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Original Investigation
July 18, 2018

Association of Apathy With Risk of Incident DementiaA Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  • 2Donders Brain Institute, Department of Neurology, Radboud University Medical Center, University of Nijmegen, Nijmegen, the Netherlands
  • 3Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  • 4Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
JAMA Psychiatry. Published online July 18, 2018. doi:10.1001/jamapsychiatry.2018.1877
Key Points

Questions  What is the association between apathy in older people without dementia and incident dementia?

Findings  In this systematic review and meta-analysis of 16 studies including 7365 patients, memory clinic patients with apathy had an approximately doubled risk of incident dementia, depending on age and cognitive function. Adjustment for apathy definition and duration of follow-up explained 95% of heterogeneity in patients with mild cognitive impairment; results seem generalizable to memory clinic populations.

Meaning  Apathy is a relevant, noninvasive, cheap, and easily implementable prognostic factor prodromal to dementia. It has important clinical significance because patients are vulnerable and tend to withdraw from care, requiring an active caregiving approach from clinicians.


Importance  Fear of dementia is pervasive in older people with cognitive concerns. Much research is devoted to finding prognostic markers for dementia risk. Studies suggest apathy in older people may be prodromal to dementia and could be a relevant, easily measurable predictor of increased dementia risk. However, evidence is fragmented and methods vary greatly between studies.

Objective  To systematically review and quantitatively synthesize the evidence for an association between apathy in dementia-free older individuals and incident dementia.

Data Sources  Two reviewers conducted a systematic search of Medline, Embase, and PsychINFO databases.

Study Selection  Inclusion criteria were (1) prospective cohort studies, (2) in general populations or memory clinic patients without dementia, (3) with clear definitions of apathy and dementia, and (4) reporting on the association between apathy and incident dementia.

Data Extraction and Synthesis  PRISMA and MOOSE guidelines were followed. Data were extracted by 1 reviewer and checked by a second.

Main Outcomes and Measures  Main outcomes were pooled crude risk ratios, maximally adjusted reported hazard ratios (HR), and odds ratios (OR) using DerSimonian-Laird random effects models.

Results  The mean age of the study populations ranged from 69.2 to 81.9 years (median, 71.6 years) and the percentage of women ranged from 35% to 70% (median, 53%). After screening 2031 titles and abstracts, 16 studies comprising 7365 participants were included. Apathy status was available for 7299 participants. Studies included populations with subjective cognitive concerns (n = 2), mild cognitive impairment (n = 11), cognitive impairment no dementia (n = 1), or mixed cognitive and no cognitive impairment (n = 2). Apathy was present in 1470 of 7299 participants (20.1%). Follow-up ranged from 1.2 to 5.4 years. In studies using validated apathy definitions (n = 12), the combined risk ratio of dementia for patients with apathy was 1.81 (95% CI, 1.32-2.50; I2 = 76%; n = 12), the hazard ratio was 2.39 (95% CI, 1.27-4.51; I2 = 90%; n = 7), and the odds ratio was 17.14 (95% CI, 1.91-154.0; I2 = 60%; n = 2). Subgroup analyses, meta-regression, and individual study results suggested the association between apathy and dementia weakened with increasing follow-up time, age, and cognitive impairment. Meta-regression adjusting for apathy definition and follow-up time explained 95% of heterogeneity in mild cognitive impairment.

Conclusions and Relevance  Apathy was associated with an approximately 2-fold increased risk of dementia in memory clinic patients. Moderate publication bias may have inflated some of these estimates. Apathy deserves more attention as a relevant, cheap, noninvasive, and easily measureable marker of increased risk of incident dementia with high clinical relevance, particularly because these vulnerable patients may forgo health care.