Academic journal article Hong Kong Journal of Psychiatry

Apathy: Case Reports and a Selected Review of the Literature

Academic journal article Hong Kong Journal of Psychiatry

Apathy: Case Reports and a Selected Review of the Literature

Article excerpt


Syndromes if apathy, demoralization and social breakdown in the elderly are long known but neglected concepts recently re-emerging, as differential diagnostic possibilities to depression particularly among the elderly. The definition and brief description of these largely ignored syndromes are provided together with two case vignettes of apathy to illustrate the diagnostic difficulties in geriatric depression.

Key words: geriatric depression, demoralization, apathy, social breakdown in the elderly


Reliable ascertainment of geriatric depression has far-reaching implications for several reasons. First, depression is not only a socially disabling psychiatric condition but it significantly contributes to an Increase In mortality (Depression Guideline Panel, 1993). Second, depression affects around 10-15% of the general population in the western world (Tiemens, et al, 1996) and at least 3 % of the population in Hong Kong (Chen et al 1993). Last, but not least, depression is a tormenting subjective experience causing immeasurable suffering to patients and also their relatives. It is, therefore, of utmost importance to keep abreast with the new developments in the diagnosis of depression.

This paper attempts to explore a diagnostic conundrum at the borderland of depressive illness in the elderly. While dementia has been, and still is, the main differential diagnostic problem in geriatric depression (McLoughlin & Levy, 1996), recently increasing attention has been paid to apathy (Marin, 1991), demoralization (Figueiredo, 1993) and the social breakdown syndrome (Radebaugh et al, 1987). These psychopathologlcal entities are frequently encountered in geriatric and psychogeriatric clinical practice but probably go unnoticed or treated as depression since they are not well-known enough among even psychiatrists let alone geriatricians and general practitioners. The aim of the following case histories is to highlight the difficulties, in the diagnosis of geriatric depression and to call attention to the clinical concepts of apathy, domoralization and the social breakdown syndrome.



Ms A, a 79-year old widowed Chinese housewife, was admitted from a nursing home for lack of motivation to the extent of neglect of personal hygiene, poor food intake, paucity of spontaneous speech and retarded movements. She preferred to stay in bed all day. When prompted she related multiple somatic complaints like headache and epigastric and back pain. In an uncertain and inconsistent manner she mentioned spirits disturbing her. No obvious psychosocial stressor was ever identified; she had a long and apparently happy marriage and up to recently she had lived an emotionally balanced and financially secure life. Following the death of her husband, her three daughters provided good support.

Over the past 3 years Ms A had three admissions to our psychogeriatric unit with similar presentation. In addition to an always prominent core symptomatology of loss of motivation, vague somatic complaints and motor slowness, she variously presented with a number of short-lived symptoms of insomnia, loss of appetite or hyperphagia, dysphoric mood and what appeared to be attention-seeking behaviour. She became increasingly detached even from her immediate family. During all her admissions, although alert, fully oriented and coherent in speech, she refused to comply with psychological testing.

Apart from longstanding hypertension well-controlled with 40 mg/day nifedipine, Ms A's medical history was, unremarkable. Physical examination yielded no abnormal findings. Routine laboratory tests including full blood picture, liver, thyroid and renal function tests, serum electrolytes and VDRL were within normal limits. EEG showed no abnormality. During her first admission a CT scan of the brain revealed generalized cerebral atrophy and hypodense areas in the right basal ganglia suggestive of old infarcts. …

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