Apathy: How to Combat: By Dr. De Leon

“Science may have found a cure for most evils; but it has found no remedy for the worst of them all- the apathy of human beings.” Helen Keller

It has been a few weeks since I have written. Why? Pure apathy or is it indifference! In our vocabulary we tend to use the words apathy, indifference, and impassivity interchangeably. However, are they really the same thing and if so what does it mean for us in our living with Parkinson’s disease? Why do we feel this way? Is it normal? And is there anything we can do to combat this feelings of inertia that seem to take over us from time to time. if not addressed and treated properly can lead to severe disruption of life as well as to isolation and depression.

Thus, I have chosen this particular topic for discussion now that my inertia has passed away. This is also a subject which has generated much interest in our community as per the choice award topics of interest gather by the former PDF ( Parkinson’s Disease Foundation). perhaps before we spend countless hours and research money on the subject we need to define exactly what we mean. As I said earlier, most of us equate apathy to indifference but they are not the same thing particularly when it is defined in terms of a neurological illness.

Apathy and indifference both denote a lack of responsiveness and interest to things that may normally stimulate, excite or cause great emotions. apathy comes from the Greek root word pathos meaning emotion ( a=pathos) without feelings or emotions. this is a deep rooted neurological problem that involves the frontal lobe of the brain which deal with personality, and executive functions. Not only do you not have much feelings or interest but you DON’T CARE! in neurology as I stated before when we use the word apathy we are saying there is a neurological problem in the wiring of the brain that has gone awry. Usually more common than not when we as neurologists see this behavior outside of structural injuries in brain (e.g. head injury,  stroke, etc.) is primarily related to dementia.

What most of us in PD experience commonly however, is not apathy but indifference. The difference between the two is the personal behavior attached to this feeling.  People with true apathy simply don’t give a hoot about anything and don’t know they are apathetic. As opposed to being indifferent or having inertia or decrease in concern or emotions; we are completely aware of the problem we want to change it and don’t want to feel this way but we lack the fortitude to do anything about it. This is the state where I have found myself recently and I am sure many of you as well.  I want to go out and socialize, get showered, write, exercise but don’t have enough stamina to make myself do these things because the energy involved to achieve these tasks supersedes our reward. Remember that the basal ganglia is also a center for reward and pleasure and if you don’t have enough dopamine to think and do necessary activities to stay alive then you wont have any surplus to go in search of feel good activities. the reason I experienced this has been due to a decrease in my dopaminergic intake due to cardiac issues being evaluated. however, once I took my regular doses of medications my concern for things that are pleasurable like socializing and writing have returned.

So what does this mean for you? evaluate your feelings? is it you feeling like you don’t care and rather not invest energy in things you normally would love to do like read or go to movies or is it your loved one saying what is wrong with you? you don’t seem to care? and it makes no difference to you, you are content in your lack of participation. You could careless if you never brush your hair or shower again in your life.

Independent of which feeling is plaguing you most, I want you to know that there are treatments available for both.

Apathy vs. indifference?

Both require evaluation by your physician/neurologist/MDS

Apathy–

• evaluate for new brain abnormalities i.e. stroke ( just because you have PD does not mean you can have other diseases), rule out thyroid disease and other metabolic abnormalities.
• Get new or follow up mini-mental status exam (MSE) or  CogTest
• neurobehavioral evaluation (needed in some cases)
• Treatments:

1. medications for dementia if present -e.g. Exelon (Rivastigimine) – only drug approved for PD dementia, but can also use  Namenda (memantine), Aricept (Donepezil), and Razadyne (galantamine). in my experience combination of Namenda plus Exelon or one of the other works best in retarding dementia particularly if introduced early on. thus I suggest yearly screening for this especially if had had PD >10 years because dementia risk increases with age and disease process. 40-50% develop PD patients develop dementia eventually.
2. anti-narcoleptics- Provigill, Nuvigil ( non-addictive- focus on alertness, no blood monitoring required, do not interfere with other PD meds.
3.  stimulants- a whole host which are amphetamines and amphetamine derivatives like Adderall, Ritalin. These are controlled substances and usually require closer monitoring some may even require blood monitoring.
4. increase dopamine – but if dementia present this may make cognition worst

Indifference–

• evaluate for depression
• adjust PD medications (usually go up)
• rule out thyroid disease/other metabolic issues
• get neuropsych/behavioral evaluation if not sure if depression vs. dementia
• Treatments

1. if depression treat with antidepressants ( e.g. Zoloft, Lexapro, Effexor, Remeron, etc.)
2. fatigue may also be a cause- treat with amantadine, and evaluate sleep.
3. may also need sleeping meds.
4. participation in activities like art, singing, exercise, dancing, biking etc. can increase natural dopamine, serotonin, and endorphins among other. these will in turn allow you break that indifference. So don’t give in to it get a buddy who can help out to over come these challenges but don’t forget to talk to physician first.

Now that you are an expert on the subject, you and your family can discuss more accurately with your physicians as to the cause of your lack of interest and participation in previous activities which brought you joy. Soon you will be on your way to finding your passion once more. Find one thing that bring you joy and pursue it …..

Carpe Diem!