APATHY DIAGNOSTIC CRITERIA – 2018
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Apathy is a very common behavioural and psychological symptom across brain disorders. In the last decade, there have been considerable advances in research on apathy and motivation. It is thus important to revise the apathy diagnostic criteria published in 2009. The main objectives were to: a) revise the definition of apathy; b) update the list of apathy dimensions; c) operationalise the diagnosis criteria; and d) suggest adapted assessment tools including new technologies.
Apathy was defined as a quantitative reduction of goal-directed activity in comparison to the patient’s previous level of functioning (criterion A). Symptoms must persist for at least four weeks, and affect at least two of the three apathy dimensions (behaviour/cognition; emotion; social interaction; criterion B).
This update was made thanks to the collaboration of a group of international experts who published the article related in the Journal European Psychiatry
http://www.innovation-alzheimer.fr/wp-content/uploads/2018/09/European-Psychiatry-Apathy-2018.pdf
Diagnostic criteria are available in English and French
http://www.innovation-alzheimer.fr/wp-content/uploads/2018/09/CRITERIA-APPENDIX.pdf
This document aims to recall the main clinical principles to best use the criteria.
As with any evaluation in current practice, it is important to use the maximum of elements on the behaviour and emotions of the patient. For this, several sources of information are available. Ideally it is the use of all these sources that allows the best diagnosis but it is not always possible to have access to all this information. Here are some rules:
- ALWAYS USE THE SYMPTOMS OBSERVED DURING THE INTERVIEW (answers to questions, spontaneous expression, attitude and involvement in the relationship, patient’s subjective point of view, scores on behavioural evaluation scales). It is these elements that, in the absence of other information, will make it possible to complete the diagnostic criteria for apathy.
- ALWAYS TAKE INTO ACCOUNT THE STORY OF THE SUBJECT and his usual social relations, his usual personality, information given by the accompanying person (when he is present),
- WHEN A FAMILY OR PROFESSIONAL CAREGIVER IS PRESENT information on daily life or behavioural disorders that can be collected either spontaneously or using an interview as the Neuropsychiatric Inventory (NPI) or Mild Behavioural Impairment (MBI) are a good complement
- WHEN A COGNITIVE / BEHAVIOURAL ASSESSMENT IS PERFORMED it is also important to observe or have information about the patient’s involvement during the tests.
- OBSERVATIONS OF THE PATIENT IN OTHER SITUATIONS (use of serious games, individual or group stimulation sessions) or information obtained through the use of new technologies (sensors, video, audio or motor) can also be useful
- THE USE OF THE APATHY DIAGNOSTIC CRITERIA takes place when the maximum of information has been collected. The diagnostic criteria must be completed by the clinician (physician, psychologist, speech therapist and any other trained clinician)
Apathy scales, apathy diagnostic criteria, how to use new technologies and other information are available by clicking directly on the words in blue in this document.
- FOR CRITERION A
There is a quantifiable reduction in goal-directed activity relative to the patient’s previous state of functioning in the areas of either behaviors / cognition, emotions, or social interactions. These changes can be reported by the patient himself or the observation exterior.
Remember the definition of Goal directed Behaviours: Behaviours / activities directed towards a goal or the realisation of a task.
- FOR CRITERION B
BEHAVIOUR AND COGNITION
EMOTION
SOCIAL INTERACTIONS
Each of the 3 dimensions includes 5 examples / situations. For each one must indicate if the patient presents the reduction / loss / diminution illustrated in the example (answer YES) or if it is not the case (answer NO)
Examples / situations illustrate situations where initiation skills (eg spontaneous emotions) or response to environmental demands (eg emotional reactions to the environment) are involved
The clinical interview should therefore include questions corresponding to the examples / situations described for each dimension. It is preferable to ask the questions in the order of presentation of the dimensions (1,2,3) but it is of course possible to take into account the information spontaneously delivered by the patient and / or his companion.
In an indirect way there are also some elements that can be useful during the interview and help to better rate each example / situation in YES or NO. These elements depend of course on the context of the interview (in consultation, during a report for a resident or hospitalised patient).
– interest in the situation of maintenance: mimicry, attention, eye contact
– the interest for staff (Does he seek to know the functions of professionals, the first names?)
– interest for other patients or residents
– interest in his state of health,
– the quantity and quality of details provided when evoking his personal interests
– the demands on his usual environment, his family
– willingness to participate in workshops or animations
– the number of interests evoked during the game of interest objectively exploring its interests
– ability to express an emotional response during a conversation with a humorous theme, or on the contrary to the evocation of something sad
– ability to express an emotional response when a reward is offered (eg in a test, play situation)
– the reaction to the evocation of the diagnosis or the results of additional examinations, especially during the medical visit
– spontaneous abilities to speak, to integrate into the conversation
- WHEN COMPLETING THE DIAGNOSTIC CRITERIA AND IN PARTICULAR THE RATING OF EACH OF THE EXEMPLES / SITUATIONS, the clinician uses all available information. In the rare cases where the clinician still feels that there is a lack of information to answer, he / she must use the NO choice by default.
- DISCORDANT INFORMATION: Sometimes the information collected (information from the patient, his entourage, direct observation) is discordant. In these cases the clinician must try, through his experience, to make the best possible synthesis by focusing, if necessary, on the data collected during the interview.