Apathy and agitation: challenges and future directions.

Apathy and agitation are frequently encountered in the practice of geriatric psychiatry and have been associated with significant adverse effects for patients and those around them. They frequently occur in the context of brain disease. Yet, these are some of the most challenging conditions affecting older patients as they are understudied, poorly understood, and hard to treat. This issue of AJGP features several articles related to apathy and agitation, illustrating advances in our knowledge about these conditions. APATHY Apathy has primarily been studied in the clinical setting, almost always in the context of other conditions such as depression or dementia. This has led to uncertainty regarding the prevalence of apathy in the general population, particularly its occurrence in the absence of a cognitive or affective disorder. Onyike and colleagues 1 report from the Cache County Dementia Progression Study, one of the first populationbased prevalence studies of apathy, that clinically significant apathy was most prevalent in individuals with dementia or milder cognitive syndromes. Among cognitively intact individuals, as judged by consensus panels, apathy was associated with worse performance on cognitive measures. These findings suggest that apathy is closely linked to cognitive impairment and indicate that the emergence of apathy in late life may itself be an indicator of degenerative disease and impending dementia. Lueken et al., 2 in a very elegant nursing home study, provide prevalence and psychometric findings about apathy. They replicate findings of others indicating that apathy is very common in this setting and associated with a variety of adverse effects on functioning. Notably, these investigators refined the measurement of apathy by developing a 10-item version of the Apathy Evaluation Scale (AES-10) with reliability and validity similar to that of the full scale. They also show that the AES-10 is highly correlated with the apathy domain of the Neuropsychiatric Inventory (NPI), the other widely used measure of apathy. In a study of the neurobiologic underpinnings of apathy, Lavretsky et al. 3 applied sophisticated volumetric methodology to examine the relationship between apathy or depression and brain regions previously hypothesized to be associated with these conditions. They take head-on the hypothesis that apathy and depression, while related, have different neurobiologic underpinnings. As expected from prior work, depression was associated with smaller volumes of the orbitofrontal areas, whereas apathy was associated with smaller volumes of the anterior cingulate. These findings make sense given recent developments in our understanding of frontal-subcortical neural circuity. 4 In addition to differentiating the brain underpinnings of apathy and depression, these findings reaffirm the importance of these brain areas, and by extension of frontal-subcortical loops, to the emergence of common psychiatric syndromes even in the absence of coarse brain disease or degeneration. 5 All three papers represent advances regarding apathy. They confirm that moderate or more apathy, especially new apathy in later life, is usually pathological, may be a harbinger of dementia, and can be