Modafinil Therapy for Apathy in an Elderly Patient

Neuroanatomical Abnormalities in Older Depressed Adults With Apathy: A Systematic Review

OBJECTIVE

Apathy is a common phenomenon in late-life depression and is associated with poor outcomes. Apathy is often unrecognized in older depressed adults, and efficacious treatment options are lacking. This review provides a systematic review of the neuroanatomical abnormalities associated with apathy in late-life depression. In addition, the review summarizes the neuroimaging findings from studies of neurodegenerative and focal brain injury conditions that frequently present with apathy. The goal is to elucidate cerebral network abnormalities that give rise to apathy in older adults with mood disturbances and to inform future treatment targets.

METHOD

Systematic literature review.

RESULTS

The few studies that have directly examined the neuroanatomical abnormalities of apathy in late-life depression suggest disturbances in the anterior cingulate cortex, insula, orbital and dorsal prefrontal cortex, striatum, and limbic structures (ie, amygdala, thalamus, and hippocampus). Studies examining the neuroanatomical correlates of apathy in other aging populations are consistent with the pattern observed in late-life depression.

CONCLUSIONS

Apathy in late-life depression appears to be accompanied by neuroanatomical abnormalities in the salience and reward networks. These network findings are consistent with that observed in individuals presenting with apathy in other aging-related conditions. These findings may inform future treatments that target apathy.

Apathy syndrome in a patient previously treated with selective serotonin reuptake inhibitors for depression

There is considerable overlap in the clinical presentations of apathy and depression. However, differential diagnosis between apathy and other psychiatric conditions, including depression and dementia, is important. In this report, we present the case of a 67-year-old woman with a history of receiving selective serotonin reuptake inhibitor (SSRI) treatment for depression. Differential diagnosis between treatment-resistant depression and SSRI-induced apathy syndrome was required. The symptoms of her apathy syndrome were relieved after the discontinuation of SSRIs and the addition of olanzapine, methylphenidate, and modafinil. Furthermore, we briefly review related literature in this article.

Pharmacological interventions for apathy in Alzheimer's disease

BACKGROUND

Despite the high prevalence of apathy in Alzheimer's disease (AD), and its harmful effects, there are currently no therapies proven to treat this symptom. Recently, a number of pharmacological therapies have been investigated as potential treatments for apathy in AD.

OBJECTIVES

Objective 1: To assess the safety and efficacy of pharmacotherapies for the treatment of apathy in Alzheimer's disease (AD).Objective 2: To assess the effect on apathy of pharmacotherapies investigated for other primary outcomes in the treatment of AD.

SEARCH METHODS

We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), MEDLINE, Embase, CINAHL, PsycINFO, LILACS, ClinicalTrials.gov and the World Health Organization (WHO) portal, ICTRP on 17 May 2017.

SELECTION CRITERIA

Eligible studies were double-blind, randomized, placebo-controlled trials (RCTs) investigating apathy as a primary or secondary outcome in people with AD.

DATA COLLECTION AND ANALYSIS

Three review authors extracted data. We assessed the risks of bias of included studies using Cochrane methods, and the overall quality of evidence for each outcome using GRADE methods. We calculated mean difference (MD), standardized mean difference (SMD) or risk ratio (RR) with 95% confidence intervals on an intention-to-treat basis for all relevant outcome measures.

MAIN RESULTS

We included 21 studies involving a total of 6384 participants in the quantitative analyses. Risk of bias is very low to moderate. All studies reported appropriate methods of randomization and blinding. Most studies reported appropriate methods of allocation concealment. Four studies, three with methylphenidate and one with modafinil, had a primary aim of improving apathy. In these studies, all participants had clinically significant apathy at baseline. Methylphenidate may improve apathy compared to placebo. This finding was present when apathy was assessed using the apathy evaluation scale (AES), which was used by all three studies investigating methylphenidate: MD -4.99, 95% CI -9.55 to -0.43, n = 145, 3 studies, low quality of evidence, but not when assessed with the neuropsychiatric inventory (NPI)-apathy subscale, which was used by two of the three studies investigating methylphenidate: MD -0.08, 95% CI -3.85 to 3.69, n = 85, 2 studies, low quality of evidence. As well as having potential benefits for apathy, methylphenidate probably also slightly improves cognition (MD 1.98, 95% CI 1.06 to 2.91, n = 145, 3 studies, moderate quality of evidence), and probably improves instrumental activities of daily living (MD 2.30, 95% CI 0.74 to 3.86, P = 0.004, n = 60, 1 study, moderate quality of evidence), compared to placebo. There may be no difference between methylphenidate and placebo in the risk of developing an adverse event: RR 1.28, 95% CI 0.67 to 2.42, n = 145, 3 studies, low quality of evidence. There was insufficient evidence from one very small study of modafinil to determine the effect of modafinil on apathy assessed with the FrSBe-apathy subscale: MD 0.27, 95% CI -3.51 to 4.05, n = 22, 1 study, low quality of evidence. In all other included studies, apathy was a secondary outcome and participants were not selected on the basis of clinically significant apathy at baseline. We considered the evidence on apathy from these studies to be indirect and associated with publication bias. There was low or very low quality of evidence on cholinesterase inhibitors (ChEIs) (six studies), ChEI discontinuation (one study), antipsychotics (two studies), antipsychotic discontinuation (one study), antidepressants (two studies), mibampator (one study), valproate (three studies) and semagacestat (one study).

AUTHORS' CONCLUSIONS

Methylphenidate may demonstrate a benefit for apathy and may have slight benefits for cognition and functional performance in people with AD, but this finding is associated with low-quality evidence. Our meta-analysis is limited by the small number of studies within each drug class, risk of bias, publication bias, imprecision and inconsistency between studies. Additional studies should be encouraged targeting people with AD with clinically significant apathy which investigate apathy as a primary outcome measure, and which have a longer duration and a larger sample size. This could increase the quality of evidence for methylphenidate, and may confirm whether or not it is an effective pharmacotherapy for apathy in AD.

Beyond ADHD and narcolepsy: psychostimulants in general psychiatry

Psychostimulants (dexamphetamine, methylphenidate, modafinil) reduce fatigue, promote alertness and wakefulness, and have possible mood-enhancing properties. In modern psychiatric practice, their use has been limited to attention-deficit hyperactivity disorder and sleep disorders such as narcolepsy. Despite this, research has continued into psychostimulant use in general psychiatry, especially in the treatment of depression and fatigue. This article reviews the recent literature regarding psychostimulant use in general and consultation-liaison psychiatry. Although psychostimulants continue to attract clinical research, there is currently not enough evidence to recommend their routine use for general psychiatric conditions.

Apathy associated with neurocognitive disorders: Recent progress and future directions

INTRODUCTION

Apathy is common in neurocognitive disorders (NCDs) such as Alzheimer's disease and mild cognitive impairment. Although the definition of apathy is inconsistent in the literature, apathy is primarily defined as a loss of motivation and decreased interest in daily activities.

METHODS

The Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART) Neuropsychiatric Syndromes Professional Interest Area (NPS-PIA) Apathy workgroup reviewed the latest research regarding apathy in NCDs.

RESULTS

Progress has recently been made in three areas relevant to apathy: (1) phenomenology, including the use of diagnostic criteria and novel instruments for measurement, (2) neurobiology, including neuroimaging, neuropathological and biomarker correlates, and (3) interventions, including pharmacologic, nonpharmacologic, and noninvasive neuromodulatory approaches.

DISCUSSION

Recent progress confirms that apathy has a significant impact on those with major NCD and those with mild NCDs. As such, it is an important target for research and intervention.

The ethics of elective psychopharmacology

Pharmacological cognitive enhancers (PCEs) are used to improve cognitive functions, such as attention, learning, memory and planning in patients with impairments in cognition resulting from traumatic brain injury (TBI) or from neuropsychiatric disorders such as Alzheimer's disease (AD), mild cognitive impairment, schizophrenia, and attention deficit hyperactivity disorder (ADHD). Moreover, PCEs have been shown to improve cognition in healthy volunteers with no psychiatric disorders. This article describes the rationale behind the need for their use in neuropsychiatric patients and illustrates how PCEs can ameliorate cognitive impairments, improve quality of life and wellbeing, and therefore reduce the economic burden associated with these disorders. We also describe evidence that PCEs are being used as cognitive enhancers by healthy people. Crucially, as the lifestyle use of these drugs becomes very popular in the healthy population, a final aim is to present an overview of the current and future neuroethical considerations of enhancing the healthy brain. As information regarding their actual use, benefits and harms in various healthy populations is currently lacking, we propose research that aims to obtain relevant empirical data, monitor the short- and long-term effectiveness and side-effects, and initiate accurate surveys to determine current patterns and quantity of usage of PCE drugs by healthy people. Furthermore, in order to instigate a dialogue between neuroethics and neuropsychopharmacology, we urge scientists to explore and communicate the social and ethical implications of their research to the public. Finally, we discuss and highlight other means of enhancing cognition in both patients and healthy adults, including education and physical exercise.

Treatment of Apathy in Huntington's Disease and Other Movement Disorders

OPINION STATEMENT

Apathy is one of the most prevalent neurobehavioral symptoms in Huntington's disease (HD), occurring in approximately 70% of the symptomatic HD population. Apathy scores in patients with HD are highly correlated with duration of illness, suggesting that apathy is an inevitable consequence of advanced disease. Although less distressing than symptoms like depression and less disruptive than irritability or aggression, apathy has a considerable adverse impact on those affected with HD because it leads to a decrease of the goal-directed behaviors that contribute much to the day-to-day quality of life. As a neuropsychiatric syndrome, apathy is also common in patients with other neuropsychiatric disorders such as Parkinson's disease, traumatic brain injury, cerebrovascular accident, dementia, and other neurodegenerative conditions. The nosologic status of apathy and lack of a clear definition has probably contributed to the paucity of therapeutic evidence in this area. Several different scales are available to measure apathy, including the Apathy Evaluation Scale, Apathy Inventory, Lilles Apathy Rating Scale, and the apathy items from the Unified HD Rating Scale, the Problem Behaviours Assessment for HD, and the Neuropsychiatric Inventory, but all are based on slightly different definitions of apathy, so the scores obtained may not be directly comparable. Assessment may also be complicated by overlap between the manifestations of apathy and other complications of HD such as depression, so the identification and treatment of these comorbid conditions is important. No adequate evidence currently supports any specific pharmacologic or psychological intervention for apathy in HD. Evidence can only be extrapolated from interventional studies done in other basal ganglia disorders such as Parkinson's disease or other neurodegenerative disorders such as dementia. The neurobiology of apathy points towards three areas of functional connectivity: connections between the dorsolateral prefrontal cortex (PFC) and basal ganglia, orbitomedial PFC and basal ganglia, and dorsomedial PFC and basal ganglia. Pharmacologic interventions such as cholinesterase inhibitors, the dopaminergic antidepressant bupropion, amantadine, levodopa, bromocriptine, methylphenidate, and atypical antipsychotics have all been tried in other neurodegenerative disorders, but not in HD. Psychosocial interventions such as cognitive stimulation therapy and multisensory stimulation, which have been used in patients with dementia, have not been properly studied in HD. Individualized treatment should be considered, using a combination of methods, as there is no evidence to support one particular type of treatment. Multidisciplinary input, environmental modifications, improved psychosocial support, and psychoeducation programs designed to help caregivers to understand and compensate for the deficits caused by this symptom may all have a role to play in the treatment of apathy.

Use of psychostimulants in patients with dementia

OBJECTIVE

To review the efficacy and safety of psychostimulants for negative behavioral symptoms (ie, apathy, excessive daytime sedation) and cognition in patients with dementia.

DATA SOURCES

Literature was accessed through PubMed and MEDLINE (1966-June 2010), using the terms stimulant, psychostimulant, methylphenidate, dexmethylphenidate, amphetamine, dextroamphetamine, lisdexamfetamine, atomoxetine, modafinil, armodafinil, dementia, Alzheimer disease, vascular dementia, Lewy body dementia, mixed dementia, frontotemporal dementia, therapy, treatment, and therapeutic. Additional references identified from the initial search were reviewed.

STUDY SELECTION AND DATA EXTRACTION

All relevant clinical trials published in English and involving primarily older adults with dementia were included. Case reports, review articles, and other preclinical literature were included as appropriate.

DATA SYNTHESIS

Psychostimulants have been employed as a treatment for cognitive and behavioral symptoms in dementia for decades, but the literature has lagged behind this practice. Eight reports on use of psychostimulants as a treatment of apathy in dementia were reviewed. Methylphenidate was the most frequently studied medication and improvements in apathy were consistently noted; however, the magnitude and duration of effect remain unclear. Six studies examining the cognitive effects of a variety of psychostimulants in patients with dementia were reviewed; psychostimulants had little to no effect on cognition. A lack of studies exists to draw conclusions about the use of psychostimulants for the treatment of excessive daytime sedation in dementia. The possibility of psychostimulants to increase blood pressure; elevate heart rate; and lead to irritability, agitation, and psychosis makes careful patient selection critical, especially in older adults with severe cardiovascular disease or other underlying cardiac abnormalities.

CONCLUSIONS

Based on limited studies, methylphenidate is a possible treatment for apathy in patients with dementia. Psychostimulants, as a group, do not appear to be broadly effective treatments for behavioral or cognitive symptoms of dementia. The potential utility of psychostimulants must be balanced with careful patient selection.

The role of dopamine in symptoms and treatment of apathy in Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is characterized by a number of serious and debilitating behavioral and psychological symptoms of dementia (BPSD). The most common of these BPSD is apathy, which represents a major source of morbidity and premature institutionalization in the AD population. Many studies have identified discrete changes to the dopaminergic (DAergic) system in patients with AD. The DAergic system is closely related to the brain reward system (BRS) and some studies have suggested that dysfunction in the DAergic system may account for symptoms of apathy in the AD population.

METHOD

Changes to the dopamine (DA) system in AD will be reviewed, and evidence supporting the involvement of the DAergic system in the development of apathy will be examined. Additionally, some pharmacological interventions with DA activity have been identified. The utility of these treatments in the AD population will be reviewed, with a focus on apathy as an outcome.

RESULTS

Evidence presented in this review suggests that DA dysfunction in discrete brain areas is an important correlate of apathy in AD and that the DAergic system may be a rational target for pharmacological treatment of apathy.

Management of sleep/wake cycles improves cognitive function in a transgenic mouse model of Huntington's disease

Normally, mice sleep during the day and are active at night. In Huntington's disease mice (R6/2 line) this circadian pattern disintegrates progressively over the course of their illness. Cognitive decline and apathy in R6/2 mice can be improved with sleeping drugs, suggesting that sleep disruption contributes to their neurological decline. We wondered if wakefulness was equally important. Here, we used two drugs to manage sleep/wake cycles in R6/2 mice, Alprazolam (to put them to sleep) and Modafinil (to wake them up). We found that both drugs improved cognitive function and apathy, but had a stronger effect when used in combination. Remarkably, beneficial effects on cognitive performance were also seen in vehicle-treated cage-mates of Alprazolam/Modafinil-treated mice, suggesting that behavioral intervention to regularize sleep/wake activity might be therapeutically useful. We suggest that focused management of sleep and wakefulness will slow the progression of cognitive decline and apathy in neurological conditions where sleep is disordered.

The impact of apathy on glycemic control in diabetes: a cross-sectional study

OBJECTIVE

Diabetes mellitus is a major public health problem with a prevalence of 6-7%. Self-care behaviors play a major role in the control of diabetes. Apathy is characterized by loss of initiative and motivation. Apathy may interfere with self-care behavior and glycemic control. The primary objective was to determine the prevalence of apathy in patients with diabetes. The secondary objective was to determine if there was an association between clinically significant apathy and factors that affect glycemic control.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional study of 100 patients with diabetes who were assessed with the Apathy Evaluation Scale-Clinician version (AES-C), the Hamilton Depression Scale (HAM-D), and the Self-Care Inventory (SCI). For this study we defined clinically significant apathy as AES-C score of >30. We excluded patients with a HAM-D score of >14 (n=19) to avoid confounding from depression. T-tests were used to compare clinical characteristics between subjects with and without apathy. Multiple linear regression modeling was used to investigate the association between clinically significant apathy and factors that affect glycemic control.

RESULTS

Fifty (61.7% of 81) patients had clinically significant apathy. Compared to the non-apathetic patients, those with apathy had a higher mean BMI (30.5 kg/m(2) versus 34.1 kg/m(2) (p=0.03)) and were less likely to adhere to an exercise plan (p=0.01) or insulin regimen (p=0.003). After adjustment for age, BMI, cholesterol, mild depression and the average Self-Care Index score, the mean HbA1C level was 0.66% greater for apathetic compared to non-apathetic subjects (P=0.08).

CONCLUSION

Apathy is highly prevalent in patients with diabetes without depression. Apathy may have a negative impact on self-care behaviors and diabetes control.