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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.
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Original Study
Apathy and Weight Loss in Nursing Home Residents: Longitudinal Study
Ladislav Volicer MD, PhD
*, Dinnus H.M. Frijters PhD
, Jenny T. van der Steen PhD
School of Aging Studies, University of South Florida, Tampa, FL, and Charles University 3rd Medical Faculty, Prague, Czech Republic
EMGO Institute for Health and Care Research, Department of Nursing Home Medicine, VU University Medical Center, Amsterdam, The Netherlands
weight loss
nutritional status
nursing homes
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 rst 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
Copyright Ó2013 - American Medical Directors Association, Inc.
Many nursing home residents experience undesirable weight
Weight loss in elderly individuals may lead to increased
increased risk of hip fracture,
pressure ulcers, infections,
anemia, muscle weakness, fatigue, and edema.
Weight loss also
predicts rapid cognitive decline in community-dwelling persons with
Alzheimer disease (AD).
Many factors may cause weight loss, including anorexia, malab-
sorption, hypermetabolism, dehydration sarcopenia, and depression.
Presence of dementia is also a major risk factor for weight loss.
of the causes of weight loss in persons with dementia may be
behavioral symptoms of dementia. A higher Cohen-Manseld Agita-
tion Inventory score was found to be 1 of the 3 factors independently
associated with weight loss in patients with AD
; however, this scale
does not differentiate which specic behavioral symptoms may be
related to weight loss. We therefore performed a longitudinal study,
investigating the relationship of specic behavioral symptoms to
weight loss in nursing home residents.
We selected four syndromes: depression, apathy, agitation, and
rejection of care (resistance), which may inuence weight in nursing
home residents. Depression is considered the most common cause of
anorexia and weight loss in nursing home residents.
Apathy was found
to be associated with more pronounced decits in nutritional status in
686 outpatients with AD.
Agitation may interfere with eating and also
may increase energy expenditure, especially if it includes pacing.
Rejection of care may interfere with feeding of individuals who have
difculty eating independently. The agitation/aggression subscale of
Neuropsychiatric Inventory, which actually measures rejectionof care,
was found to be related to weight loss in a 6-month study.
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.
The MDS assessment is based on
The authors do not have any conict of interest regarding this study.
* Address correspondence to Ladislav Volicer, MD, PhD, 2337 Dekan Lane, Land
OLakes, FL 34639.
E-mail address: (L. Volicer).
journal homepage:
1525-8610/$ - see front matter Copyright Ó2013 - American Medical Directors Association, Inc.
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
and scales for other behavioral syndromes
(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,
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).
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 rst 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 nd which baseline variables
were signicantly 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 dened 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).
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
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 signicant
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
) Apathy scale (Gerritsen et al, 2008
) MDS Depression Rating Scale (Burrows et al, 2000
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 signicant 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 signicant in both the second (F¼
5.43, P¼.02) and third quarters (F¼6.79, P¼.009).
Results of this study indicate that apathy is a signicant 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
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%.
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 specic 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.
Apathy and depression also differ in areas of the brain where there is
a decrease in glucose metabolism in patients with early AD
they have different courses.
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 deciency,
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 decits, provision of
adaptive devices for improvement of mobility, and ability to exer-
Apathy in nursing home residents with dementia has been
reduced by activity therapy,
live interactive music,
and by addi-
tion of cognitive-communication stimulation to donepezil therapy.
Change from weight loss to weight gain was also observed after
introduction of continuous activity programming.
In our study, we
also observed relationships between time involved in activities and
weight loss, even though time involved in activities did not inuence
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
and in
several case reports or case series.
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, modanil, and seligiline.
Before any
pharmacological treatment is initiated, stopping psychoactive medi-
cations that may cause apathy (eg, antipsychotics) should be
It was surprising that our study did not nd a signicant 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
It is possible that this misunderstanding happened because
apathy has been traditionally regarded as a symptom of depression.
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, condence 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.
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
and the scale had a high degree of internal consistency.
We measured presence of symptoms of depression with a scale
using seven MDS items.
This scale had high specicity when
compared with psychiatric diagnosis
and correlated well with the
Cornell and Hamilton depression scales using at least mild
depressionas a cutoff point. It was also more sensitive and specic
than the 15-item Geriatric Depression Scale (GDS) in detecting
depression in a nursing home population.
In another study, the
MDS depression scale did not correlate well with the GDS,
but the
GDS has limited validity in residents with dementia.
depression scale had acceptable specicity
and it was validated in
the Netherlands.
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 reect 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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Fig. 3. Relationship between presence or absence of apathy at each baseline and
weight changes at the follow-up assessments (number of subjects in each nal group
in parentheses, data from the fourth quarter are not shown because the numbers of
subjects in some cells were very small). For further explanation see text.
L. Volicer et al. / JAMDA xxx (2013) 1e44
... They also found GDS score became MCR-independent after removing the 3-item subscale of apathy in GDS [25]. A prospective study showed that apathy rather than depression was most strongly related to subsequent weight loss in AD patients [50]. Several common underlying risk factors may explain the serial relationships. ...
Full-text available
Background Sarcopenia has been identified as a risk factor for cognitive impairment, and motoric cognitive risk syndrome (MCR) is a recently defined pre-dementia syndrome. It is not known whether they are related. We aimed to investigate the association and potential pathways between sarcopenia and MCR in the community elderly by establishing a moderated mediation model. Methods 846 community residents aged ≥ 60 years were recruited from May 2021 to September 2021 and had a comprehensive geriatric evaluation. The diagnosis of sarcopenia followed the criteria issued by the Asian Working Group for Sarcopenia in 2019. MCR was defined as subjective cognitive decline and slow gait. Apathy symptoms and physical activity were assessed by the Apathy Evaluation Scale (AES) and the International Physical Activity Questionnaire (IPAQ). Logistic regression and moderated mediation analyses were conducted to explore the association between the four. Results 60 (7.1%) had MCR among 846 participants. After full adjustment, sarcopenia (odds ratio [OR] = 3.81, 95% confidence interval [CI] = 1.69–8.60, P = 0.001), AES score (OR = 1.09, 95% CI = 1.04–1.14, P < 0.001), and IPAQ level (OR = 0.43, 95% CI = 0.28–0.66, P < 0.001) were associated with MCR. Apathy partially mediated the relationship between sarcopenia and MCR. Physical activity played a moderation role in the indirect pathway of the mediation model. The increase in physical activity can alleviate the indirect effect of sarcopenia on MCR. Conclusion We established a moderated mediation model to uncover the underlying association mechanism of sarcopenia and MCR preliminarily. These findings suggest that attention should be paid to the management of apathy and physical activity in the context of sarcopenia to prevent early dementia actively. Further validation is needed in future longitudinal studies.
... had a 1.86 times higher chance of incident malnutrition (Fig. 2) which seems reasonable, as residents with a BMI close to the cut-off of 20 kg/m 2 at baseline may be more likely to develop malnutrition according to our definition than those with a higher BMI. Previous studies also reported this association, although they did not exclude residents with malnutrition at baseline [15,35]. ...
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Background/Objectives Malnutrition (MN) in nursing home (NH) residents is associated with poor outcome. In order to identify those with a high risk of incident MN, the knowledge of predictors is crucial. Therefore, we investigated predictors of incident MN in older NH-residents. Subjects/Methods NH-residents participating in the nutritionDay-project (nD) between 2007 and 2018, aged ≥65 years, with complete data on nutritional status at nD and after 6 months and without MN at nD. The association of 17 variables (general characteristics (n = 3), function (n = 4), nutrition (n = 1), diseases (n = 5) and medication (n = 4)) with incident MN (weight loss ≥ 10% between nD and follow-up (FU) or BMI (kg/m2) < 20 at FU) was analyzed in univariate generalized estimated equation (GEE) models. Significant (p < 0.1) variables were selected for multivariate GEE-analyses. Effect estimates are presented as odds ratios and their respective 99.5%-confidence intervals. Results Of 11,923 non-malnourished residents, 10.5% developed MN at FU. No intake at lunch (OR 2.79 [1.56–4.98]), a quarter (2.15 [1.56–2.97]) or half of the meal eaten (1.72 [1.40–2.11]) (vs. three-quarter to complete intake), the lowest BMI-quartile (20.0–23.0) (1.86 [1.44–2.40]) (vs. highest (≥29.1)), being between the ages of 85 and 94 years (1.46 [1.05; 2.03]) (vs. the youngest age-group 65–74 years)), severe cognitive impairment (1.38 [1.04; 1.84]) (vs. none) and being immobile (1.28 [1.00–1.62]) (vs. mobile) predicted incident MN in the final model. Conclusion 10.5% of non-malnourished NH-residents develop MN within 6 months. Attention should be paid to high-risk groups, namely residents with poor meal intake, low BMI, severe cognitive impairment, immobility, and older age.
... In our study, we found that body weight decrease was significantly associated with decreased food intake, more prominently during the active phase (night), in accordance with previous studies in the same mouse model of AD [45]. It has also been reported that behavioral factors such as anhedonia and depression in AD patients are correlated to decreased food intake and weight loss [51]. Poor food intake may lead to malnutrition in 5xFAD mice. ...
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Increasing evidence links metabolic disorders with neurodegenerative processes including Alzheimer’s disease (AD). Late AD is associated with amyloid (Aβ) plaque accumulation, neuroinflammation, and central insulin resistance. Here, a humanized AD model, the 5xFAD mouse model, was used to further explore food intake, energy expenditure, neuroinflammation, and neuroendocrine signaling in the hypothalamus. Experiments were performed on 6-month-old male and female full transgenic (Tg5xFAD/5xFAD), heterozygous (Tg5xFAD/-), and non-transgenic (Non-Tg) littermates. Although histological analysis showed absence of Aβ plaques in the hypothalamus of 5xFAD mice, this brain region displayed increased protein levels of GFAP and IBA1 in both Tg5xFAD/- and Tg5xFAD/5xFAD mice and increased expression of IL-1β in Tg5xFAD/5xFAD mice, suggesting neuroinflammation. This condition was accompanied by decreased body weight, food intake, and energy expenditure in both Tg5xFAD/- and Tg5xFAD/5xFAD mice. Negative energy balance was associated with altered circulating levels of insulin, GLP-1, GIP, ghrelin, and resistin; decreased insulin and leptin hypothalamic signaling; dysregulation in main metabolic sensors (phosphorylated IRS1, STAT5, AMPK, mTOR, ERK2); and neuropeptides controlling energy balance (NPY, AgRP, orexin, MCH). These results suggest that glial activation and metabolic dysfunctions in the hypothalamus of a mouse model of AD likely result in negative energy balance, which may contribute to AD pathogenesis development.
... Given this evidence, it is tempting to speculate that a higher body mass index (BMI) should be one of the manifestations of apathy, given its association with exercise. However, apathy has been associated with lower BMI and weight loss in patients with pre-existing neurological diseases (Rodríguez-Violante et al., 2014;Sobów et al., 2014;Volicer et al., 2013). Apathy in outpatients with Alzheimer's disease has actually been associated with nutritive deficits (Benoit et al., 2008), suggesting that apathetic patients may be less inclined to eat. ...
Apathy is a reduction in motivated goal-directed behavior (GDB) that is prevalent in cerebrovascular disease, providing an important opportunity to study the mechanistic underpinnings of motivation in humans. Focal lesions, such as those seen in stroke, have been crucial in developing models of brain regions underlying motivated behavior, while studies of cerebral small vessel disease (SVD) have helped define the connections between brain regions supporting such behavior. However, current lesion-based models cannot fully explain the neurobiology of apathy in stroke and SVD. To address this, we propose a network-based model which conceptualizes apathy as the result of damage to GDB-related networks. A review of the current evidence suggests that cerebrovascular disease-related pathology can lead to network changes outside of initially damaged territories, which may propagate to regions that share structural or functional connections. The presentation and longitudinal trajectory of apathy in stroke and SVD may be the result of these network changes. Distinct subnetworks might support cognitive components of GDB, the disruption of which results in specific symptoms of apathy. This network-based model of apathy may open new approaches for investigating its underlying neurobiology, and presents novel opportunities for its diagnosis and treatment.
... On the other hand, it is easy to imagine that some BPSD, such as apathy, leads to loss of appetite and inactivity, resulting in weight loss and nutritional problems in AD patients. Actually, some studies reported that apathy was a risk factor for weight loss in AD patients [39,46]. Although a causal relationship has not been elucidated, structural and functional changes in the brain have been suggested as the common underlying mechanism of a significant link between BPSD and nutritional problems. ...
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We examined the nutritional status and its association with behavioral psychiatric symptoms of dementia (BPSD) among 741 memory clinic patients (normal cognition (NC), 152; mild cognitive impairment (MCI), 271; early-stage Alzheimer disease (AD), 318). Nutritional status and BPSD were assessed using the Mini Nutritional Assessment Short-Form (MNA-SF) and the Dementia Behavior Disturbance Scale (DBD), respectively. Compared to subjects with NC, more subjects with MCI and early-stage AD were at risk of malnutrition (MNA-SF, 8–11: NC, 34.2%; MCI, 47.5%; early-stage AD, 53.8%) and were malnourished (MNA-SF, 0–7: NC, 4.6%; MCI, 5.9%; early-stage AD, 8.2%). Among patients with MCI or early-stage AD, those at risk of/with malnutrition showed higher DBD scores than those well-nourished (12.7 ± 9.0 vs. 9.5 ± 7.3; p < 0.001). Moreover, analysis of covariance adjusting for confounders showed that nutritional status was significantly associated with specific BPSD, including “verbal aggressiveness/emotional disinhibition” (F = 5.87, p = 0.016) and “apathy/memory impairment” (F = 15.38, p < 0.001), which were revealed by factor analysis of DBD. Our results suggest that malnutrition is common among older adults with mild cognitive decline, and possibility that nutritional problems are associated with individual BPSD.
... Bakımevinde kalan bireylerle yapılan bir çalışmada, kilo kaybına neden olan önemli faktörlerden birinin de apati olduğu bulunmuştur. 47 Apati ayrıca tedaviyi uyumu da etkilemektedir. Apatili hastaların tedaviye daha fazla uyumsuz olduğu belirtilmektedir. ...
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Apathy is one of the most common behavioral changes in elderly patients with neuropsychiatric disorders. Apathy is especially common among dementia patients. Researchs in recent years shows that apathy in Alzheimer's disease is associated with aging, more severe cognitive deficits, depression, and declines in Daily life activities. Individuals needs help to continue their daily living activities and can be dependent on someone else because of apathy. In addition, the physical and psychological changes caused by apathy make it difficult to adapt to the individual's drug treatment. It is also being adversely affected by both the individual and the caregiver's quality of life and caregiver burden is also increasing. For this reason, it is very important to adopt a multidisciplinary team approach in the management of apathy. Nurses have important responsibilities in this team. Proper identification of signs and symptoms of apathy that can be confused with depression by nurses and other health professionals, and planning appropriate interventions in this direction will help to reduce negative consequences and help early treatment of apathy. The effectiveness of nursing management is important for determination of factors affecting apathy frequency/severity, selection of appropriate pharmacological and non-pharmacological treatment, raising the quality of life of both the individual and the caregiver. In this review article, it was aimed to guide nurses and other health professionals by discussing apathine definition, prevalence, risk factors, diagnostic criteria, negative results, treatment options and nursing management.
... Since persons who are apathetic do not represent any problems for their care providers, apathy is often not recognized and treated. Untreated apathy decreases the quality of life for persons with dementia [16] and may cause weight loss [17]. The severity of apathy increases with the severity of dementia and apathy is present in up to 92% of persons with advanced dementia [18]. ...
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Background: Persons with advanced dementia cannot initiate activities because of the executive dysfunction. The lack of activities was identified as one of the most important factors contributing to behavioral problems of these persons. The unmet needs were boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activities. There is a need for activities designed specifically for residents with advanced dementia. Objective: A description of patient's needs and of programs that intend to maintain quality of life for people with dementia and facing death. Data sources: A literature review of programs used for persons with advanced dementia and residing in long-term facilities, using the PubMed data base and collateral sources. Results: Since palliative care is appropriate for persons with advanced dementia, attention has to be paid to three following important aspects of care: Medical issues, behavioral symptoms, and meaningful activities. Medical interventions should be limited to those which have more benefits than burdens, behavioral symptoms should be distinguished according to the context in which they occur, and treated by non-pharmacological interventions that involve meaningful activities. This review describes four programs that may promote the quality of life in persons with advanced dementia and facing death. They are designed for persons with advanced dementia, taking into account their functional impairments. Most of these programs involve short infrequent sessions. In contrast, Namaste Care is a daily extended program of enhanced nursing care that can provide quality of life until the last breath. Conclusions: It is possible to maintain quality life for people with advanced dementia if a special program of activities is available.
Late-life depression (LLD) is a particularly debilitating illness. Older adults suffering from depression commonly experience poor outcomes in response to antidepressant treatments, medical comorbidities, and declines in daily functioning. This review aims to further our understanding of the brain network dysfunctions underlying LLD that contribute to disrupted cognitive and affective processes and corresponding clinical manifestations. We provide an overview of a network model of LLD that integrates the salience network, the default mode network (DMN) and the executive control network (ECN). We discuss the brain-based structural and functional mechanisms of LLD with an emphasis on their link to clinical subtypes that often fail to respond to available treatments. Understanding the brain networks that underlie these disrupted processes can inform the development of targeted interventions for LLD. We propose behavioral, cognitive, or computational approaches to identifying novel, personalized interventions that may more effectively target the key cognitive and affective symptoms of LLD.
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Aim: Establishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes. Design: Cross-sectional, observational study among patients aged 18-≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes. Methods: According to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory-Nursing Home version, the Cohen-Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini-Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020. Discussion: Little is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS. Impact: Patients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long-term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients.
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If depression is associated with apathy, then they should be expressed together in different dementia syndromes and should co-occur at varying levels of disease severity. The authors performed a cross-sectional comparison of neuropsychiatric symptoms in 30 Alzheimer's disease, 28 frontotemporal dementia, 40 Parkinson's disease, 34 Huntington's disease, and 22 progressive supra-nuclear palsy patients, using a standardized rating scale (the Neuropsychiatric Inventory). Apathy did not correlate with depression in the combined sample; apathy (r‫ס‬ –0.40, PϽ0.0001), but not depression, correlated with lower cogni-tive function as measured by the Mini-Mental State Examination. The relationship of apathy to depression also varied across diagnostic groups. Apathy is a specific neuropsychiatric syndrome that is distinct from depression. Distinguishing these two syndromes has therapeutic implications.
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Background. Involuntary weight loss resulting from malnutrition is a major problem among residents in long-term care facilities. Although body weight is easily measured, the evaluation of unintended weight loss in long-term care facilities is difficult. Methods. The Council for Nutritional Clinical Strategies in Long-Term Care, an expert panel of interdisciplinary thought leaders representing academia and the medical community, derived a structured approach aimed at improving management of malnutrition in long-term care settings, using literature review and consensus development. The Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care is based on a best-evidence approach to the management of nutritional problems in long-term care. Results. The Clinical Guide is divided into two parts, one designed for nursing staff, dietary staff, and dietitians, and a second directed to physicians, pharmacists, and dietitians. Conclusions. A structured approach to the management of unintended weight loss or malnutrition in long-term care is intended to ensure a comprehensive resident evaluation. While the Clinical Guide is presented in a linear fashion, many of the considerations can be done simultaneously and the order varied dependent on the individual resident's needs. Further research to validate the effectiveness of using the algorithm in long-term care settings will be required.
Objective: this research examined the psychometric properties of the Minimum Data Set Depression Rating Scale for use among older adults living in nursing homes. Methods: interviews with 145 older adults in three nursing homes were conducted to complete the Hamilton Depression Rating Scale and the Geriatric Depression Scale. Information relevant to completing the Minimum Data Set Depression Rating Scale was gathered from the Minimum Data Set. Results: the Minimum Data Set Depression Rating Scale did not perform well when validated against the Hamilton Depression Rating Scale and the Geriatric Depression Scale. Minimum Data Set Depression Rating Scale cut‐off levels of ≥2 and ≥3 were associated with relatively low total score correlations and sensitivity rates, but acceptable specificity. Conclusions: findings suggest that the Minimum Data Set Depression Rating Scale may be of limited clinical value to identify depression among older adults living in nursing homes.
Objectives: To test the hypothesis that unintentional weight loss increases the rate of bone loss and risk of hip fracture more than intentional weight loss. Design: Prospective cohort study. Setting: Four communities within the United States. Participants: Six thousand seven hundred eighty-five elderly white women with measurement of weight change and assessment of intention to lose weight. Measurements: Weight change between baseline and fourth examinations (average 5.7 years between examinations) and assessment of intention to lose weight. Weight loss was defined as a decrease of 5% or more from baseline weight, stable weight was defined as less than a 5% change from baseline weight, and weight gain was defined as an increase of 5% or more from baseline weight. Rate of change in bone mineral density at the hip between fourth and sixth examinations (average 4.4 years between examinations) was measured using dual-energy x-ray absorptiometry. Incident hip fractures occurring after the fourth examination until June 1, 2001 (average follow-up 6.6 years) was confirmed using radiographic reports. Results: The adjusted average rate of decline in total hipbone density steadily increased from −0.52% per year in women with weight gain to −0.68% per year in women with stable weight to −0.92% per year in women with weight loss (P-value for trend <.001). Higher rates of hip-bone loss were observed in women with weight loss irrespective of body mass index (BMI) or intention to lose weight. During follow-up of an average 6.6 years after the fourth examination, 400 (6%) of the cohort suffered a first hip fracture. Women with weight loss had 1.8 times the risk (95% confidence interval (CI)=1.43–2.24) of subsequent hip fracture as those with stable or increasing weight. The association between weight loss and increased risk of hip fracture was consistent across categories of BMI and intention to lose weight. Even voluntary weight loss in overweight women with a BMI of 25.9 kg/m2 (median) or greater increased the risk of hip fracture (multivariate hazard ratio=2.48, 95% CI=1.33–4.62). Conclusion: Older women who experience weight loss in later years have increased rates of hip-bone loss and a two-fold greater risk of subsequent hip fracture, irrespective of current weight or intention to lose weight. These findings indicate that even voluntary weight loss in overweight elderly women increases hip fracture risk.
Weight loss is a frequent complication of Alzheimer's disease (AD) and a strong predictor of adverse outcomes in patients suffering from this disease. The aim of this study was to determine whether weight loss was a predictor of rapid cognitive decline (RCD) in AD. Four hundred fourteen community-dwelling ambulatory patients with a diagnosis of probable AD and a Mini-Mental State Examination (MMSE) score between 10 and 26 from the REAL.FR (REseau sur la maladie d'ALzheimer FRançais) cohort were studied and followed up during 4 years. Patients were classified in 2 groups according to weight loss defined by a loss of 4% or more during the first year of follow-up. RCD was defined as the loss of 3 points or more in MMSE over 6 months. The incidence of RCD was determined among both groups over the last 3 years of follow-up. MMSE, Katz's Activity of Daily Living scale, Mini-Nutritional Assessment scale, co-morbidities, behavioral and psychological symptoms of dementia, medication, level of education, living arrangement, and caregiver's burden were assessed every 6 months. Eighty-seven patients (21.0%) lost 4% or more of their initial weight during the first year. The incidence of RCD for all patients was 57.6 (95% confidence interval (CI) = 51.6-64.8) per 100 person-year (median follow-up of 15.1 months). In Cox proportional hazards models, after controlling for potential confounders, weight loss was a significant predictor factor of RCD (adjusted hazard ratio (HR) = 1.50, 95% CI = 1.04-2.17). In conclusion, weight loss predicted RCD in this cohort. Whether the prevention of weight loss (by improving nutritional status) impacts cognitive decline remains an open question.
This represents the fifth article in the series on yearly updates of hot topics in long term care.