Apathy: Why Care?

(Reprinted with permission from The Journal of Neuropsychiatry and Clinical Neurosciences 2005; 17:7-19).

Discrepancies in Cornell Scale for Depression in Dementia (CSDD) items between residents and caregivers, and the CSDD's factor structure.

PURPOSE: This validation study aims to examine Cornell Scale for Depression in Dementia (CSDD) items in terms of the agreement found between residents and caregivers, and also to compare alternative models of the Thai version of the CSDD. PATIENTS AND METHODS: A cross-sectional study was conducted of 84 elderly residents (46 women, 38 men, age range 60-94 years) in a long-term residential home setting in Thailand between March and June 2011. The selected residents went through a comprehensive geriatric assessment that included use of the Mini-Mental State Examination, Mini-International Neuropsychiatric Interview, and CSDD instruments. Intraclass correlation (ICC) was calculated in order to establish the level of agreement between the residents and caregivers, in light of the residents' cognitive status. Confirmatory factor analysis (CFA) was adopted to evaluate the alternative CSDD models. RESULTS: The CSDD yielded a high internal consistency (Cronbach's alpha = 0.87) and moderate agreement between residents and caregivers (ICC = 0.55); however, it was stronger in cognitively impaired subjects (ICC = 0.71). CFA revealed that there was no difference between the four-factor model, in which factors A (mood-related signs) and E (ideational disturbance) were collapsed into a single factor, and the five-factor model as per the original theoretical construct. Both models were found to be similar, and displayed a poor fit. CONCLUSION: The CSDD demonstrated a moderate level of interrater agreement between residents and caregivers, and was more reliable when used with cognitively impaired residents. CFA indicated a poorly fitting model in this sample.

The Use of GDS-15 in Detecting MDD: A Comparison Between Residents in a Thai Long-Term Care Home and Geriatric Outpatients.

BACKGROUND: To assess the psychometric properties of the Thai version of the 15-item Geriatric Depression Scale (TGDS-15) when screening for major depression (MDD) among geriatric outpatients (GOs) and long-term care (LTC) home residents in Thailand. METHODS: This was a cross-sectional study of 156 geriatric outpatients and 81 LTC home residents. All 237 participants were given a Mini-Mental State Examination, a MDD diagnosis according to the Mini-International Neuropsychiatric Interview, and completed a TGDS-15 questionnaire. Sensitivity, specificity, overall accuracy, and positive and negative predictive values were calculated. A comparison between the two groups was carried out. Differential Item Functioning (DIF) using logistic regression and factor analytic study were also applied. RESULTS: Overall, 38.4% of the participants were found to have MDD. The TGDS-15 was found to perform better when used with the GOs than with the LTC home residents, revealing a sensitivity of 0.92 and a specificity of 0.87 in the GOs (cut-off score of ≥ 5), but a sensitivity of 100% and a specificity of 49% with the LTC home group (cut-off score of ≥ 8), when comparing only cognitively intact subjects. The negative predictive value (NPV) was very good for both groups, but the positive predictive value (PPV) for the GO group was much better than for those in the LTC group (83.3% vs. 31.2%). Seven uniform DIF items were found - 2 by gender and 4 by age. Cronbach's alpha was higher for the GO group than for the LTC home residents. Factor analysis supported a two-factor solution, using the 'depressed mood' and 'positive mood' factors, which accounted for 46.55% of the total variance. CONCLUSIONS: The TGDS-15 scale was effective at screening for MDD in elderly cognitively intact Thais, those in both GO and LTC settings, as the sensitivity and NPV were shown to be very good in both groups. However, in the LTC setting, the low specificity and PPV found leads to the need for a further assessment to be carried among the potentially depressed individuals, based on the GDS results. Taking the factor analytic study into account, a more suitable version of the GDS should be developed.

Social inhibition as a mediator of neuroticism and depression in the elderly.

BACKGROUND: A number of factors, such as demographics, cognitive function, personality and interpersonal relationship) play a role in late-life depression. This study investigates the influence of social inhibition on the inverse emotional stability (neuroticism) and depressive symptoms found in elderly Thai people. METHODS: In total, 123 elderly Thais aged 60 years of age or older were tested using the 64-item Inventory of Interpersonal Problems, Symptom Checklist-90, and the 16 Personality Factors Questionnaire. Hierarchical regression and path analyses were performed in order to identify the relationships among these variables. RESULTS: The age of the participants ranged from 60 to 93 years old (mean = 71.7; SD = 6.2), and out of the group, 51.2% were male, 56.1% were married and 61.8% were on a low income. The average number of years spent in education among the participants was 7.6 (SD = 5.1). The variables found to be significantly associated with depression were age, intellect, social inhibition and possession of inverse emotional stability (neuroticism). Low levels of emotional stability were most strongly associated with depressive symptoms (standardized regression coefficients -0.29), but this effect was found to be reduced (mediated, to -0.26) by social inhibition. In total, 30% of the total variance could be explained by this model, and there was an excellent statistical fit. CONCLUSIONS: The variables found to be significantly associated with depression were a younger age, as well as lower levels of intellectual skill, social inhibition and inversed emotional stability (neuroticism). It was found that a lack of emotional stability is, along with a younger age, the strongest predictor of depressive symptoms, but can be mediated by social inhibition.

Executive function and suicidal risk in women with Borderline Personality Disorder.

A range of executive function (EF) deficits have been associated with Borderline Personality (BPD), a disorder characterized by high rates of suicide. However, the role of EF and suicide risk in BPD has not been examined. This exploratory study compared working memory, Stroop interference, motor inhibition (SSRT) and Iowa Gambling Task (IGT) decision making performance in 42 women with BPD and 41 healthy controls. The sensitivity of EF to suicidal risk as assessed by the Suicide Behaviour Questionnaire-R (Osman et al., 2001) was also tested. Women with BPD performed similar to controls on all EF except decision making. Weaker Stroop interference control, however, was the only significant EF contributor to suicide risk, demonstrating near equivalent contributions to that of depression. EF and depression collectively explained 34% of the adjusted variance in total suicide risk. Contrary to expectations, IGT decision making and motor inhibition were not associated with overall suicide risk. Only Stroop interference control contributed significantly to lifetime suicide intent/attempt beyond depression or BPD severity. As prior suicide attempt remains the strongest predictor of future attempt (Soloff et al., 2003), the sensitivity of stroop performance to suicidal risk may be clinically important. Interference control may represent a "diathesis" for suicide that is independent of psychiatric diagnoses.

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 Alzheimer's 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.

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 participant's 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.

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.

Alzheimer's disease and infection: do infectious agents contribute to progression of Alzheimer's disease?

Infection with several important pathogens could constitute risk factors for cognitive impairment, dementia, and Alzheimer's disease (AD) in particular. This review summarizes the data related to infectious agents that appear to have a relationship with AD. Infections with herpes simplex virus type 1, picornavirus, Borna disease virus, Chlamydia pneumoniae, Helicobacter pylori, and spirochete were reported to contribute to the pathophysiology of AD or to cognitive changes. Based on these reports, it may be hypothesized that central nervous system or systemic infections may contribute to the pathogenesis or pathophysiology of AD, and chronic infection with several pathogens should be considered a risk factor for sporadic AD. If this hypothesis holds true, early intervention against infection may delay or even prevent the future development of AD.

Psychological distress and risk for dementia.

The concept of mild cognitive impairment (MCI) primarily emphasizes changes in individuals' mental abilities, but it has recently been suggested that neuropsychiatric symptoms should also be considered important factors in age-related neurodegeneration. Psychological distress, defined as a reaction of an individual to external and internal stresses, is characterized by a mixture of psychological symptoms. It also may be considered a neuropsychiatric symptom encompassing depression, anxiety, and apathy. This paper reviews and summarizes recent evidence and relevant issues regarding the presence of psychological distress in healthy older adults and MCI patients and its relationship to risk for developing dementia. Results presented in this review show that psychological distress and depressive, anxious, and apathetic symptoms can be present in MCI and may predict progression to dementia. This article also provides suggestions for future research.

Smell test predicts performance on delayed recall memory test in elderly with depression.

INTRODUCTION: Elderly with depression are at increased risk for cognitive dysfunction and dementia. Smell tests are correlated with performance on cognitive tests in the elderly and therefore might serve as a screening test for cognitive impairment in depressed elderly. PURPOSE: To assess the validity of the CC-SIT (Cross-Cultural Smell Identification Test) as a screening test for cognitive impairment in elderly with depression. METHODS: Forty-one patients, aged 60 and over, were assessed with the CC-SIT and CVLT (California Verbal Learning Test) after 3 months treatment of a Major Depressive Episode (DSM-IV) at the Day Hospital for Depression, Baycrest. Patients already diagnosed with dementia, or other psychiatric and neurological disorders, were excluded. Receiver Operating Characteristics (ROC) analysis was applied to assess the CC-SIT's accuracy in identifying individuals with impairment (2 SD below the mean for age and education or less) on CVLT delayed recall trials. RESULTS: Forty-one patients (33 women and eight men) were assessed. Mean age was 76.8 (SD: 6.5), mean HRSD scores before treatment was 22.0 (SD: 5.1). Nine patients had impairment on CVLT delayed recall measures. The area under the ROC curve was 0.776 (95% CI = 0.617-0.936). CONCLUSIONS: Our results support the use of the CC-SIT as a screening tool for cognitive impairment among elderly with depression as an indicator for the need of a comprehensive neuropsychological evaluation. Replication with larger samples is necessary.

Apathy in dementia: clinical and sociodemographic correlates.

The authors examine prevalence and the sociodemographic and clinical correlates of apathy in dementia. Apathy was assessed in 121 outpatients in a behavioral neurology clinic using the Informant and Clinician versions of the Apathy Evaluation Scale (AES-I, AES-C). Apathy was found to be very prevalent across the dementias. Functional impairment, aberrant motor behavior, and irritability were associated with a greater likelihood of being apathetic upon evaluation with the AES-I. Additionally, with the AES-C, persons with dementia who lived with individuals other than their spouses were more likely to suffer apathy compared to those who lived with their spouses. These findings have clinical and research implications.

Comparability of the clinical diagnostic criteria for vascular dementia: a critical review. Part I.

This review is the first of a two-part series focusing on the comparability of eight clinical criteria used for the diagnosis of vascular dementia: the Hachinski Ischemic Scale; the Ischemic Scale of Rosen; the criteria proposed by the Diagnostic and Statistical Manual of Mental Disorder-Third Edition (DSM-III), DSM-III-R, DSM-IV; International Classification of Diseases, 10th Revision (ICD-10); State of California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC); and the National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN). The authors discuss the critical issues related to the definition of the cognitive syndromes as well as the vascular causes and associated heterogeneity of symptomatology across these criteria.

Validity of the clinical diagnostic criteria for vascular dementia: a critical review. Part II.

This review is the second of a two-part series focusing on the validity of eight clinical criteria for vascular dementia. Sixteen studies were selected according to their purposes and quality of experimental design. The analysis revealed that criteria for vascular dementia are not interchangeable; the eight criteria sets yielded different sensitivity and specificity results, as well as marked variability in incidence, prevalence, and frequency rates. Although the State of California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC) were the most sensitive and useful criteria in clinical settings and the National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) were the most specific and useful criteria in research, all criteria shared similar flaws. A definition of the cognitive syndrome, associated vascular causes or lesions, and methods of assessment should be clearly specified in the future. Suggestions for improvement are made.

Narcissistic personality and vulnerability to late-life suicidality.

OBJECTIVE: Narcissistic personality (NP) has been implicated as a potential vulnerability factor for late-life suicide. The present study investigated whether NP increases vulnerability to suicidal ideation and behavior among geriatric depression day-hospital patients. METHODS: Using a retrospective database analysis, the authors examined demographic data, diagnostic information, and scores on self-report (Geriatric Depression Scale [GDS]) and clinician-rated depression measures (Hamilton Rating Scale for Depression [HAM-D]), for 608 geriatric psychiatry patients 65 years or older. RESULTS: Of the 538 patients meeting study inclusion criteria, 20 had NP, defined as either narcissistic personality disorder (n = 13) or narcissistic personality traits (n = 7). Patients with NP were rated significantly higher on the HAM-D suicide item than those without NP, controlling for age, sex, depression (GDS), and cognitive functioning. CONCLUSION: Findings suggest that NP may be a clinical marker of elevated suicide risk among depressed older adults. Clinicians are advised to assess the presence of self-pathology and its potential impact upon psychological functioning in depressed older patients, and to incorporate discussions of life transitions into therapeutic work with those at-risk for suicide.

An appraisal of the psychometric properties of the Clinician version of the Apathy Evaluation Scale (AES-C).

This article examines the psychometric properties of the clinician version of the Apathy Evaluation Scale (AES-C) to determine its ability to characterize, quantify and differentiate apathy. Critical appraisals of the item-reduction processes, effectiveness of the administration, coding and scoring procedures, and the reliability and validity of the scale were carried out. For training, administration and rating of the AES-C, clearer guidelines, including a more standardized list of verbal and non-verbal apathetic cues, are needed. There is evidence of high internal consistency for the scale across studies. In addition, the original study reported good test-retest and inter-rater reliability coefficients. However, there is a lack of replication on these more stable and informative measures of reliability and as such they warrant further investigation. The research evidence confirms that the AES-C shows good discriminant, convergent and criterion validity. However, evidence of its predictive validity is limited. As this aspect of validity refers to the scale's ability to predict future outcomes, which is important for treatment and rehabilitation planning, further assessment of the predictive validity of the AES-C is needed. In conclusion, the AES-C is a reliable and valid measure for the characterization and quantification of apathy.

A systematic review of the rehabilitation of moderate to severe acquired brain injuries.

OBJECTIVE: To conduct a systematic review of the rehabilitation literature of moderate to severe acquired brain injuries (ABI) from traumatic and non-traumatic causes. METHODS: A review of the literature was conducted for studies looking at interventions in ABI rehabilitation. The methodological quality of each study was determined using the Downs and Black scale for randomized controlled trials (RCTs) and non-RCTs as well as the Physiotherapy Evidence Database (PEDro) scale for RCTs only. RESULTS: Almost 14 000 references were screened from which 1312 abstracts were selected. A total of 303 articles were chosen for careful review of which 275 were found to be interventional studies but only 76 of these interventional studies were RCTs. From this, 5 levels of evidence were determined with 177 conclusions drawn; however of the 177 conclusions only 7 were supported by two or more RCTs and 41 were supported by one RCT. CONCLUSION: Only 28% of the interventional studies were RCTs. Over half of the 275 interventional studies were single group interventions, pointing to the need for studies of improved methodological quality into ABI rehabilitation.

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

BACKGROUND: It has been reported for over the past decade that the use of selective serotonin reuptake inhibitors (SSRI's) may associate with the emergence of apathy. The authors hypothesized that depressed patients treated with SSRI's 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. METHODS: Baycrest Centre for Geriatric Care's 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. RESULTS: Among 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. CONCLUSION: Even 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.

Towards a cognitive stimulation program using an errorless learning paradigm in amnestic mild cognitive impairment.

Considering the high risk for amnestic mild cognitive impairment (A-MCI) individuals to progress towards dementia, it is crucial to study the efficacy of innovative treatment strategies such as cognitive stimulation techniques. The present study is a case report of two individuals presenting with A-MCI who were enrolled in a memory training program. After a broad neuropsychological assessment, the two participants were trained with an errorless (EL) learning paradigm on an individual basis, twice a week, over three weeks. Two follow-up sessions took place one and five weeks after the end of the training. Results showed that the program was well tolerated and feasible, and enhanced daily memory abilities. For the second participant only, a re-evaluation of her cognitive profile was completed 23 months after her first assessment and training. In addition, EL was directly compared with a control condition using an errorful (EF) learning paradigm to teach her new names over two sessions (one session for each condition). Her improvement on the trained material supported the preliminary efficacy of EL compared with EF for learning episodic material. These results are compatible with previous work that has preliminarily demonstrated the efficacy of an EL paradigm in patients with dementia.