Apathy: a practical guide for neurologists

Apathy is an under-recognised and underestimated problem for people with chronic neurological disorders. Despite being common and disabling, it is seldom volunteered as a symptom by patients or even their caregivers. Yet apathy undoubtedly has an important impact on caregiver stress, functional disability and quality of life. A detailed clinical assessment can distinguish apathy from depression and allow clinicians to make practical suggestions to reduce the impact of symptoms on individual patients and their families. Pharmacological approaches to treatment include cholinesterase inhibitors, dopamine agonists and stimulants. CASE 1A 66-year-old man with progressive supranuclear palsy returned to clinic for review. His wife was upset and finding it difficult to cope. She described him as 'completely lazy', as he just sat in his chair all day watching television, even though he could still do things for himself. She felt that he could not be bothered to speak to her anymore because he was 'obsessed with TV'. He did not seem to engage with the visits to the grandchildren that she arranged. He said that he felt fine apart from the problems with his walking.The neurologist was confident that the patient was not depressed, and that the wife's concerns reflected the apathy that is often very pronounced in progressive supranuclear palsy. By explaining to the man's wife that these problems were due to his disease, their relationship improved and she felt more able to cope with caring for him. CASE 2A 75-year-old man attended clinic with his wife. She had worried about him for over a year, as he had become increasingly withdrawn. He used to enjoy going to the local pub but now stayed at home all day. He seemed less concerned about his personal appearance, about which he used to be meticulous. More recently, she had noticed that he had become forgetful. On examination, he had a mild episodic memory deficit but no impairments in other domains.He was diagnosed with mild cognitive impairment but the presence of apathy suggested a high risk of him developing Alzheimer's disease. He did not improve with a trial of antidepressant treatment but had useful input from an occupational therapist. His apathy improved after he started a cholinesterase inhibitor a year later, when his cognitive symptoms had progressed.