ClinicSpeak: apathy in MS

Apathy: another reminder of how bad the shredder can be. #MSBlog #MSResearch #ClinicSpeak

“Are  you apathetic? This is not that uncommon in MS and is associated with cognitive impairment. In general apathy refers to someone with lacks emotion and is indifferent to what is happening in their environment. They lack of interest and enthusiasm for things they enjoyed doing in the past. An apathetic person may appear unconcerned, uninterested and unresponsiveness to novel stimuli. They are detached and dispassionate and simply don’t get involved; I suspect that apathetic MSer would not be reading this blog.”
“How would you know if you were apathetic? You could ask a partner or close friend. Another option is to download, print and complete the short survey below. The scoring of this scale is not clear-cut and is designed for an older patient group. I will need to look into how well validated it is in MS and get back to you on this.”

“Apathy is due to frontal lobe disease and tends to occur in MSers with longstanding disease and a lot of end-organ damage; i.e. a high lesion load and gross brain atrophy. Apathy is seen in many other degenerative conditions and post-head injury and is very difficult to manage. People who are apathetic don’t engage with rehabilitation very well. Apathy may be reversible; I have had several patients with relapses who have had reversible frontal lobe symptoms and signs.”

“Apathy is particularly difficult for family members to deal with; they interpret it as depression and a change in personality. If apathy is a problem please raise the issue with your medical team so that it can be investigated. I tend to rescan patients who have become apathetic; you can’t assume it is due to MS. For example, it could be due a subdural haematoma that i snot that uncommon in MSers, in particular those MSers who fall a lot. Subdurals are probably due to minor head injuries.”

Raimo et al. Apathy in multiple sclerosis: A validation study of the apathy evaluation scale. J. Neurol Sci. 2014 Oct 23;347(1-2):295-300. 

BACKGROUND: Apathy is defined as lack of motivation affecting cognitive, emotional, and behavioral domains and is usually assessed by standardized scales, such as the Apathy Evaluation Scale (AES). Recently, apathy has been recognized as a frequent behavioral symptom in multiple sclerosis (MS).

OBJECTIVE: To evaluate applicability and clinical-metric properties of AES in MS and the agreement between patients’ and caregivers’ evaluation of apathy.

MATERIALS AND METHODS: Seventy non-demented MSers underwent a thorough clinical and neuropsychological assessment, including evaluation of apathy according to established clinical criteria. All MSers also completed the self-report version of AES (AES-S).

RESULTS: AES-S was easy to administer and acceptable, and showed fair internal consistency (Cronbach’s alpha, α=0.87). The factorial analysis identified three factors, representing the cognitive dimension (α=0.87), a general aspect of apathy (α=0.84), and the behavioral-emotional aspects (α=0.74), respectively. The factors were significantly correlated with the total AES score (all rrho≥0.73, p<0.001). The total AES score showed fair convergent validity (rrho=0.38) and discriminant validity when compared to Expanded Disability Status Scale (rrho=0.38), Mini Mental State Examination (rrho=-0.17), and Hamilton Depression Rating Scale (rrho=0.37). Receiver-operating characteristic curve analysis demonstrated that a cutoff>35.5 can identify clinically significant apathy with good sensitivity (88%) and specificity (72%); such a cutoff identified apathy in 35.7% of our sample of non-demented MS patients. Total AES score was significantly correlated with reduced global cognitive efficiency and more severe frontal executive dysfunctions.

CONCLUSION: AES-S can be considered as an easy and reliable tool to assess apathy in non-demented MS. The use of AES-S in non-demented MS patients is clinically important since apathy is relatively frequent and is correlated to more severe cognitive dysfunction.

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • This is bad. What I considered personal character traits are turning out to be possible side-effects of MS.

    If you describe someone as unconcerned, uninterested and unresponsiveness it's negative.
    But if you say detached and calm then it's almost positive, something that philosophers aspire to.

  • Apathy may not always be directly due to the shredder and lesions.

    When you have limited energy you learn to let things be or let things go. No point getting worked up about things outside your circle of control or influence

    • Hear, Hear – I second this motion.
      There are so many things that I don't even start on, because I know I have no physical capacity to get them finished. Prioritisation is the name of the game, and a bit of delegation would help – if only I had someone to delegate to………..

    • Learning to prioritize when you have limited energy is just being intelligent not apathetic. Apathy or indifference comes from reading papers such as the one above regarding copaxone and cognition in mice.

By Prof G



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