Robert van Reekum

Are the available apathy measures reliable and valid? A review of the psychometric evidence

OBJECTIVE Apathy is highly prevalent among neuropsychiatric populations and is associated with greater morbidity and worse functional outcomes. Despite this, it remains understudied and poorly understood, primarily due to lack of consensus definition and clear diagnostic criteria for apathy. Without a gold standard for defining and measuring apathy, the availability of empirically sound measures is imperative. This paper provides a psychometric review of the most commonly used apathy measures and provides recommendations for use and further research. METHODS Pertinent literature databases were searched to identify all available assessment tools for apathy in adults aged 18 and older. Evidence of the reliability and validity of the scales were examined. Alternate variations of scales (e.g., non-English versions) were also evaluated if the validating articles were written in English. RESULTS Fifteen apathy scales or subscales were examined. The most psychometrically robust measures for assessing apathy across any disease population appear to be the Apathy Evaluation Scale and the apathy subscale of the Neuropsychiatric Inventory based on the criteria set in this review. For assessment in specific populations, the Dementia Apathy Interview and Rating for patients with Alzheimers dementia, the Positive and Negative Symptom Scale for schizophrenia populations, and the Frontal System Behavior Scale for patients with frontotemporal deficits are reliable and valid measures. CONCLUSION Clinicians and researchers have numerous apathy scales for use in broad and disease-specific neuropsychiatric populations. Our understanding of apathy would be advanced by research that helps build a consensus as to the definition and diagnosis of apathy and further refine the psychometric properties of all apathy assessment tools.

Apathy Symptom Profile and Behavioral Associations in Frontotemporal Dementia vs Dementia of Alzheimer Type

BACKGROUND Apathy is a common and significant problem in patients with dementia, regardless of its cause. Observations about frontosubcortical circuit syndromes indicate that apathy may have affective, behavioral, or cognitive manifestations. OBJECTIVES To explore whether the apathy manifested in frontotemporal dementia (FTD), with its predominantly anterior brain neuropathologic features, differs from the apathy in dementia of Alzheimer type (DAT), with its predominantly hippocampal- and temporoparietal-based neuropathologic features, and to determine whether other behavioral disturbances reported in frontosubcortical circuit syndromes correlate with apathy. DESIGN Analyses included individual items within Neuropsychiatric Inventory subscale items. Items of the apathy/indifference subscale were designated by consensus as affective (lacking in emotions), behavioral (inactive, chores abandoned), or cognitive (no interest in the activities of others). Proportions of correlated nonapathy Neuropsychiatric Inventory items were calculated. SETTING Several neurology specialty clinics contributed to our data set. PARTICIPANTS A total of 92 participants with FTD and 457 with DAT. MAIN OUTCOME MEASURES The Neuropsychiatric Inventory was analyzed. RESULTS Apathy was more prevalent in patients with FTD than in those with DAT, but when present, the specific apathy symptoms associated with both types of dementia were rarely restricted to 1 of the 3 domains of apathy. Dysphoria concurrent with apathy was unique to the DAT group and negatively correlated in the FTD group. Participants with affective apathy more frequently copresented with an orbital frontosubcortical syndrome in FTD (impulsivity and compulsions). Affective apathy also copresented with uncooperative agitation, anger, and physical agitation in both types of dementia. CONCLUSIONS Apathy is common in patients with FTD and DAT, although it is more common in those with FTD. When present, it usually involves changes in affect, behavior, and cognition. It is associated with behaviors that have previously been shown to affect patient safety, independence, and quality of life.

Borderline Personality Disorder and Substance Abuse: Consequences of Comorbidity

The objective of this paper was to examine the prognostic significance of borderline personality disorder (BPD) and substance abuse in a cohort of former inpatients screened for BPD and followed up prospectively seven years after the index admission. The impact of comorbidity on borderline psychopathology, impulsivity and psychosocial functioning was examined. The original cohort was assembled between April 1983 and December 1985. Admissions were screened for borderline characteristics which resulted in a sample of 130 subjects, 88 of whom were positive for BPD based on the Diagnostic Interview for Borderlines. At seven years follow-up, 81 out of 130 (62.3%) subjects were re-interviewed. Six (4.6%) had committed suicide, two (1.5%) were deceased and 41 (31.6%) were lost to follow-up. The subjects with BPD and substance abuse were significantly differentiated from subjects with BPD only, substance abuse only and neither disorder on the basis of demonstrating more borderline psychopathology and more self-destructive and suicidal thoughts and behaviours. Probands with initial diagnoses of BPD and substance abuse were twice as likely to be diagnosed BPD on follow-up as probands with initial diagnosis of BPD only (relative risk = 2.19, 95% CI, 1.21 to 3.97). These findings and other research suggest that patients with comorbid BPD and substance abuse should be encouraged to focus on their abuse problems as a priority.

Providing Nutrition Supplements to Institutionalized Seniors with Probable Alzheimer's Disease Is Least Beneficial to Those with Low Body Weight Status

Objectives: To examine whether providing a midmorning nutrition supplement increases habitual energy intake in seniors with probable Alzheimers disease (AD) and to investigate the effects of body weight status and cognitive and behavioral function on the response to the intervention.

Prospective follow-up study of borderline personality disorder: prognosis, prediction of outcome, and Axis II comorbidity.

Objective: To examine the rate of persistence of borderline personality disorder (BPD), the existence of concomitant personality disorders on follow-up, and the predictors of outcome in patients who met criteria for BPD compared with patients with borderline features who failed to meet all of the criteria. Method: This prospective cohort study reassessed subjects for BPD diagnosis and cooccurring personality pathology at 7 years follow-up. Initial measures of borderline and comorbid personality psychopathology were used to predict levels of borderline or other personality disorder psychopathology at follow-up. Results: Of the 5 7 subjects who initially met the criteria for BPD, 30 (52.6%) were found to have remitted BPD, and 27 (47.4%) were characterized as having persistent BPD. The remitted group met significantly fewer comorbid personality disorder diagnoses than the persistent group (mean = 0.8, mean = 3.5 respectively; P < 0.05). Results also indicated that the initial level of borderline psychopathology was predictive of borderline psychopathology at follow-up, which explained 17% of the variance. Conclusions: This prospective follow-up study found that almost 50% of former inpatients with BPD continue to test positive for BPD at 7 years follow-up, and these persistent BPD patients also had significantly more comorbid personality psychopathology. Borderline psychopathology at follow-up was primarily predicted by the level of borderline psychopathology recorded at the initial assessment.

Relationship of psychosis to aggression, apathy and function in dementia.

Psychosis has been associated with aggression in dementia, but the nature of this relationship has been unclear. There has been very little research into the relations between apathy and functional status to psychosis in dementia. The purpose of this study is to investigate the relationship between psychosis and aggression, apathy, and functional status in outpatients with dementia.

A randomized, placebo-controlled trial of the discontinuation of long-term antipsychotics in dementia.

The objectives of this randomized clinical trial were to investigate the impact of the discontinuation of long-term antipsychotics in residents with dementia in chronic care institutions and to identify clinical predictors of safe discontinuation. Subjects included 34 residents with dementia who were on antipsychotics for more than 6 months and whose behavior was currently stable. Subjects were randomized to either continue receiving their regular dosage of antipsychotics or to receive placebo for 6 months. Early withdrawal from the study was not statistically different between the groups (relative risk [RR] = 1.57, 95% confidence interval [CI] 0.76-3.26), and though not significantly different, subjects in the placebo group were more likely to be withdrawn from the study because of worsening behavior (RR = 1.25, 95% Cl 0.33-4.76). Three subjects in the placebo group were withdrawn from the study due to worsening of extrapyramidal symptoms. The active treatment group had more behavioral problems (e.g., physical aggression towards others, p < .05) compared to the placebo group. The placebo group developed more apathy, but balancing this outcome was a relative improvement in cognitive functioning. Baseline antipsychotic dose was predictive of behavioral worsening upon discontinuation of long-term antipsychotic drugs. The primary limitation of the study was the small sample size. In conclusion, a trial of discontinuation of antipsychotics should be considered in this population.

Selective serotonin reuptake inhibitor use associates with apathy among depressed elderly: a case-control study

BackgroundIt has been reported for over the past decade that the use of selective serotonin reuptake inhibitors (SSRIs) may associate with the emergence of apathy. The authors hypothesized that depressed patients treated with SSRIs would show more signs of apathy than patients treated with non-SSRI antidepressants. This case control study was conducted to investigate the possibility of the association between SSRI use and the occurrence of apathy.MethodsBaycrest Centre for Geriatric Cares Day Hospital Database of elderly depressed patients who received antidepressants was divided into 2 groups depending on antidepressant use at discharge: SSRI user group-SUG, and non-SSRI user group-NSUG. Apathy scales developed by the authors were selected from the Geriatric depression Scale (GDS) and the Hamilton Rating Scale for Depression (HAMD), and were titled as GDS-apathy subscale (GAS) and HAMD-apathy subscale (HAS). Demographic data, baseline apathy, underlying medical conditions and medication use were studied. Proportion, analysis of variances, Chi-square test, odds ratio with 95% confidence interval were reported.ResultsAmong 384 patients (160 SUG and 224 NSUG), mean GDS and HAM-D at discharge were 12.46 and 10.61 in SUG, and were 11.37 and 9.30 in NSUG, respectively. Using GAS for apathy assessment, 83.7% of patients in SUG and 73.4% in NSUG stayed apathetic at discharge. As evaluated by HAS, 44.2% of patients in SUG and 36.5% in NSUG stayed apathetic. SSRI use was not a predictor of apathy at admission, while it was at discharge, p = 0.029. The SUG showed more patients with apathy than that found in NSUG (adjusted OR = 1.90 (1.14–3.17). Age 70–75 years tended to be a predictor for the apathy (p = 0.058). Using HAS, age 70–75 years and living situation were associated with apathy at discharge, p = 0.032 and 0.038 respectively.ConclusionEven though depression was improved in elderly patients receiving antidepressants, apathy appeared to be greater in patients who were treated with SSRI than that found in patients who were not. Frontal lobe dysfunction due to alteration of serotonin is considered to be one of the possibilities.

Efficacy of a cognitive training programme for mild cognitive impairment: Results of a randomised controlled study

This study aimed to determine the efficacy of cognitive training in a 10-week randomised controlled study involving 22 individuals presenting with mild cognitive impairment of the amnestic type (MCI-A). Participants in the experimental group (n = 11) learned face–name associations using a paradigm combining errorless (EL) learning and spaced retrieval (SR) whereas participants in the control group (n = 11) were trained using an errorful (EF) learning paradigm. Psycho-educational sessions on memory were also provided to all participants. After neuropsychological screening and baseline evaluations, the cognitive training took place in 6 sessions over a 3-week period. The post-training and follow-up evaluations, at one and four weeks respectively, were performed by research assistants blind to the participants study group. The results showed that regardless of the training condition, all participants improved their capacity to learn face–name associations. A significant amelioration was also observed in participant satisfaction regarding their memory functioning and in the frequency with which the participants used strategies to support memory functions in daily life. The absence of difference between groups on all variables might be partly explained by the high variability of scores within the experimental group. Other studies are needed in order to verify the efficacy of EL learning and SR over EF in MCI-A.

Central Serotonergic Activity is Related to the Aggressive Behaviors of Alzheimer's Disease

The clinical correlates of reduced serotonin (5-HT) in Alzheimers disease (AD) remain unknown. The hypothesis of this study was that altered central serotonergic activity is related to aggression in AD. Twenty-two institutionalized, nondepressed elderly (12 M/10 F, mean age ± SD: 82.2 ± 6.4) with probable AD, severe cognitive impairment (MMSE = 4.1 ± 4.7) and significant behavioral disturbance (Neuropsychiatric Inventory (NPI) score ⩾ 8) were studied. The prolactin (PRL) response to d,l-fenfluramine (60 mg p.o.) was used as an index of central serotonergic function. The NPI aggression score, NPI irritability score, and Behavioral Pathology in AD aggression score were positively correlated to prolactin concentrations following fenfluramine challenge (rS = .61, p = .003; rS = .53, p = .012; and rS = .47, p = .029 respectively). In addition, aggressive patients showed a greater mean PRL increase (% baseline) (215 ± 60, n = 11) than nonaggressive subjects (123 ± 54, n = 11) (p = .01, 2-tailed t-test). The change in PRL concentration depended on level of cognitive impairment (p = .0004) and the gender x aggression interaction (p = .015) with the overall regression model accounting for 74% of the variance (r = 0.86, F = 11.9, p = .0001). Female aggressive subjects with less cognitive impairment had the largest response to fenfluramine challenge. These results suggest a complex link between aggression in AD and central serotonergic dysfunction having interactions with gender and cognitive impairment.