L’apathie dans la démence est un important défi comportemental

Conférencière : Tiffany Chow, M.D., Clinicienne-chercheure, Institut de recherche Rotman ; Professeure adjointe, Neurologie et psychiatrie gériatrique, Université de Toronto, Toronto, ON.

La D^re Tiffany Chow a commencé par exprimer toute son estime, en tant que neurologue, à l’égard de ses collègues en gériatrie, dont elle admire la défense d’une approche plus holiste des patients atteints de démence, et de l’importance du travail d’équipe.
Elle a défini des aspects fondamentaux de la qualité de vie des personnes atteintes de démence : ne pas avoir de douleurs ; se sentir en sécurité ; pouvoir participer à des activités intéressantes ; et être à même de conserver le plus haut degré possible d’autonomie. La D^re Chow a également décrit des facteurs de qualité de vie pour les aidants : des liens affectifs ; la capacité d’aider le patient (p. ex., en le nourrissant) ; passer de bons moments ensemble ; et savoir que tout ce qui peut être fait est fait.

La D^re Chow a mis en garde contre les effets de l’apathie chez les patients atteints de démence, qui peut avoir des répercussions sur toutes les dimensions de la qualité de vie décrites précédemment. L’apathie est un symptôme commun et important de la démence. Bien que l’apathie puisse signifier une dépression, elle peut aussi survenir en l’absence de dépression, et chacune peut exacerber l’autre. L’apathie peut empêcher les patients atteints de démence d’être motivés à prendre physiquement part à des activités quotidiennes et, du fait du manque de stimulation, cet état peut hâter le déclin cognitif.¹ L’apathie intensifie aussi le désarroi de l’aidant, et nuit au lien affectif avec le patient. Elle diminue également l’adhésion au traitement (pharmacologique ou autre, p. ex. ludothérapie). L’apathie peut contribuer au placement en établissement ; des études ont révélé des taux plus bas d’apathie parmi les patients résidant dans leur communauté.

La D^re Chow a expliqué qu’il existe plusieurs réseaux neuronaux qui gèrent notre façon de prioriser ce que nous avons à faire et à ne pas faire, et une tentative de localiser l’apathie dans le cerveau a été faite (Figure 1). La recherche sur l’apathie a mis en évidence son lien avec le lobe temporal droit, le lobe frontal droit, le noyau caudé, la circonvolution cingulaire antérieure (ou le cortex frontal médian supérieur), et le cortex orbito-frontal.²

 

Dans leur étude récente,³ la D^re Chow et ses collègues ont cherché à déterminer de façon empirique des groupements de symptômes d’empathie, chez des patients atteints de démence, pour voir si les symptômes affectifs, comportementaux ou cognitifs de l’apathie avaient tendance à se produire ensemble ou de façon isolée, et si l’apathie se ma-nifestait typiquement en cooccurrence avec d’autres types de désordres comportementaux.

La D^re Chow a montré des données provenant de Baycrest, Sunnybrook [Centre des Sciences de la Santé], UC San Francisco, et UCLA, combinées pour donner les résultats de l’Inventaire neuropsychiatrique (NPI). Dans la section du NPI traitant de l’apathie, des patients sont interrogés sur l’activité spontanée, la spontanéité conversationnelle, la participation à leurs anciennes activités et à d’anciennes tâches, la démonstration de leur intérêt pour autrui, leur relations avec leurs amis et leur famille, et le degré d’affection.
Les résultats ont montré que, chez ceux qui présentaient soit une DFT, soit une démence de type Alzheimer (DTA), le type d’apathie le plus courant était, le cas échéant, une diminution de l’activité spontanée. Une comparaison du pourcentage d’apathie dans les deux types de démence a montré qu’il y avait plus de patients atteints de DFT (72 %) qui présentaient aussi une apathie que ceux qui avaient une DTA (56 %).

Ils ont également fait apparaître tous les types d’apathie : apathie affective (émoussement émotionnel) ; apathie comportementale (manque d’activation spontanée) ; et apathie cognitive (manque d’intérêt à s’engager dans une nouvelle activité cognitive). De nombreux patients présentaient les trois types, et presque tous en présentaient au moins deux. Et c’était le cas pour les deux types de démence.

Ils ont recherché sur le NPI une association entre l’apathie et d’autres variables non liées à l’apathie, comme l’impulsivité, l’angoisse de séparation et le comportement de résistance, et ont trouvé que ceux qui présentaient une apathie de type affectif étaient plus susceptibles d’avoir ces symptômes que ceux présentant d’autres types d’apathie ou aucune apathie.

Elle a parlé des résultats d’une étude de Robert et coll.⁴ qui indiquent que l’apathie peut être un prédicteur, en vertu duquel des patients ayant un trouble cognitif léger (TCL) évoluent en DTA.

Deux groupes, l’un en Amérique du Nord, l’autre en Europe, travaillent à faire inscrire l’apathie au DSM-V (Manuel diagnostique et statistique des troubles mentaux). Les critères en seraient le manque de motivation (relativement aux conditions initiales), le manque d’acti-vités dirigées vers un but (apathie cognitive), le manque d’intérêts ou de buts, et des réponses émotionnelles affaiblies (émoussement émotionnel).

Il convient d’envisager le traitement de l’apathie selon le type d’apathie.^1,5 Pour ceux qui présentent une apathie affective, un antidépresseur pourrait être de rigueur. On peut utiliser les psycho-stimulants dans l’apathie comportementale. Les inhibiteurs de la cholinestérase ont démontré une efficacité sur l’apathie cognitive. On a montré l’efficacité et la bonne tolérance de psychostimulants comme le méthylphénidate ; bien que la dextroamphétamine appartienne à la même classe thérapeutique, on ne dispose de preuves suffisantes que pour l’usage du premier. Des antidépresseurs et des agents dopaminergiques ont également été utilisés.

La D^re Chow a examiné si certains de ces médicaments, comme les neuroleptiques ou d’autres calmants, pouvaient occasionner une apathie en cas de démence. Avec ses collègues, elle a examiné ce point au cours d’une étude transversale chez 69 patients atteints de DFT. Sur les quatre médicaments de ce groupe les plus couramment utilisés – les anti-inflammatoires non stéroïdiens (probablement contre les symptômes de douleurs arthritiques), les inhibiteurs sélectifs du recaptage de la sérotonine, les inhibiteurs de la cholinestérase et les neuroleptiques – elle n’en a trouvé aucun qui augmente le risque d’apathie.

La D^re Chow a recommandé les articles de Robert et coll., 2009⁶ et de van Reekum et coll., 2005¹ à ceux qui désirent en apprendre d’avantage sur l’apathie.

Références:

1. van Reekum R, Stuss DT, and Ostrander L. Apathy: why care? J Neuropsychiatry Clin Neurosci 2005;17:7–19.
2. Mendez J, Lauterbach EC, and Sampson, SM. An evidence-based review of the psychopathology of frontotemporal dementia: a report of the ANPA Committee on Research. J Neuropsychiatry Clin Neurosci 2008;20:130–49.
3. Chow TW, Binns MA, Cummings JL, et al. Apathy symptom profile and behavioural associations in frontotemporal dementia vs. Alzheimer’s disease. Arch Neurol 2009;In press.
4. Robert PH, Berr C, Volteau M, et al. Importance of lack of interest in patients with mild cognitive impairment. Am J Geri Psych 2008;16:770–6.
5. Malloy PF and Boyle PA. Apathy and its treatment in Alzheimer’s disease and other dementias. Psychiatric Times 2005;XXII(13).
6. Robert P, Onyike CU, Leentjens AF, et al. Proposed diagnostic criteria for apathy in Alzheimer’s disease and other neuropsychiatric disorders. European Psychiatry 2009;24:98–104.

Apathy in Dementia Is a Significant Behavioural Challenge

Speaker: Tiffany Chow, MD, Clinician-Scientist, Rotman Research Institute; Assistant Professor, University of Toronto, Neurology & Geriatric Psychiatry, Toronto, ON.

Dr. Tiffany Chow began with expressing her appreciation, as a neurologist, for her colleagues in geriatrics, whom she honoured for promoting a more holistic approach to patients with dementia, and stressed the importance of working together.

She identified fundamental aspects of quality of life for people with dementia: being pain-free; safe; able to participate in meaningful activities; and able to maintain the greatest degree of autonomy possible. Dr. Chow also described contributors to quality of life for caregivers: emotional connection; the ability to aid the patient (e.g., in feeding); having good downtime together; and the knowledge that everything that can be done is being done.

Dr. Chow cautioned against the effects of apathy in patients with dementia, which can impact all dimensions of life quality described above. Apathy is a common and significant symptom in dementia. While apathy can signify depression, it can also occur in depression’s absence, and each can worsen the other. Apathy can keep patients with dementia from being physically motivated to participate in everyday activities and, due to lack of stimulation, this state can hasten cognitive decline.¹ Apathy also intensifies caregiver distress and thwarts emotional connection to the patient. It also diminishes treatment compliance (pharmacological or other, e.g., recreational therapy). Apathy may contribute to institutionalization; studies have found lower rates of apathy among community-dwelling patients.

Dr. Chow explained that there are several neuronal networks that manage how we prioritize what we need to do and not do, and they have attempted to localize apathy in the brain (Figure 1). Research into apathy has identified its association with the right temporal lobe, right frontal lobe, caudate, anterior cingulate gyrus (or superior medial frontal cortex), and the orbital-frontal cortex.²

 

In their recent study,³ Dr. Chow and her colleagues set out to localize clusters of apathy symptoms empirically, with actual patients with dementia, to see whether the affective, behavioural, or cognitive apathy symptoms tended to occur together or in isolation, and whether apathy typically co-occurs with other types of behavioural disturbances.

Dr. Chow showed combined data from Baycrest, Sunnybrook [Health Sciences Centre], UC San Francisco, and UCLA, showing results on the Neuropsychiatric Inventory (NPI). On the section of the NPI that deals with apathy, patients are questioned on spontaneous activity, spontaneity in conversation, participation in former activities, participation in former chores, demonstration of interest in others, investment in friends and family, and degree of affection.

Results showed that, for those with either FTD or Dementia of Alzheimer’s type (DAT), the most common type of apathy, when present, was a decrease in spontaneous activity. Comparing the percentage of apathy in the two types of dementia, more of the patients with FTD (72%) had apathy than those with DAT (56%).

They also demonstrated all the types of apathy: affective apathy (emotional blunting); behavioural apathy (lack of spontaneous activation); and cognitive apathy (lack of interest in engaging in new cognitive activity). Many patients had all three types, and almost all had at least two. This was true for both types of dementia.

They looked for an association between apathy and other non-apathy variables on the NPI, including impulsivity, separation anxiety, and resistant behaviour, and found that those with the affective type of apathy were much more likely to experience these symptoms than those with other types of apathy or no apathy.

She discussed the results of a study by Robert et al.⁴ that showed that apathy could be a predictive factor for which patients with mild cognitive impairment (MCI) will convert to DAT.

There are two groups, one in North America and one in Europe, who are working to get apathy added to the DSM-V (Diagnostic and Statistical Manual of Mental Disorders). The criteria would be lack of motivation (relative to baseline), lack of goal-directed activity (cognitive apathy), lack of interests or goals, and diminished emotional responses (emotional blunting).

Treatment for apathy should be considered on the basis of type of apathy.^1,5 For those with affective apathy, an antidepressant might be in order. For behavioural apathy, psychostimulants might be used. For cognitive apathy, cholinesterase inhibitors have shown efficacy. Psychostimulants such as methylphenidate have been shown to be effective and well-tolerated; while dextroamphetamine is in the same drug class, there is only sufficient evidence supporting use of the former. Antidepressants and dopaminergic agents have also been used.

Dr. Chow has looked at whether some of these drugs, for example antipsychotics or other sedatives, might cause apathy in dementia. She and her colleagues investigated this in a cross-sectional study on 69 patients with FTD. Of the four most commonly used medications in this group—nonsteroidal anti-inflammatories (probably for arthritic pain symptoms), selective serotonin reuptake inhibitors, cholinesterase inhibitors, and antipsychotics—none was found to contribute to a higher risk of apathy.

For those interested in learning more on the subject of apathy, Dr. Chow recommended articles by Robert et al., 2009⁶ and van Reekum et al., 2005.¹

References:

1. van Reekum R, Stuss DT, and Ostrander L. Apathy: why care? J Neuropsychiatry Clin Neurosci 2005;17:7–19.
2. Mendez J, Lauterbach EC, and Sampson, SM. An evidence-based review of the psychopathology of frontotemporal dementia: a report of the ANPA Committee on Research. J Neuropsychiatry Clin Neurosci 2008;20:130–49.
3. Chow TW, Binns MA, Cummings JL, et al. Apathy symptom profile and behavioural associations in frontotemporal dementia vs. Alzheimer’s disease. Arch Neurol 2009;In press.
4. Robert PH, Berr C, Volteau M, et al. Importance of lack of interest in patients with mild cognitive impairment. Am J Geri Psych 2008;16:770–6.
5. Malloy PF and Boyle PA. Apathy and its treatment in Alzheimer’s disease and other dementias. Psychiatric Times 2005;XXII(13).
6. Robert P, Onyike CU, Leentjens AF, et al. Proposed diagnostic criteria for apathy in Alzheimer’s disease and other neuropsychiatric disorders. European Psychiatry 2009;24:98–104.

Michael J. Passmore, MD, FRCPC, Clinical Assistant Professor, Department of Psychiatry, Geriatric Psychiatry Program, University of British Columbia, Vancouver, BC.

The following review uses case studies to illustrate the importance of a biopsychosocial approach to the assessment and management of behavioural and psychological symptoms of dementia (BPSD). Practical BPSD assessment strategies are reviewed, in addition to evidence-based and guideline-supported recommendations for acute and long-term BPSD management.
Key words: dementia, behaviour, agitation, antipsychotic, memantine.

Rita Moretti, MD, Clinica Neurologica, Dipartimento Medicina Clinica e Neurologia, Università degli Studi, Trieste, Italy.
Paola Torre, MD, Clinica Neurologica, Dipartimento Medicina Clinica e Neurologia, Università degli Studi, Trieste, Italy.
Rodolfo M. Antonello, MD, Clinica Neurologica, Dipartimento Medicina Clinica e Neurologia, Università degli Studi, Trieste, Italy.

Cerebrovascular disease is a potential cause of vascular dementia. Vascular dementia is not an univocal entity; it encompasses at least four types of dementia: multi-infarct, subcortical, strategic infarct, and posthemorrhage dementia. Vascular dementia does not contain cognitive problems only. There are also noncognitive behavioural alterations. The major noncognitive behavioural situations are depression, anxiety, agitation, delusions, and insomnia. Disorders such as depression, anxiety, and psychosis not only affect the quality of life of a patient but also that of the caregiver. Behavioural disturbances may also contribute to morbidity and are a major cause of institutionalization since they result in inadequate nutrition and sleep and enhance cognitive disruption. Diagnosing depression in the context of vascular dementia is challenging given the overlap of signs and symptoms between depression and dementia. Both disorders can be characterized by apathy and loss of interest, an impaired ability to think, psychomotor agitation, and psychomotor retardation.
Key words: behaviour, subcortical vascular dementia,, vascular dementia, small-vessel dementia.

The focus of this issue is Altered Mood and Behaviour in the Older Adult. Although the most common diseases producing changes in mood or behaviour are depression and dementia, altered behaviour may also be the first indication of delirium. Whenever an older adult’s behaviour changes abruptly, delirium should be the first thought that comes to the clinician’s mind. I served as an expert witness several years ago at a coroner’s inquest for an older woman who died in long-term care. The nurse had meticulously detailed changes in behaviour that were classic signs of delirium, but did not understand the significance of these changes and so did not inform the attending physician of them. When the doctor arrived on her usual day to round on her patients, she immediately recognized the gravity of the situation and sent the patient to hospital, where she died shortly thereafter of sepsis and hyperglycemia. A totally preventable death would have been avoided had the staff understood the significance of the change in the patient’s behaviour. The Registered Nurses’ Association of Ontario has been very active in developing educational modules to help nurses distinguish delirium, dementia, and depression, to the great benefit of hospitalized patients.

Over the last few years, our understanding of vascular dementia has expanded beyond the mere presence of strokes in an individual with dementia, and we are now appreciating the more subtle manifestations of the disease. One of the most common behavioural issues that geriatricians see, “Post-Stroke Depression” is discussed by Drs. Lana Rothenburg, Nathan Herrmann, and Krista Lanctôt in their article, which serves as the basis for our CME module. The next piece, “Behavioural Disorders in Vascular Dementia” is by Drs. Rita Moretti, Paola Torre, and Rodolfo M. Antonello. For those of us particularly interested in the differential diagnosis of the type of dementia our patient has, the article “Clinical Differences among Four Common Dementia Syndromes” by Dr. Weerasak Muangpaisan will be especially helpful. Our regular column on dementia this month is “Behavioural Interventions Can Minimize Functional Decline in Mild Cognitive Impairment and Dementia” by Drs. Angela Troyer and Kelly Murphy.

We also have our usual collection of interesting articles on diverse topics. Our CVD article this month is “Diagnosis and Management of Mitral Valve Disease in Older Adults” by Drs. Indranil Dasgupta, Marc Tecce, and Bernard Segal. Dr. Mary Anne Huggins and Laura Brooks have provided the article “Discussing End-of-Life Care with Older Patients: What Are You Waiting For?” Our last two articles are particularly intriguing. Older adults today are often much wealthier than previous generations, and extensive travel is often common during retirement, making the article “Fever in the Returning Traveller” by Dr. Alberto Matelli, Dr. Anna Cristina Carvalho, and Dr. Veronica Dal Punta particularly relevant. Finally we are reminded that social and economic factors result in quite different experiences of aging in the article “Aging in Africa” by Dr. Irene Turpie and Leigh Hunsinger.

Enjoy this issue,
Barry Goldlist

Dorothy A Forbes, RN, PhD, CIHR New Investigator, Associate Professor, College of Nursing, University of Saskatchewan, Saskatoon, SK.
Shelley Peacock, RN, MN, Faculty Member, Saskatchewan Institute of Applied Science and Technology, Saskatoon, SK.
Debra Morgan, RN, PhD, Associate Professor, Institute of Agricultural, Rural, and Environmental Health, University of Saskatchewan, Saskatoon, SK.

Strategies such as simulated presence therapy, pet therapy, light therapy, validation therapy, music, massage, therapeutic touch, aromatherapy, and multisensory stimulation have shown promising results in decreasing physical aggression, physical nonaggression, verbal aggression, and verbal nonaggression in older adults with dementia. Further research is needed to identify which strategies are most effective in managing symptoms of agitation associated with the different types of dementia and at different levels of cognitive impairment.

Key words: Alzheimer’s disease, dementia, nonpharmacological strategies, agitation, aggression, behaviour.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Ann Schmidt Luggen, PhD, GNP, Professor, Department of Nursing and Health Professions, Northern Kentucky University, Highland Heights, KY; Gerontological Nurse Practitioner, Evercare, Cincinnati, OH, USA.

Medical management of Alzheimer’s disease patients involves drugs that temporarily relieve or stabilize symptoms, or lessen the expected decline in cognition, function, and behaviour, but ultimately fail to halt progression of the disease. Commonly used agents in the management of early- to mid-stage dementias--albeit with modest outcomes--are the cholinesterase inhibitors (ChEIs). Antipsychotics have been used with mixed success to treat psychiatric symptoms that occur in 30-60% of patients with moderate-to-severe AD. In the terminal stages of dementia, palliation of symptoms and a focus on comfort care is important. Management of pain and relief from depression and anxiety are useful.

Key words: dementia, Alzheimer’s disease, cholinesterase inhibitors, behaviour, antipsychotics.