Apathy is a lack of motivation. This includes lack of initiative, lack of interests or concerns, and lack of emotional response. Apathy of HD can occur before motor onset, and it increases in severity with disease stage. Though it can be hard to tell the difference between apathy of HD from the apathy of depression, apathy of HD lacks the sadness, negative, and suicidal thoughts that goes along with depression.

It is important to know that slowness of responses that are due to motor and cognitive impairments of HD can look like apathy, but isn't. Though the experts agreed that structured physical and social activities might be helpful, there are no drug treatments for apathy in HD, as is the case for apathy in other neurodegenerative diseases.

Clinical Practice Guidelines for Apathy in HD

Note that this author has changed some of the wording that appears in the journal article for purposes of making it more user friendly. If you wish to share with your medical provider, it would be best to copy the journal link [Anderson KE 2018] for the doctor's review.

General Recommendations

  1. Try to differentiate apathy from impaired abiltiy to perform motor or cognitive tasks (the individual with HD may not be able to respond quickly which can be mistaken for apathy)
  2. Try reducing dosage of medications that may be causing some of the apathy (antidepressents, antipsychotics, mood stabiilizers)
  3. Treat depression (because depression can cause apathy)

Behavior Recommendations

  1. Provide prompts and encourage social and physical activities adapted to each individual

Drug Recommendations

  1. Treat with an antidepressant if not sure whether it is apathy of HD or apathy of depression
  2. Consider a trial of an activating antidepressent or stimulant even if the individual is not depressed
  3. Warning should be given that activating drugs can worsen irritability and sleep disturbance

Author's comments: Though not a part of the guidelines, this author believe that "demoralization" or feelings of helplessness and hopelessness common to HD can look like apathy. In similar situations in other diseases, the importance of regular, supportive and empathetic contact with healthcare providers is emphasized [Sirri L 2007]. In the bupropion trial for treatment of apathy in HD, both those on the drug and placebo improved [Gelderblom H 2017]. In this HD study, the authors proposed that it may have been a combination of placebo effect and frequent interaction with health care providers during study participation that resulted in improved apathy scores for both groups.

References

Anderson KE, van Duijn E, Craufurd D, Drazinic C, Edmondson M, Goodman N, van Kammen D, Loy C, Priller J, Goodman LV. Clinical Management of Neuropsychiatric Symptoms of Huntington Disease: Expert-Based Consensus Guidelines on Agitation, Anxiety, Apathy, Psychosis and Sleep Disorders. J Huntingtons Dis. 2018;7(3):239-250. doi: 10.3233/JHD-180293. PubMed abstract

Sirri L, Fabbri S, Fava GA, Sonino N. New strategies in the assessment of psychological factors affecting medical conditions. J Pers Assess. 2007 Dec;89(3):216-28. PubMed abstract

Gelderblom H, Wüstenberg T, McLean T, Mütze L, Fischer W, Saft C, Hoffmann R, Süssmuth S, Schlattmann P, van Duijn E, Landwehrmeyer B, Priller J. Bupropion for the treatment of apathy in Huntington's disease: A multicenter, randomised, double-blind, placebo-controlled, prospective crossover trial. PLoS One. 2017 Mar 21;12(3):e0173872. doi: 10.1371/journal.pone.0173872. eCollection 2017. PubMed abstract