Apathy and depression in dementia

Many families notice that a person living with dementia has stopped doing things. They sit for hours, stop calling friends, or no longer care about a hobby they loved. Sometimes this is depression, a mood illness with sadness or hopelessness. Often it is apathy, a loss of drive and interest that comes from changes in the brain. Many people have both.

Telling them apart matters, because they are treated in different ways. This page explains the difference, what treatment can and cannot do, and how everyday activity can help the person feel more like themselves.

What is the difference between apathy and depression?

Apathy means reduced motivation. The person starts fewer things on their own, shows less interest in people or activities, and may show less emotion.² They often still enjoy an activity once someone helps them start it. They may not seem upset about doing less.

Depression is a mood illness. The person may feel sad, empty, worthless, guilty or hopeless. They may cry, worry, become irritable, or talk about death.^1,2

The two overlap. Both can cause low energy and less pleasure in life. Apathy can happen without depression, and the two can also happen together.²

These are general patterns, not a test. Only a careful checkup can sort out what is going on.

Why do these changes happen?

Apathy is closely tied to damage in brain areas at the front of the brain. These areas help a person plan, start tasks and feel driven to act.² It tends to grow more common as dementia moves forward. In some people, it shows up early, even before memory problems are severe.²

Apathy is a hallmark of behavioral variant frontotemporal dementia (bvFTD). This type of FTD is often mistaken for depression at first.⁸ See frontotemporal dementia.

Depression can come from changes in the brain, too. It can also come from very human reactions to losing skills, independence, a driver's license or friends. It is especially common in the early and middle stages.¹

How common are they?

Experts estimate that up to 40% of people with Alzheimer's or another dementia, about 4 in 10, may have significant depression.¹

Apathy is even more common. Studies differ, but it may affect up to 70% of people with Alzheimer's at some point. One large pooled study found it in about 44%, a little under half.²

Apathy matters for the whole family. It is linked with faster loss of daily skills, lower quality of life, more strain on caregivers, and an earlier move to a care home.²

How depression can look different in dementia

Depression in a person with dementia may not look like the depression you know. It may be milder, come and go, and show up as body complaints such as pain or tiredness.¹ In later stages, the person may not be able to put sadness or hopelessness into words.¹

Because of this, doctors use criteria made for people with dementia. They look for a low mood or less pleasure in usual activities, plus at least two other signs for two weeks or more.¹ These signs can include:¹

• Pulling away from people
• Changes in appetite or sleep
• Restlessness, or moving and speaking more slowly
• Irritability
• Tiredness or low energy
• Feeling worthless, hopeless or very guilty
• Repeated thoughts of death, or a suicide plan or attempt

Getting checked

No single test can tell you whether it is depression, apathy or something else.¹ A good checkup includes a medical history, a physical exam, a review of mood and thinking, and a talk with family members who know the person well.¹ A geriatric psychiatrist (a doctor who treats mental health in older adults) can help with hard cases.

The doctor also looks for other causes. Side effects of medicines and other medical problems can look like depression.¹ Pain, poor hearing or eyesight, poor sleep, and some medicines can make a person withdraw. See medicines that can worsen memory and treatable conditions that look like dementia.

What helps

Doctors usually combine several steps: treating other health problems, adding enjoyable activities and contact with people, counseling when it fits, and sometimes medicine.¹ Telling the person to "cheer up" rarely helps.¹

Medicines: what to know

For depression. Antidepressants are still used, often SSRIs (a common group of antidepressants), because they tend to mix more safely with other medicines.¹ But the evidence is weaker than many families expect.

A Cochrane review pooled 10 trials with about 1,600 people with dementia. After about 12 weeks, depression scores were about the same with an antidepressant or a placebo.³ More people did fully recover from depression on an antidepressant: about 40 in 100, compared with about 22 in 100 on placebo. That finding was less certain.³ People on antidepressants had more side effects, such as dry mouth and dizziness.³

In daily life, this means an antidepressant may help some people, but it is not a sure fix. It works best as one part of a wider plan. Ask the doctor what change to look for, and when to decide whether it is working. See antidepressant medicines for side effects that matter in older adults.

For apathy. No medicine has strong proof for apathy. A Cochrane review found low-quality evidence that methylphenidate (Ritalin, a stimulant) may help. Other drugs, such as memory medicines and antidepressants, showed no reliable benefit for apathy.⁵ Limited research

In a later U.S. and Canadian trial called ADMET 2, 200 people with Alzheimer's took methylphenidate or a placebo for six months. Apathy improved a bit more on methylphenidate, mostly in the first 100 days. Thinking and quality of life did not differ between the groups.⁶ More people on methylphenidate lost a lot of weight, and caregiver stress did not improve.² Methylphenidate is FDA-approved for ADHD and some sleep disorders, not apathy, so using it this way is "off-label."⁶

Antipsychotic medicines may make apathy worse.² If the person takes one, ask the doctor whether it is still needed. See medicines for agitation and behavior.

Never start, stop or change a medicine on your own. Talk with the doctor or pharmacist before changing anything.

Everyday ways to help

Apathy is not laziness, and depression is not a choice. The person usually cannot "try harder." What helps most is making it easy to start and easy to succeed. See meaningful activities for ideas by stage.

1. Lead, don't ask. "Want to go for a walk?" often gets a "no." Instead, try "Let's step outside. Here's your jacket," and begin together.
2. Build on old interests. A person who loved gardening may still enjoy watering plants. A former office worker may like sorting papers or coins.⁷
3. Break it into small steps. Give one simple step at a time. Do the hard parts yourself, like measuring, and let them stir.⁷
4. Choose the best time of day. Plan activities for the hours when the person is most alert.⁷
5. Aim for enjoyment, not results. A half-folded basket of towels is a success if they felt useful.⁷
6. Give them a role. Let the person help with family life, such as setting the table. Celebrate small wins.¹
7. Offer comfort. For depression, name the feeling ("You seem down today"), offer hope, and remind them they are loved and will not be left alone.¹
8. Stop if it frustrates them. If attention fades or frustration grows, stop and try again later.⁷

An adult day program can add structure, company and activities to the week. It also gives you a break.

Take care of yourself, too

Living with someone who has withdrawn can feel lonely. You may feel hurt, sad or worn down. Those feelings are understandable and do not mean you are failing. Watch for signs of depression in yourself, and get support. See caregiver stress and burnout and depression in later life.

When to get help

Call the doctor soon if:

• The person seems sad, hopeless or irritable most days for two weeks or more
• They stop eating, lose weight or sleep much more or less
• Withdrawal is new or getting worse quickly
• You feel unable to cope

Get help right away if:

• The person talks about wanting to die, makes a plan, or tries to hurt themselves. People with Alzheimer's are less likely to talk about or attempt suicide, but it can happen.¹ Call or text 988, or chat at 988lifeline.org. It is free and open 24 hours a day.⁹
• Someone is in immediate danger, or the person is very hard to wake. Call 911.

You can also make a safety plan with the person's care team.

Is apathy just part of getting older?

No. Losing all interest is not a normal part of aging. In dementia, apathy comes from changes in the brain.² It is worth raising with the doctor, because some causes, like pain or medicine side effects, can be treated.

If antidepressants help so little, should the person stop theirs?

Not on your own. Some people do benefit.³ Stopping suddenly can also cause problems. Ask the doctor to review whether the medicine is still helping and whether the plan should change.

Can a person have both apathy and depression?

Yes. They often happen together, and they share some signs, like low energy and less pleasure.² A doctor can help decide which one to focus on first.

The person refuses everything I suggest. What now?

Try starting the activity next to them instead of asking. Hand them one item, like a towel to fold, and see if they join in. Short, simple and familiar works best.⁷ See refusing baths, help or medicine.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.