely available content and the absence of technical difficulties made the delivery of a VR reminiscence intervention highly feasible. Participants had improved semantic scores (t14=−3.27; P=.006) but not phonemic fluency scores (t14=0.55; P=.59) immediately after the intervention. Those with higher levels of apathy demonstrated the greatest cognitive improvements after a VR reminiscence experience, which was indicated by a strong positive relationship between the AES and semantic verbal fluency change scores postminus pre-VR (r=0.719; 95% CI 0.327 to 0.900; P=.003). All participants enjoyed the experience despite 35% (6/17) of participants experiencing temporary side effects. Conclusions This study provides initial evidence that it is feasible to use VR with HMDs for therapy to treat symptoms of apathy in older adults in residential aged care. However, there is a need to closely monitor the side effects of HMD use in older adults. Further research is needed using an active control group to compare the use of VR with traditional forms of reminiscence therapy.
Collapse
|
24
|
Takemoto M, Ohta Y, Hishikawa N, Yamashita T, Nomura E, Tsunoda K, Sasaki R, Tadokoro K, Matsumoto N, Omote Y, Abe K. The Efficacy of Sertraline, Escitalopram, and Nicergoline in the Treatment of Depression and Apathy in Alzheimer's Disease: The Okayama Depression and Apathy Project (ODAP). J Alzheimers Dis 2020; 76:769-772. [PMID: 32568205 DOI: 10.3233/jad-200247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neuropsychiatric symptoms of dementia such as depression and apathy in patients with Alzheimer's disease (AD) are associated with a lower quality of life. OBJECTIVE We aimed to determine the efficacy of two antidepressants and one antipathy drug in the treatment of depression and apathy in AD patients. METHODS In the present study, we evaluated the efficacy of sertraline (n = 11; average dose = 31.8 mg), escitalopram (n = 13; average dose = 7.3 mg), and nicergoline (n = 9; average dose = 14.5 mg) in treating depression and apathy over a period of 3 months (M).The 33 patients with AD demonstrated high Geriatric Depression Scale (GDS) (>5) or a high Apathy Scale (AS) (>16) scores. RESULTS The patients receiving escitalopram treatment showed a significant improvement in GDS score from baseline (8.2±3.5) to 3 M (5.7±2.6, p = 0.04), and the patients receiving sertraline treatment showed a significant improvement in AS score from baseline (20.8±5.2) to 3 M (16.8±6.1, p = 0.05); however, no significant changes were noted in patients receiving nicergoline. CONCLUSION These results provide novel information on the efficacy of sertraline and escitalopram in the treatment of apathy and depression, respectively, in patients with AD.
Collapse
Affiliation(s)
- Mami Takemoto
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Yasuyuki Ohta
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Nozomi Hishikawa
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Toru Yamashita
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Emi Nomura
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Keiichiro Tsunoda
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Ryo Sasaki
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Koh Tadokoro
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Namiko Matsumoto
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Yoshio Omote
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| | - Koji Abe
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Kita-ku, Okayama, Japan
| |
Collapse
|
25
|
Zeghari R, Manera V, Fabre R, Guerchouche R, König A, Phan Tran MK, Robert P. The “Interest Game”: A Ludic Application to Improve Apathy Assessment in Patients with Neurocognitive Disorders. J Alzheimers Dis 2020; 74:669-677. [DOI: 10.3233/jad-191282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Radia Zeghari
- Université Côte d’Azur, CoBTeK Laboratory, Nice, France
- Association IA (Alzheimer-Affect-Autism), Nice, France
| | - Valeria Manera
- Université Côte d’Azur, CoBTeK Laboratory, Nice, France
- Association IA (Alzheimer-Affect-Autism), Nice, France
| | - Roxane Fabre
- Université Côte d’Azur, CoBTeK Laboratory, Nice, France
- Centre Hospitalier Universitaire de Nice, Département de Santé Publique, Nice, France
| | | | - Alexandra König
- Université Côte d’Azur, CoBTeK Laboratory, Nice, France
- Inria Sophia Antipolis, STARS team, Sophia Antipolis, France
| | - Minh Khue Phan Tran
- Université Côte d’Azur, CoBTeK Laboratory, Nice, France
- Inria Sophia Antipolis, STARS team, Sophia Antipolis, France
| | - Philippe Robert
- Université Côte d’Azur, CoBTeK Laboratory, Nice, France
- Association IA (Alzheimer-Affect-Autism), Nice, France
- Centre Hospitalier Universitaire de Nice, Resource & Research Memory Centre, Nice
| |
Collapse
|
26
|
Bogdan A, Manera V, Koenig A, David R. Pharmacologic Approaches for the Management of Apathy in Neurodegenerative Disorders. Front Pharmacol 2020; 10:1581. [PMID: 32038253 PMCID: PMC6989486 DOI: 10.3389/fphar.2019.01581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/05/2019] [Indexed: 01/10/2023] Open
Abstract
Apathy is one of the most frequent behavioral disturbances in many neurodegenerative disorders and is known to have a negative impact on the disease progression, particularly in Alzheimer’s disease. Therapeutic options are currently limited and non-pharmacological approaches should constitute first line treatments. Pharmacological agents likely to reduce apathy levels are lacking. The objective of the present article is to review recent pharmacological treatments for apathy in neurodegenerative disorders. The Pubmed database was searched with a particular focus on articles published as of January 2017. Current main levels of evidence have been reported so far with cholinergic, glutamatergic and dopaminergic agents to reduce levels of apathy, despite several conflicting results. Treatment duration and samples sizes may have however decreased the validity of previous results. Ongoing studies involving more participants/treatment duration or distinct neural pathways may provide new insights in the treatment of apathy in neurodegenerative disorders.
Collapse
Affiliation(s)
- Anamaria Bogdan
- Centre Hospitalier Universitaire de Nice, Centre Mémoire de Ressources et de Recherche, Nice, France
| | - Valeria Manera
- CoBTeK Lab "Cognition Behaviour Technology", University of Nice Sophia Antipolis, Nice, France
| | - Alexandra Koenig
- CoBTeK Lab "Cognition Behaviour Technology", University of Nice Sophia Antipolis, Nice, France
| | - Renaud David
- Centre Hospitalier Universitaire de Nice, Centre Mémoire de Ressources et de Recherche, Nice, France
| |
Collapse
|
27
|
Starkstein S, Hayhow B. Apathy in Dementia: Time to StandUp. Am J Geriatr Psychiatry 2019; 27:406-407. [PMID: 30765290 DOI: 10.1016/j.jagp.2018.12.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Sergio Starkstein
- Department of Medicine (SS), School of Psychiatry, University of Western Australia, Fremantle, Australia.
| | - Bradley Hayhow
- School of Psychiatry (BH), University of Notre Dame, Notre Dame, IN
| |
Collapse
|