REVIEW: Apathy Diagnosis,Assessment, and Treatment in Alzheimer's Disease

Apathy is defined as a disorder of motivation. There is wide acknowledgement that apathy is an important behavioral syndrome in Alzheimer's disease and in various neuropsychiatric disorders. In light of recent research and the renewed interest in the correlates and impacts of apathy and in its treatments, it is important to develop criteria for apathy that will be widely accepted, have clear operational steps, and be easy to apply in clinical practice and in research settings. Meeting these needs was the focus for a task force that included members of the European Psychiatric Association, the European Alzheimer's Disease Consortium and experts from Europe, Australia and North America.     

Unraveling Apathy in Korsakoff Syndrome Patients Receiving Long-Term Care With and Without Cerebrovascular Comorbidity

Background

Korsakoff syndrome (KS) is a severe neuropsychiatric disorder caused by acute deficiency of vitamin B1 and concomitant alcoholism. Patients with KS are particularly vulnerable for cerebrovascular comorbidity. KS is characterized by cognitive and neuropsychiatric symptoms, one of which is apathy. Apathy is a pathological lack of goal-directed behaviors, goal-directed cognitions, and goal-directed emotions. Cerebrovascular accidents are known to carry a risk for developing apathy. Apathy has a dramatic effect on the autonomy and daily lives of patients suffering from this condition.

Methods

We assessed general apathy and related subconstructs in fifteen patients with KS, fifteen patients with KS and cerebrovascular comorbidity who reside in a 24-hour care facility, and fifteen healthy controls.

Results

Compared with healthy controls, both KS patient groups showed higher levels of apathy as rated by a close informant. We found no difference between both KS patient groups and the healthy control group on the self-report section of the Pleasant Activities List, suggesting that motivation is still intact in KS patients. It is important to note a discrepancy was found between self-reporting and proxy reporting on this list. KS patients with cerebrovascular comorbidity showed more severe emotional blunting compared to both KS patients without cerebrovascular comorbidity and healthy controls. The competency to consent was lower in patients compared with healthy controls, but no difference was found between KS patients with cerebrovascular comorbidity and those without.

Conclusions

Our results suggest that KS patients show increased levels of general apathy compared with healthy controls. Patients show a diminished competency to consent and increased emotional blunting, while motivation is not compromised. Cerebrovascular comorbidity in KS forms a high risk for emotional blunting. The results of this study suggest that apathy is a severe problem in KS. More attention in both the literature and clinical practice would benefit this complex patient population.

     

Four Potentially Practice-Changing Articles From 2018

Four key articles published in 2018 have been selected to represent clinical situations where recent evidence may prompt changes in practice relevant to the nursing home population. There is no evidence of benefit for levothyroxine replacement in mild subclinical hypothyroidism. Duloxetine may be considered as an option for the treatment of pain and stiffness in osteoarthritis of the knees. Supplemental oxygen in the absence of hypoxemia is unnecessary and potentially harmful. Methylphenidate has modest benefit in treating apathy in dementia. For each subject, a brief review of the pertinent article is followed by a “bottom line” recommendation.     

Behavioral effects of subthalamic deep brain stimulation in Parkinson's disease

To date, few studies have utilized standardized measures to assess the neurobehavioral changes that can accompany deep brain stimulation (DBS) of the subthalamic nuclei (STN) for the treatment of Parkinson's disease (PD), yet behavioral changes are the most debated among practitioners. We evaluated behavior with the Frontal Systems Behavior Scale (FrSBe), which includes a large-scale normative sample for self- and collateral ratings and is particularly relevant to PD with subscales assessing Apathy, Disinhibition, and Executive Dysfunction. Data were collected from 16 (11 males) PD patients. All FrSBe subscale scores increased significantly when retrospective preoperative scores and current (postoperative) scores were compared. Self- and collateral FrSBe ratings were not significantly correlated with each other, though for both scores at least half of the group met criteria for a clinically significant level of symptoms postoperatively. No significant correlations were seen for collateral current FrSBE ratings with cognitive or motor variables. Higher self-ratings of behavior characteristic of apathy were related to higher self-ratings of depressive symptoms, and to a smaller decrease in antiparkinsonian medications following surgery. We propose that the standardized assessment of behavioral aspects of executive dysfunction adds information that is largely dissociable from the motor and cognitive assessment of function in PD patients undergoing STN DBS. In future, prospective standardized measurement of behavior may allow for better prediction of which patients will experience significant behavioral issues postoperatively.     

Personal determinants of burnout in nursing staff at geriatric centers

Apathy is the most common neuropsychiatric syndrome in Alzheimer's disease (AD) affecting 19–76% of patients, but is difficult to distinguish from depression, because of the frequent comorbidities and a considerable overlap in key symptoms. A structured clinical interview and a specific set of diagnostic criteria to diagnose apathy in dementia have been recently validated, but so far its nosological position is still a debated issue, even if several studies tend to consider apathy a discrete and specific syndrome. The pathopshysiology of apathy in neuropsychiatric disorders is still unknown, however, recent studies suggest that an important role is played by dysfunctions of the frontal lobe and basal ganglia. Both apathy and depression can have a negative impact on the progression of AD, therefore, an accurate differential diagnosis is fundamental to reach an appropriate family education and to obtain a possibly effective treatment.     

Differential impact of severity of drug use on frontal behavioral symptoms

Increasing evidence indicates that substance abusers are impaired in cognitive-executive control tasks relying on different functional systems converging in the prefrontal cortex (PFC). Different PFC functional systems relevant to addiction have been described: the dorsolateral (DLC), orbitofrontal (OFC), and anterior cingulate (ACC) circuits. Each system is associated with different behavioral, cognitive, and emotional deficits, including apathy, disinhibition, and executive dysfunction. In this study, we examined the effects of severity of use of different drugs on apathy, disinhibition and executive dysfunction behavioral deficits as measured by the Frontal Systems Behavior Scale (FrSBe). The FrSBe, and a severity of substance use interview were administered to 32 poly-substance abusers. Multiple regression analyses showed that severity of cannabis use significantly predicted greater apathy and executive dysfunction behavior; and that severity of cocaine use significantly predicted greater disinhibition behavior. These results are consistent with previous studies using cognitive measures and support the notion that severity of substance use significantly affects behavioral symptoms associated with PFC systems functioning. These clinical symptoms should be specifically addressed during rehabilitation.     

精神分裂症患者情感淡漠评定现状分析

目的 分析精神分裂症患者情感淡漠评定现状,探讨提高对情感淡漠评定一致性的方法。方法 调查85例精神分裂症情感淡漠的出现率,并按不同病期、不同临床类型、不同性别分组比较。结果 精神分裂症患者情感淡漠出现率为54．12％,多见于慢性期、单纯型、紧张型及男性。结论 精神分裂症患者虽然情感淡漠多见．但临床有过高评定的倾向。     

Frontal behavioral and emotional symptoms in Spanish individuals with acquired brain injury and substance use disorders

INTRODUCTION: Patients with acquired brain injury affecting the frontal cortex and individuals with substance use disorders share a range of behavioral problems, including apathy, poor self-control, and executive dysfunction. The Frontal Systems Behavioral Scale (FrSBe) is a self-report instrument designed to measure behavioral problems resulting from damage to the frontal-striatal neural systems, involved both in brain insult and addiction. The aim of this study was twofold: (1) to compare the scores from the Spanish version of the FrSBe with the norms collected for American, English-speaking population; and (2) to examine the ability of the FrSBe to discriminate between two clinical populations (acquired brain injury (ABI) and addiction) with putative frontal dysfunction, as compared to a group of healthy participants. PATIENTS AND METHODS: A total of 139 volunteers participated including 46 patients with frontal ABI (F-ABI), 57 abstinent substance abusers, and 36 healthy controls from the Spanish population. A Spanish version of the FrSBe was administered to all participants. We conducted multivariate analyses of variance to examine group differences across the three subscales: apathy, disinhibition, and executive dysfunction; and in the FrSBe total score. RESULTS: F-ABI and substance abusers had higher scores (i.e., greater impairment) than controls on the FrSBe total score; F-ABI patients scored significantly higher than substance abusers, and substance abusers significantly higher than controls. For specific subscales, F-ABI patients had higher scores than substance abusers and controls in the subscales of apathy, disinhibition and executive dysfunction, whereas substance abusers had greater executive dysfunction than controls. CONCLUSIONS: The Spanish version of the FrSBe is a useful instrument for the detection of behavioral problems associated with frontal systems dysfunction in two clinical samples of Spanish-speakers.     

Reduced daytime activity in patients with acquired brain damage and apathy: a study with ambulatory actigraphy

Primary objective: Apathy is difficult to assess in clinical practice. Ambulatory actigraphy was used with the aim to measure locomotor activity during the daytime as a correlate of self-initiated action in brain-damaged patients with apathy.

Research design: Twenty-four patients with acquired brain damage and high levels of apathy or low levels of apathy as well as 12 healthy controls were investigated using a parallel group design.

Methods and procedures: Apathy was diagnosed after clinical observation and evaluated with the apathy evaluation scale. Locomotor activity was measured with a wrist-worn actigraph over 3 days.

Results: High apathy patients showed significantly reduced locomotor activity and more episodes of inactivity (naps) during the daytime. Self-rated apathy correlated with daytime activity, nap frequency and cognitive (executive) deficits.

Conclusions: Ambulatory actigraphy is a promising method to evaluate self-initiated action in patients with apathy.     

Management of psychiatric disorders in Parkinson’s disease: Neurotherapeutics - Movement Disorders Therapeutics

Affective disorders (depression and anxiety), psychosis, impulse control disorders, and apathy are common and sometimes disabling psychiatric conditions in Parkinson disease (PD). Psychiatric aspects of PD are associated with numerous adverse outcomes, yet in spite of this and their high frequency, there remains incomplete understanding of epidemiology, presentation, risk factors, neural substrate, and management strategies. Psychiatric features are typically co- or multimorbid, and there is great intra- and interindividual variability in presentation [1]. The neuropathophysiological changes that occur in PD, as well as the association between PD treatment and particular psychiatric disorders, suggest a neurobiological contribution to many psychiatric symptoms. There is evidence that psychiatric disorders in PD are still under-recognized and undertreated, and although psychotropic medication use is common, randomized controlled trials demonstrating efficacy and tolerability are largely lacking. Future research on neuropsychiatric complications in PD should be oriented toward determining modifiable correlates or risk factors, and most importantly, establishing efficacious and well-tolerated treatment strategies.Electronic supplementary materialThe online version of this article (10.1007/s13311-020-00875-w) contains supplementary material, which is available to authorized users.