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Apathy in Dementia — MRCPsych Paper B MCQ

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HardOld Age PsychiatryApathy in DementiaMRCPsych Paper B

A 74-year-old man with mild-to-moderate Alzheimer's disease has persistent, clinically significant apathy despite a structured personalised activity programme. He shows markedly reduced initiation and interest but has no pervasive sadness, guilt, hopelessness, suicidal thinking, psychosis or agitation. Delirium, pain and medication adverse effects have been excluded. He is taking donepezil and has no significant cardiovascular disease. Which medication class has the strongest direct randomised-trial evidence for reducing the severity of apathy in this situation?

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Correct answer: A — Central nervous system stimulants, such as methylphenidate

Explanation lettering: E = shown as A · C = shown as B · D = shown as C · A = shown as D · B = shown as E

E is correct. The ADMET 2 randomised trial found that methylphenidate reduced apathy severity more than placebo in mild-to-moderate Alzheimer's disease. This is stronger direct evidence for treating established apathy than the indirect and inconsistent behavioural evidence for AChE inhibitors; donepezil should be continued for its dementia indication rather than switched solely for apathy. Apathy without a depressive syndrome is unlikely to respond to an SSRI, which can itself cause emotional blunting. Antipsychotics are reserved for selected cases involving severe agitation or psychosis, while benzodiazepines can worsen sedation, cognition and falls. In UK practice, methylphenidate for dementia-related apathy is off-label, is not routine NICE treatment, and would require specialist risk-benefit assessment and cardiovascular, psychiatric, sleep and weight monitoring.

Reference: Mintzer J et al. Effect of Methylphenidate on Apathy in Patients With Alzheimer Disease: The ADMET 2 Randomized Clinical Trial. JAMA Neurology. 2021;78(11):1324–1332. https://pubmed.ncbi.nlm.nih.gov/34570180/