Apathy and Weight Loss in Nursing Home Residents: Longitudinal Study

Abstract

Objectives:
Determine which behavioral syndromes of dementia are independently related to weight loss.

Design:
Longitudinal study using four subsequent quarterly Minimum Data Set (MDS) 2.0 assessments. Characteristics obtained in one period were related to weight loss observed in the next period.

Setting:
Eight nursing homes in the Netherlands.

Participants:
The initial population was 2031 nursing home residents with four quarterly MDS assessments within a period of 15 months. We selected 1850 subjects who were at least 65 years old at the time of the first assessment and who were not comatose.

Measurements:
Information about the presence of four behavioral syndromes (depression, apathy, agitation, and rejection of care), demographic data, cognition status, body mass index (BMI), and time that residents were involved in activities were obtained from MDS 2.0.

Results:
Bivariate correlation showed that weight loss at follow-up assessments was related to all baseline behavioral syndromes, degree of cognitive impairment, body mass index, and time that residents were involved in activities. Multivariable binary logistic regression with these factors showed that the only behavioral syndrome that was independently related to subsequent weight loss was apathy. In multivariable analysis, the degree of cognitive impairment and BMI were also independently related to weight loss.

Conclusion:
These results suggest that of all behavioral factors we have assessed, apathy had the strongest association with weight loss in nursing home residents even when adjusted for the degree of cognitive impairment.

Full text

Original Study
Apathy and Weight Loss in Nursing Home Residents: Longitudinal Study
Ladislav Volicer MD, PhD
a
,
*, Dinnus H.M. Frijters PhD
b
, Jenny T. van der Steen PhD
b
a
School of Aging Studies, University of South Florida, Tampa, FL, and Charles University 3rd Medical Faculty, Prague, Czech Republic
b
EMGO Institute for Health and Care Research, Department of Nursing Home Medicine, VU University Medical Center, Amsterdam, The Netherlands
Keywords:
Apathy
weight loss
nutritional status
depression
nursing homes
abstract
Objectives: Determine which behavioral syndromes of dementia are independently related to weight loss.
Design: Longitudinal study using four subsequent quarterly Minimum Data Set (MDS) 2.0 assessments.
Characteristics obtained in one period were related to weight loss observed in the next period.
Setting: Eight nursing homes in the Netherlands.
Participants: The initial population was 2031 nursing home residents with four quarterly MDS assess-
ments within a period of 15 months. We selected 1850 subjects who were at least 65 years old at the
time of the first assessment and who were not comatose.
Measurements: Information about the presence of four behavioral syndromes (depression, apathy,
agitation, and rejection of care), demographic data, cognition status, body mass index (BMI), and time
that residents were involved in activities were obtained from MDS 2.0.
Results: Bivariate correlation showed that weight loss at follow-up assessments was related to all baseline
behavioral syndromes, degree of cognitive impairment, body mass index, and time that residents were
involved in activities. Multivariable binary logistic regression with these factors showed that the only
behavioral syndrome that was independently related to subsequent weight loss was apathy. In multivar-
iable analysis, the degree of cognitive impairment and BMI were also independently related to weight loss.
Conclusion: These results suggest that of all behavioral factors we have assessed, apathy had the strongest
association with weight loss in nursing home residents even when adjusted for the degree of cognitive
impairment.
Copyright Ó2013 - American Medical Directors Association, Inc.
Many nursing home residents experience undesirable weight
loss.
1
Weight loss in elderly individuals may lead to increased
mortality,
2
increased risk of hip fracture,
3
pressure ulcers, infections,
anemia, muscle weakness, fatigue, and edema.
4
Weight loss also
predicts rapid cognitive decline in community-dwelling persons with
Alzheimer disease (AD).
5
Many factors may cause weight loss, including anorexia, malab-
sorption, hypermetabolism, dehydration sarcopenia, and depression.
6
Presence of dementia is also a major risk factor for weight loss.
7
One
of the causes of weight loss in persons with dementia may be
behavioral symptoms of dementia. A higher Cohen-Mansfield Agita-
tion Inventory score was found to be 1 of the 3 factors independently
associated with weight loss in patients with AD
8
; however, this scale
does not differentiate which specific behavioral symptoms may be
related to weight loss. We therefore performed a longitudinal study,
investigating the relationship of specific behavioral symptoms to
weight loss in nursing home residents.
We selected four syndromes: depression, apathy, agitation, and
rejection of care (resistance), which may influence weight in nursing
home residents. Depression is considered the most common cause of
anorexia and weight loss in nursing home residents.
9
Apathy was found
to be associated with more pronounced deficits in nutritional status in
686 outpatients with AD.
10
Agitation may interfere with eating and also
may increase energy expenditure, especially if it includes pacing.
11
Rejection of care may interfere with feeding of individuals who have
difficulty eating independently. The agitation/aggression subscale of
Neuropsychiatric Inventory, which actually measures rejectionof care,
12
was found to be related to weight loss in a 6-month study.
13
We decided
to consider 3 additionalfactors that potentially relate to intake or energy
expenditure: cognition, body mass index (BMI), and involvement in
activities, and adjusted for these factors to determine independent
associations of the behavioral syndromes and weight loss.
Methods and Subject Population
Data Elements
All variables were derived from Minimum Data Set (MDS) 2.0
items for nursing home care.
14
The MDS assessment is based on
The authors do not have any conflict of interest regarding this study.
* Address correspondence to Ladislav Volicer, MD, PhD, 2337 Dekan Lane, Land
O’Lakes, FL 34639.
E-mail address: lvolicer@cas.usf.edu (L. Volicer).
JAMDA
journal homepage: www.jamda.com
1525-8610/$ - see front matter Copyright Ó2013 - American Medical Directors Association, Inc.
http://dx.doi.org/10.1016/j.jamda.2012.12.004
JAMDA xxx (2013) 1e4

a combination of physical examination, patient history, observation,
consultation of other caregivers, and information found in medical
records. Full MDS assessments were performed within 7 days of
admission to the facility, quarterly thereafter, and whenever a signif-
icant change in status occurred. Evidence for presence of a symptom
was obtained from MDS items and included the Depression Rating
Scale
15
and scales for other behavioral syndromes
16
(Table 1). Resi-
dents were considered depressed if they had a score of 3 or higher on
the Depression Rating Scale, being agitated, or apathetic if they had at
least one positive symptom for each scale. Presence of resistiveness to
care (item E4eA) and demographic data (age, gender, diagnosis of
dementia, Cognitive Performance Score,
17
time involved in activities)
were also obtained from the MDS. BMI was calculated from the height
and weight listed in the MDS and the subjects were divided into 5
different categories (Table 2).
Subjects
MDS assessments were collected from 2031 nursing home resi-
dents cared for in eight nursing homes in the Netherlands. The
inclusion criteria were availability of four approximately quarterly
follow-up assessments within a period of 15 months. Of this popu-
lation, we selected to study 1850 subjects who were at least 65 years
old at the time of the first assessment and who were not comatose.
We excluded 179 subjects who were younger than 65 and two
subjects who were comatose.
Statistical Analysis
Binary correlation was performed to find which baseline variables
were significantly related to the weight loss recorded in the next
assessment. Relationships of age, BMI, severity of cognitive impair-
ment, behavioral syndromes, depression, and time involved in
activities to weight loss 3 months after each baseline assessment
were evaluated with binary logistic regression analyses. For each
3-month period, weight losses at the end of the period were
compared between those subjects who were and who were not
apathetic at the beginning of that period by an analysis of variance.
Weight loss was defined as a decrease in weight by the resident of 5%
or more in 30 days or 10% or more in 180 days. All analyses were
performed with PASW version 19 (Quarry Bay, Hong Kong).
Results
Most of the subjects of this study were elderly women (Table 2).
Only 15.5% of subjects were cognitively intact, but 40.1% did not have
any diagnosis of dementia. About one-half of the subjects were
involved in activities for more than two-thirds of the time and 5.6%
were not involved in activities at all. Involvement in activities
decreased slightly with severity of cognitive impairment (r¼e0.198,
P<.001) (Figure 1). Behavioral syndromes occurred in about one-half
of the subjects. Apathy and depression coexisted in 26.9% of the
residents.
Binary correlations showed that all baseline behavioral syndromes
were related to weight loss recorded in the next assessment
(depression r¼0.071, P¼.002; apathy r¼0.131, P<.001; agitation
r¼0.078, P¼.001; rejection of care r¼0.103, P<.001). Weight loss
was also related to the degree of cognitive impairment (r¼0.126, P<
.001), time involved in activities (r¼0.052, P¼.026), and BMI (r¼
e0.140, P<.001). We therefore included all factors with significant
correlations in multivariable binary logistic regression to investigate
which factors were independently related to weight loss.
Multivariable binary logistic regression showed that risk of weight
loss in the next 3 months is increased by previous severity of
cognitive impairment and apathy, whereas a high BMI decreased the
risk of weight loss (Table 3,Figure 2). Prevalence of apathy increased
with the severity of cognitive impairment (r¼0.335, P<.001)
(Figure 1) but decreased with increasing BMI (r¼e0.095, P<.001)
Table 1
Items From the MDS Used for Measurement of Apathy and Depression
Agitation scale (Gerritsen et al, 2008
16
) Apathy scale (Gerritsen et al, 2008
16
) MDS Depression Rating Scale (Burrows et al, 2000
15
)
Periods of restlessness (B5d)
Repetitive physical movements (E1n)
Wandering (E4aa)
Socially inappropriate/disruptive behavior (E4da)
Withdrawal from activities of interest (E1o)
Reduced social interaction (E1p)
Negative statements (E1a)
Anger (E1d)
Expression of what appear to be unrealistic fears (E1f)
Repetitive health complaints (E1b)
Repetitive anxious complaints or concerns (E1i)
Sad (E1l)
Crying (E1m)
Alpha ¼0.59e0.62 Alpha ¼0.88 e0.89*Alpha ¼0.73e0.78*
MDS, Minimum Data Set.
*Data from this study for individual assessment periods.
Table 2
Characteristics of Residents at the Initial Assessment
Characteristic Mean SD or n (%)
Age (n ¼1850) 83.6 7.4
Gender (n ¼1753)
Females 1310 (70.8)
Males 443 (29.2)
Diagnosis of dementia (n ¼1843)
Alzheimer disease (AD) only 491 (26.7)
Other dementia(s) only 581 (31.4)
Both AD and other dementia(s) 29 (1.6)
No diagnosis of dementia 742 (40.1)
Cognitive performance score (n ¼1848)
Mean 2.99 1.89
0 288 (15.5)
1 183 (9.9)
2 184 (9.9)
3 510 (27.5)
4 116 (6.3)
5 421 (22.7)
6 146 (7.9)
Time involved in activities (n ¼1822)
More than 2/3 of time 928 (50.1)
From 1/3 to 2/3 of time 495 (26.7)
Less than 1/3 of time 321 (17.3)
None 78 (5.6)
Behavioral syndromes*(n ¼1849)
Resistiveness (rejection of care) 487 (26.3)
Apathy 812 (43.9)
Agitation 1102 (59.5)
Both apathy and depression 495 (26.9)
Depression 807 (43.6)
Body Mass Index (n ¼1383)
<16.0 38 (2.1)
16.0e18.4 89 (4.8)
18.5e24.9 747 (40.4)
25.0e30.0 379 (20.5)
>30.0 130 (7.0)
*Sum total of these syndromes >100%.
L. Volicer et al. / JAMDA xxx (2013) 1e42

(Figure 2). Depression, agitation, and rejection of care did not increase
the risk of weight loss (Table 3). Time involved in activities did not
have a significant independent effect on the risk of weight loss.
To analyze further the association between apathy and weight
loss, we compared weight losses during the following 3 months in
subjects who had or did not have apathy on previous assessments
(Figure 3). This comparison showed that subjects with apathy always
lost more weight in the following 3 months than subjects without
apathy. In addition, a change in their status was either followed by
decreased weight loss in those who became nonapathetic at the next
assessment (14 patients), or increased weight loss in those who
became apathetic (71 patients, the dotted line with greater angle).
The difference in weight loss was significant in both the second (F¼
5.43, P¼.02) and third quarters (F¼6.79, P¼.009).
Discussion
Results of this study indicate that apathy is a significant factor
related to weight loss in nursing home residents. Additional inde-
pendent risk factors found in this study were more severe cognitive
impairment and low BMI. Severity of cognitive impairment is known
to be associated with weight loss in persons with AD
18,19
and possibly
also with other types of dementia.
Apathy has been recognized recently as a common psychiatric
syndrome in the elderly, with prevalence ranging from 32% to 93%.
20
It is different from depression, although apathy and depression often
coexist as happened in more than one-quarter (26.9%) of our subjects.
Some symptoms are present in both apathy and depression, but each
syndrome has specific symptoms of its own: blunted emotional
response, indifference, low social engagement, diminished initiation,
and poor persistence in apathy, and dysphoria, suicidal ideation, self-
criticism, guilt feelings, pessimism, and hopelessness in depression.
20
Apathy and depression also differ in areas of the brain where there is
a decrease in glucose metabolism in patients with early AD
21
and
they have different courses.
22
Apathy, of course, is not the only factor that may result in a weight
loss of elderly individuals. Initial interventions in residents who are
losing weight should include eliminating or limiting psychoactive
medications and other medications that may cause anorexia (eg,
antirheumatics, cardiovascular and gastrointestinal agents). Medical
causes of anorexia, such as hypothyroidism, vitamin B12 deficiency,
infections, cancer, and gastrointestinal symptoms, should be also
eliminated. These interventions may also help in reversing apathy,
and may have played role in apathy reversal, which we observed in
some of our subjects.
Apathy may be managed by both nonpharmacological (psycho-
social) and pharmacological strategies. Unfortunately, many residents
with apathy are not treated because their behavior does not disturb
other residents and staff. Psychosocial treatments require multidis-
ciplinary approaches involving aggressive treatment of coexisting
medical conditions, correction of sensory deficits, provision of
adaptive devices for improvement of mobility, and ability to exer-
cise.
20
Apathy in nursing home residents with dementia has been
reduced by activity therapy,
23
live interactive music,
24
and by addi-
tion of cognitive-communication stimulation to donepezil therapy.
25
Change from weight loss to weight gain was also observed after
introduction of continuous activity programming.
26
In our study, we
also observed relationships between time involved in activities and
weight loss, even though time involved in activities did not influence
the risk of weight loss independently.
Several drugs were studied for treatment of apathy but should be
used only if psychosocial approaches are not effective. The most
commonly used is methylphenidate, which was found to have limited
clinical effectiveness in one double-blind, randomized study
27
and in
several case reports or case series.
20
Acetylcholinesterase inhibitors
were found in several studies to decrease apathy in patients with AD
or diffuse Lewy body disease, but some other studies were negative.
Other medications used for treatment of apathy include dopami-
nergic agents, bupropion, modafinil, and seligiline.
20
Before any
pharmacological treatment is initiated, stopping psychoactive medi-
cations that may cause apathy (eg, antipsychotics) should be
considered.
It was surprising that our study did not find a significant effect of
depression on the risk for weight loss despite the current opinion that
depression is the most common cause of weight loss in nursing
homes.
28
It is possible that this misunderstanding happened because
apathy has been traditionally regarded as a symptom of depression.
29
Fig. 1. Apathy, weight loss and activity involvement in residents with different degrees
of cognitive impairment (CPS score).
Table 3
Multivariable Binary Logistic Regression of Factors Associated With Weight Loss in Nursing Home Residents
Characteristics Follow-up 1 Follow-up 2 Follow-up 3
OR 95% CI POR 95% CI POdds Ratio 95% CI P
Depression 1.015 0.969e1.072 .580 1.050 0.998e1.105 .058 1.001 0.955e1.049 .955
Apathy 1.122 1.001e1.257 .048 1.139 1.024e1.266 .015 1.138 1.035e1.256 .010
Agitation 1.036 0.917e1.169 .571 0.948 0.841e1.069 .383 1.014 0.907e1.134 .807
Resistiveness (rejection of care) 1.124 0.854e1.479 .405 1.044 0.807e1.349 .740 1.054 0.835e1.331 .658
Body mass index 0.919 0.883e0.955 <.001 0.901 0.868e0.935 <.001 0.914 0.884e0.945 <.001
Cognitive performance score 1.100 0.991e1.220 .070 1.128 1.024e1.241 .015 1.134 1.034e1.244 .007
Time in activities 1.033 0.869e1.227 .713 1.087 0.928e1.275 .302 1.101 0.947e1.281 .212
CI, confidence interval; OR, odds ratio.
Fig. 2. Apathy and weight loss in residents with different BMIs.
L. Volicer et al. / JAMDA xxx (2013) 1e43

It is important to distinguish between these two syndromes because
treatment with selective serotonin reuptake inhibitor antidepressants
may actually increase apathy.
30
In our study, 17.9% (56) of subjects
who had symptoms of apathy were treated with antidepressants only.
This study has several limitations. Our determination of pres-
ence of apathy and depression was based on limited MDS 2.0 data
and not clinical diagnosis or research testing. However, the two
items used for detection of apathy are part of the core symptoms of
apathy included in the screening questions in the Neuropsychiatric
Inventory
31
and the scale had a high degree of internal consistency.
We measured presence of symptoms of depression with a scale
using seven MDS items.
15
This scale had high specificity when
compared with psychiatric diagnosis
32
and correlated well with the
Cornell and Hamilton depression scales using “at least mild
depression”as a cutoff point. It was also more sensitive and specific
than the 15-item Geriatric Depression Scale (GDS) in detecting
depression in a nursing home population.
15
In another study, the
MDS depression scale did not correlate well with the GDS,
33
but the
GDS has limited validity in residents with dementia.
34
The MDS
depression scale had acceptable specificity
35
and it was validated in
the Netherlands.
36
Another limitation was that we had data only from approximately
3-month intervals. It is possible that the apathy or depression status
changed during the 3-month period and the initial evaluation was no
longer valid. However, in most subjects, apathy evaluation did not
change even when 3-month evaluations were compared. Another
limitation was that apathy might have been confounded by some-
thing that was not being measured, such as a high burden of co-
morbidities. Finally, it is possible that apathy may reflect some of the
actual underlying pathology related to weight loss in dementia, such
as lack of taste and odor detection, which can lead to lack of appetite.
In conclusion, our results indicate that apathy is a behavioral
syndrome that has the strongest association with weight loss in
nursing home residents. The results also suggest that apathy should
be differentiated from depression so as to provide optimal treatment.
Further studies are needed to determine if treatment of apathy will
help in preventing weight loss.
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L. Volicer et al. / JAMDA xxx (2013) 1e44