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Prasad Padala, M.D. |
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Cyrus Desouza, M.D. |
It’s easy to be apathetic. It’s something we all experience. Some days we just wake up and have no motivation. Nothing seems to matter.
However, in some chronic diseases apathy turns into a clinical syndrome characterized by poor initiation, loss of motivation, indifference and lack of persistence.
Apathy syndrome impairs self-management behaviors, leads to functional decline, poor compliance with treatment and generally poor outcomes in chronic diseases.
That’s why two UNMC physicians — Prasad Padala, M.D., and Cyrus Desouza, M.D. — zeroed in on apathy as one of the key culprits in patients with Alzheimer’s disease and chronic conditions such as diabetes and obesity.
Dr. Padala, assistant professor, psychiatry, and Dr. Desouza, associate professor, endocrinology, also hold appointments at the Omaha Division-VA Nebraska-Western Iowa Health Care System. Dr. Padala has two grants to study the connection between apathy and Alzheimer’s disease. Dr. Desouza’s grants focus on the impact of apathy treatment in people who are obese. They also have two federal grants that are under review.
The two researchers are studying a well-known drug — ritalin — as a treatment for apathy. Yes, the same ritalin that is used to slow hyperactive children.
“It works differently in adults and children,” Dr. Padala said. “With adults, it gives them more energy. Simply put, it increases the dopamine in the brain.”
Dopamine is like the gas in your car. Low dopamine levels in the front of the brain can lead to apathy.
“Apathy is one of the most profound and disabling aspects of Alzheimer’s disease,” said William Burke, M.D., professor and vice chairman of the UNMC Department of Psychiatry.
One study determined that apathetic persons are nearly three times more likely than those without apathy to be impaired in day-to-day activities such as dressing, bathing, walking, eating and using the toilet.
In addition, apathy is linked to cognitive dysfunction in dementia patients. With no interest or motivation, it becomes difficult for these patients to use their remaining cognitive function. Their memory, learning and communication skills deteriorate.
“People are getting excited about apathy now because it may be a behavioral marker for a more rapidly progressing dementia,” Dr. Padala said. “Apathy is considered an untapped behavioral problem. If treated well, it can have significant impact on management of dementia and diabetes.”
Dr. Padala is conducting a VA-funded placebo-controlled study for apathy treatment in 60 veterans with Alzheimer’s dementia. He said that early study results have been promising, as illustrated by the comments from the wife of an Alzheimer’s patient who is taking ritalin.
“After one month in the study, she came to me and said, ‘Thank you for giving my husband back to me. He’s doing things that he hasn’t done in the last five years,'” Dr. Padala said.
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“The key to living with diabetes is disease management,” Dr. Desouza said. “You have to exercise, watch your diet closely, keep your weight down and continually monitor your blood sugars. It’s not easy. You have to be driven.
“Apathy can be devastating for patients with diabetes. Once they lose interest and stop managing the disease, the health ramifications can be dramatic,” he said.
Dr. Desouza knows how difficult it is to motivate patients with diabetes. Despite all the innovations in treatment and guidelines, only about 10 percent of patients meet the benchmarks for diabetes control (blood sugar, blood pressure and cholesterol).
The use of ritalin is encouraging in the group of study participants, he said.
“However, the brain is very complicated,” Dr. Desouza said. “We don’t know if improvement is due to the neuro chemical reaction resulting from taking ritalin. More research needs to be done.”
Ritalin is not the optimal drug, Dr. Desouza said. Although it does increase dopamine, it also has several side effects, such as sleep disturbances, decreased appetite and increased blood pressure.
Children who are hyperactive receive 80 mg of ritalin as their daily dose. Adults in the studies are given much lower doses with Alzheimer’s patients receiving 10 mg and obesity patients receiving 20 mg. The lower dose helps lessen the side effects.
“We need to find a pharmaceutical agent that can impact apathy,” Dr. Desouza said. “Ritalin is the best drug we have right now, but we are hopeful that we can find a better agent.”
Dr. Desouza has funding to study the impact of treating apathy on weight loss initiatives. Through the Omaha VA, 125 veterans were enrolled in the pharmacological and non-pharmacological treatments for apathy.
As part of the study, Drs. Padala and Desouza also are investigating a group therapy, “Medical crisis counseling,” for treatment of apathy.
“There seems to be a common thread linking Alzheimer’s disease and diabetes, since people with diabetes are three times more likely to develop Alzheimer’s disease than non-diabetic individuals,” Dr. Padala said.
Apathy may be that thread. Dr. Padala recently received funding from the Alzheimer’s Association to improve functional status, quality of life and glycemic control in patients with co-morbid dementia and diabetes.
“This is ground-breaking work,” Dr. Burke said. “They are trying to determine if treating apathy will not only benefit the day-to-day life of people with Alzheimer’s but if it might also have additional medical benefits in improving glucose control and increasing activity levels. This is a completely novel and exciting approach to a number of well known, often intractable, problems.”