Apathy, anxiety and depression

2. Apathy

Many people feel short of ‘drive’ or ‘lose their ‘spark’ occasionally, but apathy is a persistent loss of motivation to do things, or a lack of interest in things. It is different from depression. Apathy is much more common among people with dementia than in older people without dementia. About 2–5% of older people without dementia have apathy at any one time, but about 50–70% of people with dementia have apathy.

A person with any type of dementia can have apathy but it is particularly common in frontotemporal dementia. Apathy can start at any stage of dementia but often develops early on. Many studies suggest that apathy becomes more common as dementia progresses. Once present, apathy tends to persist rather than come and go.

What are the symptoms of apathy?

A person with dementia and apathy will have less motivation, as well as some of the following changes:

  • lack of effort or energy to do everyday tasks (such as personal hygiene)
  • reliance on others to structure daily activities
  • loss of interest or curiosity in new things (such as people or conversation)
  • lack of concern about their own problems
  • unemotional responses to news or personal events (seeming indifferent or detached).

Some of these symptoms (such as loss of interest in things and lack of energy) are also common in depression. It can be hard to know whether a person has depression or apathy – even for a doctor. The main difference is that a person with depression will have feelings of sadness, be tearful, feel hopeless or have low self-esteem – see the next section ‘Depression’. A person with apathy alone will not have these symptoms of low mood, more a feeling of being without energy or spark.

A person with apathy and dementia is often not concerned by their symptoms. However, these symptoms can make the person’s life less enjoyable and often put a strain on anyone helping them. Carers can feel frustrated because the person needs more support with daily tasks and because they seem so withdrawn and unresponsive.

Causes of apathy

One of the reasons that people with dementia are thought to develop apathy is damage to the brain’s frontal lobes. These control motivation, planning and sequencing of tasks. When someone withdraws, stops doing things and loses their confidence and abilities, their apathy can get worse and so they become even less motivated. It is important for anyone supporting the person to help them avoid this.

Treating apathy

Compared with depression and anxiety (see below), there is less evidence about what treatments do or do not help someone with apathy and dementia. Non-drug approaches should generally be tried first. According to recent research, music therapy, group art therapy and cognitive stimulation (when delivered by a trained professional) can all help.

What you can do to help a person with apathy: tips for carers

  • Try tasks and activities that the person can do, enjoys and finds meaningful. A daily routine may help.
  • Break tasks down into manageable chunks. Several smaller steps may be easier to take than one bigger step and help the person to feel like they are achieving things.
  • You will often need to gently prompt or help the person, or start an activity (such as dressing). Offer lots of encouragement to keep them engaged, but don’t fuss over them. Be positive and focus on what they have achieved.
  • Don’t blame the person for being ‘lazy’, unhelpful or not caring – it’s not their choice. If you feel frustrated, try to remain calm. The person may pick up a negative mood.
  • Look after yourself: take regular breaks and see if replacement (respite) care is an option. Talk to someone you trust or join a support group, perhaps online. Others may have helpful tips to share.

Drugs play only a small part in the treatment of apathy. Some people who are already taking a cholinesterase inhibitor (donepezil, rivastigmine or galantamine) for Alzheimer’s disease or mixed Alzheimer’s-vascular dementia will have an improvement in their motivation, as well as in memory and concentration.

A person with apathy may also be offered an antidepressant drug, although there is very little evidence that common antidepressants bring any benefits for apathy in Alzheimer’s disease, mixed or vascular dementia. There is some evidence that these drugs make apathy worse.