Skip to main content Accessibility help

Association between environmental stimulation and apathy in nursing home residents with dementia

  • Ying-Ling Jao (a1), Wen Liu (a2), Kristine Williams (a3), Habib Chaudhury (a4) and Jyotsana Parajuli (a1)...



Prior research and theories established the link between care environments and apathy. Yet, empirical evidence on how environmental stimulation impacts apathy is lacking. This study examined the association between environmental stimulation and apathy in nursing home residents with dementia.


This repeated-measure study analyzed 104 video observations of staff caregiver–resident interactions.


12 nursing homes.


63 unique staff caregiver–resident dyads that involved 42 caregivers and 44 residents with moderate to severe dementia.


Second-by-second behavioral coding using Noldus Observer software was conducted to assess apathy and environmental stimulation, using the Person-Environment Apathy Rating scale. The environment subscale includes six items: stimulation clarity, stimulation strength, stimulation specificity, interaction involvement, physical accessibility, and environmental feedback. The apathy subscale includes six items: facial expression, eye contact, physical engagement, purposeful activity, verbal tone, and verbal expression. Multilevel linear models were used for analysis.


Results showed that apathy was not associated with the overall quality of environmental stimulation but was significantly associated with stimulation specificity (coefficient = −2.23, p = 0.049). However, the association was not significant after controlling for resident characteristics (p = 0.082). In addition, higher levels of environmental feedback were associated with lower apathy levels (coefficient = −2.14, p = 0.001). The association remained significant after controlling for resident characteristics (coefficient = −1.65, p = 0.014).


Findings reveal that when environmental stimulation is individually tailored and prompts engagement, residents are less apathetic. This study highlights the effect of environmental stimulation on apathy. Future research should explore interventions that modify environmental stimulation to reduce apathy and improve dementia care.


Corresponding author

Correspondence should be addressed to: Ying-Ling Jao, Pennsylvania State University, College of Nursing, 307E Nursing Sciences Building, University Park, PA, 16802, USA Email:


Hide All
Bakker, C. et al. (2013). Predictors of the time to institutionalization in young-versus late-onset dementia: results from the Needs in Young Onset Dementia (NeedYD) study. Journal of the American Medical Directors Association, 14, 248253.
Brodaty, H. and Burns, K. (2012). Nonpharmacological management of apathy in dementia: a systematic review. The American Journal of Geriatric Psychiatry, 20, 549564.
Chaudhury, H., Cooke, H. A., Cowie, H. and Razaghi, L. (2017). The influence of the physical environment on residents with dementia in long-term care settings: a review of the empirical literature. The Gerontologist, 58, e325e337.
Cipriani, G., Lucetti, C., Danti, S. and Nuti, A. (2014). Apathy and dementia: nosology, assessment and management. The Journal of nervous and mental disease, 202, 718724.
Clarke, D. E. et al. 2008. Apathy in dementia: clinical and sociodemographic correlates. The Journal of Neuropsychiatry and Clinical Neurosciences, 20, 337347.
Colling, K. B. (1999). Passive behaviors in Alzheimer’s disease: a descriptive analysis. American Journal of Alzheimer’s Disease, 14, 2740.
Cummings, J. L., Mega, M., Gray, K., Rosenberg-Thompson, S., Carusi, D. A. and Gornbein, J. (1994). The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology, 44, 23082308.
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.
Hall, G. R. and Buckwalter, K. C. (1987). Progressively lowered stress threshold: a conceptual model for care of adults with Alzheimer’s disease. Archives of Psychiatric Nursing, 1, 399406.
Harrison, F., Aerts, L. and Brodaty, H. (2016). Apathy in dementia: systematic review of recent evidence on pharmacological treatments. Current Psychiatry Reports, 18, 103.
Hölttä, E. H., Laakkonen, M. L., Laurila, J. V., Strandberg, T. E., Tilvis, R. S. and Pitkälä, K. H. (2012). Apathy: prevalence, associated factors, and prognostic value among frail, older inpatients. Journal of the American Medical Directors Association, 13, 541545.
I.B.M. Corp. (2013). IBM SPSS Statistics for Windows (version 25.0). Armonk, NY: IBM.
Ishii, S., Weintraub, N. and Mervis, J. R. (2009). Apathy: a common psychiatric syndrome in the elderly. Journal of the American Medical Directors Association, 10, 381393.
Jao, Y.-L., Algase, D. L., Specht, J. K. and Williams, K. (2015). The association between characteristics of care environments and apathy in residents with dementia in long-term care facilities. The Gerontologist, 55, S27S39.
Jao, Y.-L., Algase, D. L., Specht, J. K. and Williams, K. (2016). Developing the Person–Environment Apathy Rating for persons with dementia. Aging & Mental Health, 20, 861870.
Jao, Y.-L., Loken, E., MacAndrew, M., Van Haitsma, K. and Kolanowski, A. (2018). Association between social interaction and affect in nursing home residents with dementia. Aging & Mental Health, 22, 778783.
Kaplan, S. and Kaplan, R. (1936). Cognition and Environment: Functioning in an Uncertain world. Ann Arbor, MI: Ulrich’s Bookstore.
Kolanowski, A. et al. (2017). Determinants of behavioral and psychological symptoms of dementia: a scoping review of the evidence. Nursing Outlook, 65, 515529.
Lawton, M. P. and Nahemow, L. (1973). Ecology and the aging process. In: Eisdorfer, C. and Lawton, M. P. (Eds.), Psychology of Adult Development and Aging (pp. 619674). Washington, DC: American Psychological Association.
Leone, E. et al. (2013). Management of apathy in nursing homes using a teaching program for care staff: the STIM–EHPAD study. International Journal of Geriatric Psychiatry, 28, 383392.
Levy, R. and Dubois, B. (2005). Apathy and the functional anatomy of the prefrontal cortex–basal ganglia circuits. Cerebral Cortex, 16, 916928.
Lyketsos, C. G., Steinberg, M., Tschanz, J. T., Norton, M. C., Steffens, D. C. and Breitner, J. C. (2000). Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. American Journal of Psychiatry, 157, 708714.
Marin, R. S. (1996). Apathy: concept, syndrome, neural mechanisms, and treatment. Seminars in Clinical Neuropsychiatry, 1, 304314.
Mega, M. S., Cummings, J. L., Fiorello, T. and Gornbein, J. (1996). The spectrum of behavioral changes in Alzheimer’s disease. Neurology, 46, 130135.
Mjørud, M., Kirkevold, M., Røsvik, J., Selbæk, G. and Engedal, K. (2014). Variables associated to quality of life among nursing home patients with dementia. Aging & Mental Health, 18, 10131021.
Morris, J. C. (1997). Clinical dementia rating: a reliable and valid diagnostic and staging measure for dementia of the Alzheimer type. International Psychogeriatrics, 9, 173176.
Nijsten, J. M., Leontjevas, R., Pat–El, R., Smalbrugge, M., Koopmans, R. T. and Gerritsen, D. L. (2017). Apathy: risk factor for mortality in nursing home patients. Journal of the American Geriatrics Society, 65, 21822189.
Proitsi, P. et al. 2011. A multiple indicators multiple causes (MIMIC) model of behavioural and psychological symptoms in dementia (BPSD). Neurobiology of Aging, 32, 434442.
Reisberg, B. (1988). Functional assessment staging (FAST). Psychopharmacology Bulletin, 24, 653659.
Robert, P. et al. (2009). Proposed diagnostic criteria for apathy in Alzheimer’s disease and other neuropsychiatric disorders. European Psychiatry, 24, 98104.
Saliba, D., DiFilippo, S., Edelen, M. O., Kroenke, K., Buchanan, J. and Streim, J. (2012). Testing the PHQ-9 interview and observational versions (PHQ-9 OV) for MDS 3.0. Journal of the American Medical Directors Association, 13, 618625.
Samus, Q. M. et al. (2005). The association of neuropsychiatric symptoms and environment with quality of life in assisted living residents with dementia. The Gerontologist, 45, 1926.
Sclan, S. G. and Reisberg, B. (1992). Functional assessment staging (FAST) in Alzheimer’s disease: reliability, validity, and ordinality. International Psychogeriatrics, 4, 5569.
Starkstein, S. E., Ingram, L., Garau, M. L. and Mizrahi, R. (2005). On the overlap between apathy and depression in dementia. Journal of Neurology, Neurosurgery & Psychiatry, 76, 10701074.
Starkstein, S. E., Jorge, R. and Mizrahi, R. (2006). The prevalence, clinical correlates and treatment of apathy in Alzheimer’s disease. The European Journal of Psychiatry, 20, 96106.
van Reekum, R., Stuss, D. T. and Ostrander, L. (2005). Apathy: why care? The Journal of Neuropsychiatry and Clinical Neurosciences, 17, 719.
Vilalta-Franch, J., Calvó-Perxas, L., Garre-Olmo, J., Turró-Garriga, O. and López-Pousa, S. (2013). Apathy syndrome in Alzheimer’s disease epidemiology: prevalence, incidence, persistence, and risk and mortality factors. Journal of Alzheimer’s Disease, 33, 535543.
Wahl, H. W. and Lang, F. R. (2003). Aging in context across the adult life course: integrating physical and social environmental research perspectives. Annual Review of Gerontology and Geriatrics, 23, 133.
Weisman, G. D. (2001). Theory and Practice of Place: Toward an Integrative Model. The Many Dimensions of Aging. New York, NY: Springer Publishing.
Williams, K. N., Ilten, T. B. and Bower, H. (2005). Meeting communication needs: topics of talk in the nursing home. Journal of Psychosocial Nursing and Mental Health Services, 43, 3845.
Williams, K. N., Perkhounkova, Y., Herman, R. and Bossen, A. (2016). A communication intervention to reduce resistiveness in dementia care: a cluster randomized controlled trial. The Gerontologist, 57, 707718.
Wood, S. et al. (2000). The use of the neuropsychiatric inventory in nursing home residents: characterization and measurement. The American Journal of Geriatric Psychiatry, 8, 7583.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed