60 year old male presents with a year history of forgetfulness and reduced motivation. On examination, the patient has reduced verbal and non-verbal expression, otherwise, his neurological examination is normal. Neuropsychological assessment shows preserved cognition. There was no other behavioural or mood disorder.
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This FDG PET study shows mild reduced uptake in the medial frontostriatum bilaterally.
Apathy is common, but an under-recognised, neuropsychiatric syndrome consisting of multiple components: reduced initiative, interest and emotional responsiveness1. Clinically, these symptoms overlap with melancholic depression, negative symptoms of schizophrenia, Parkinson's disease, akinetic disorders and catatonia2. The use of rating scales can be useful for determining the presence of apathy as it is prone to misdiagnosis3. For example, in the demonstrated case, 'forgetfulness' is elaborated as reduced interest in sustaining a task (e.g. making a cup of tea), as oppose to an amnesia.
Functional and structural imaging of apathy frequently show abnormalities in the anterior cingulate area4,5. This area is conceived to be a fundamental component of reward-motivation behaviour. Other frontostriatal abnormalities commonly co-exist in apathy. Both anterior cingulate and frontostriatal abnormalities are demonstrated in this PET study, while his MRI brain is unremarkable (MRI not demonstrated in here).
Apathy is a robust clinical correlate of various neurodegenerative disorders and poses a significant emotional burden on the caregiver. The sedentary nature of apathy may lead to self-neglect, malnutrition, venous thrombosis and pressure wound in the patient. Furthermore, apathy can be a prodrome to neurodegenerative diseases such as behavioural variant frontotemporal dementia, corticobasal degeneration and Parkinson's-plus disorders. However, these features are not present in this case, and a sole diagnosis of apathy is made for his mild behavioural impairment.
- 1. Stanton BR, Carson A Apathy: a practical guide for neurologists Practical Neurology 2016;16:42-47.
- 2. Starkstein SE, Leentjens AFG The nosological position of apathy in clinical practice Journal of Neurology, Neurosurgery & Psychiatry 2008;79:1088-1092.
- 3. Starkstein SE, Mayberg HS, Preziosi TJ, Andrezejewski P, Leiguarda R, Robinson RG. Reliability, validity, and clinical correlates of apathy in Parkinson's disease. J Neuropsychiatry Clin Neurosci. 1992 Spring;4(2):134-9.
- 4. Pagonabarraga, Javier et al. Apathy in Parkinson's disease: clinical features, neural substrates, diagnosis, and treatment. The Lancet Neurology , Volume 14 , Issue 5 , 518 - 531
- 5. Starkstein, S. (2014). Imaging apathy in Alzheimer's disease. International Psychogeriatrics, 26(2), 193-193. doi:10.1017/S1041610213002214