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Apathy and cognitive and functional decline in community-dwelling older adults: results from the Baltimore ECA longitudinal study

  • Diana E. Clarke (a1) (a2), Jean Y. Ko (a1), Constantine Lyketsos (a3), George W. Rebok (a1) and William W. Eaton (a1)...


Background: Apathy, a complex neuropsychiatric syndrome, commonly affects patients with Alzheimer's disease. Prevalence estimates for apathy range widely and are based on cross-sectional data and/or clinic samples. This study examines the relationships between apathy and cognitive and functional declines in non-depressed community-based older adults.

Methods: Data on 1,136 community-dwelling adults aged 50 years and older from the Baltimore Epidemiologic Catchment Area (ECA) study, with 1 and 13 years of follow-up, were used. Apathy was assessed with a subscale of items from the General Health Questionnaire. Logistic regression, t-tests, χ2 and Generalized Estimating Equations were used to accomplish the study's objectives.

Results: The prevalence of apathy at Wave 1 was 23.7%. Compared to those without, individuals with apathy were on average older, more likely to be female, and have lower Mini-mental State Examination (MMSE) scores and impairments in basic and instrumental functioning at baseline. Apathy was significantly associated with cognitive decline (OR = 1.65, 95% CI = 1.06, 2.60) and declines in instrumental (OR = 4.42; 95% CI = 2.65, 7.38) and basic (OR = 2.74; 95%CI = 1.35, 5.57) function at 1-year follow-up, even after adjustment for baseline age, level of education, race, and depression at follow-up. At 13 years of follow-up, apathetic individuals were not at greater risk for cognitive decline but were twice as likely to have functional decline. Incidence of apathy at 1-year follow up and 13-year follow-up was 22.6% and 29.4%, respectively.

Conclusions: These results underline the public health importance of apathy and the need for further population-based studies in this area.


Corresponding author

Correspondence should be addressed to: Dr. Diana E. Clarke, 624 N. Broadway Street, 8th floor, Baltimore, MD 21205, U.S.A. Phone: +1 (410) 955-0416; Fax: +1 (410) 955-9088. Email:


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American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders (DSM III). Washington, DC: American Psychiatric Association.
American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (DSM III-R). Washington, DC: American Psychiatric Association.
Clarke, D. E., van Reekum, R., Simard, M., Streiner, D. L., Freedman, M. and Conn, D. (2007). Apathy in dementia: an examination of the psychometric properties of the Apathy Evaluation Scale. Journal of Neuropsychiatry and Clinical Neurosciences, 19, 5764.
Clarke, D. E. et al. (2008). Apathy in dementia: clinical and sociodemographic correlates. Journal of Neuropsychiatry and Clinical Neurosciences, 20, 337347.
Eaton, W. W. et al. (1997). Natural history of Diagnostic Interview Schedule/DSM-IV major depression: the Baltimore Epidemiologic Catchment Area follow-up. Archives of General Psychiatry, 54, 993999.
Fogel, J., Eaton, W. W. and Ford, D. E. (2006). Minor depression as a predictor of the first onset of major depressive disorder over a 15-year follow-up. Acta Psychiatrica Scandinavica, 113, 3643.
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189198.
Freels, S. et al. (1992). Functional status and clinical findings in patients with Alzheimer's disease. Journal of Gerontology, 47, M177M182.
Goldberg, D. (1978). Manual of the General Health Questionnaire. Windsor, U.K.: NFER Publishing Company.
Kukull, W. A., Larson, E. B., Teri, L., Bowen, J., McCormick, W. and Pfanschmidt, M. L. (1994). The Mini-mental State Examination score and the clinical diagnosis of dementia. Journal of Clinical Epidemiology, 47, 10611067.
Landes, A. M., Sperry, S. D. and Strauss, M. E. (2005). Prevalence of apathy, dysphoria, and depression in relation to dementia severity in Alzheimer's disease. Journal of Neuropsychiatry and Clinical Neurosciences, 17, 342349.
Lavretsky, H., Lesser, I. M., Wohl, M., Miller, B. L. and Mehringer, C. M. (1999). Clinical and neuroradiologic features associated with chronicity in late-life depression. American Journal of Geriatric Psychiatry, 7, 309316.
Lechowski, L. et al. (2009). Persistent apathy in Alzheimer's disease as an independent factor of rapid functional decline: the REAL longitudinal cohort study. International Journal of Geriatric Psychiatry, 24, 341346.
Lyketsos, C. G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J. and DeKosky, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. JAMA, 288, 14751483.
Marin, R. S. (1991). Apathy: a neuropsychiatric syndrome. Journal of Neuropsychiatry and Clinical Neuroscience, 3, 243254.
Marin, R. S., Biedrzycki, R. C. and Firinciogullari, S. (1991). Reliability and validity of the Apathy Evaluation Scale. Psychiatry Research, 38, 143162.
Miech, R. A., Breitner, J. C. S., Zandi, P. P., Khachaturian, A. S., Anthony, J. C. and Mayer, L. (2002). Incidence of AD may decline in the early 90s for men, later for women: the Cache County Study. Neurology, 58, 209218.
Mielke, M. M. et al. (2007). Vascular factors predict rate of progression in Alzheimer disease. Neurology, 69, 18501858.
Muthén, L. K. and Muthén, B. O. (2000). MPlus User's Guide, 5th edition. Los Angeles, CA: Muthén and Muthén.
Onyike, C. U. et al. (2007). Epidemiology of apathy in older adults: the Cache County Study. American Journal of Geriatric Psychiatry, 15, 365375.
Robert, P. H. et al. (2006). Apathy in patients with mild cognitive impairment and the risk of developing dementia of Alzheimer's disease: a one-year follow-up study. Clinical Neurology and Neurosurgery, 108, 733736.
Schützwohl, M., Kallert, T. and Jurjanz, L. (2007). Using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.1) as a diagnostic interview providing dimensional measures: cross-national findings on the psychometric properties of psychopathology scales. European Psychiatry, 22, 229238.
Silverstein, M. et al. (2006). Cerebrovascular reactivity and cognitive decline in patients with Alzheimer disease. Stroke, 37, 10101015.
Starkstein, S. E., Petracca, G., Chemeerinksi, E. and Kremer, J. (2001). Syndromic validity of apathy in Alzheimer's disease. American Journal of Psychiatry, 158, 872877.
Starkstein, S. E., Jorge, R., Mizrahi, R. and Robinson, R. G. (2006). A prospective longitudinal study of apathy in Alzheimer's disease. Journal of Neurology, Neurosurgery, and Psychiatry, 77, 811.
Thomas, P., Clément, J. P., Hazif-Thomas, C. and Leger, J. M. (2001). Family, Alzheimer's disease, and negative symptoms.International Journal of Geriatric Psychiatry, 16, 192202.
Turró-Garriga, O. et al. (2009). A longitudinal study of apathy in patients with Alzheimer's disease. Revista de Neurologia, 48, 713.
van Reekum, R., Stuss, D. T. and Ostrander, L. (2005). Apathy: why care? Journal of Neuropsychiatry and Clinical Neuroscience, 17, 719.
World Health Organization (1994). Schedules for Clinical Assessment in Neuropsychiatry: Version 2. 1993–1994. Geneva: American Psychiatric Press.



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