Apathy is a state of profound indifference characterised by a marked reduction in emotion, motivation, concern, enthusiasm, and interest in activities that were once considered meaningful or enjoyable.
Within clinical psychology and psychiatry, apathy is recognised as a measurable neuropsychiatric syndrome rather than simply a personality trait or a normal consequence of ageing. It may occur as a maladaptive response to illness, but it is also an important clinical sign that can indicate an underlying neurological or mental health condition. One of its defining features is a significant reduction in goal-directed behaviour, resulting in diminished initiative, emotional responsiveness, and engagement with everyday life.
Case Presentation
A 72-year-old woman with dementia was admitted to a dementia care centre for a 12-day respite stay. Her two daughters, both general practitioners (GPs), were scheduled to attend several medical conferences and wanted to ensure their mother received continuous professional care, including the timely administration of her prescribed medications, while they were away.
Throughout her respite stay, she received attentive care from the multidisciplinary team, and her admission progressed smoothly according to her planned care routine. Upon returning from their conferences, both daughters visited their mother immediately.
During our conversation, I expressed my interest in learning more about her mother’s condition and explained that I was supervising a group of university students undertaking their clinical placement. One of the daughters smiled warmly and said,
“My mother is a very educational case.”
She then generously shared her mother’s clinical journey with me.
She explained that when her mother was 67 years old, an unusual event first raised concern. One morning, she unexpectedly failed to answer her daughters’ regular telephone call—something that had never happened before.
After several unsuccessful attempts to contact her, one of her daughters, drawing upon both her concern as a daughter and her experience as a general practitioner, went directly to her mother’s home.
She found her sitting quietly on the edge of her bed. Although fully conscious, her responses were unusually slow and delayed. Her face appeared pale, with a markedly flat, emotionless expression that gave her a mask-like appearance. The daughter also noticed an unusual odour in the room, immediately suggesting that an underlying medical condition might be responsible for her mother’s presentation.
Using a home blood glucose monitor, she first performed a capillary blood glucose test to exclude hypoglycaemia. The result was within the normal range.
She then attempted to obtain a urine sample for a home urine dipstick test. Although collecting even a small sample proved difficult, the results strongly suggested the presence of a urinary tract infection (UTI).
Recognising the urgency of the situation, she immediately transferred her mother to hospital.
Following catheterisation, laboratory urine analysis confirmed a severe urinary tract infection, and her body temperature was recorded at 40°C, indicating a significant systemic infection (sepsis).
She was admitted to hospital and commenced on a high-dose course of intravenous cephalexin for one week, followed by oral antibiotic therapy.
Before discharge, however, her daughter remained concerned because her mother’s pulse rate consistently remained between 58 and 61 beats per minute. She requested additional blood investigations, which revealed previously undiagnosed hypothyroidism.
Appropriate thyroid hormone replacement therapy was commenced and recommended as lifelong treatment.
The daughter described her mother as an outgoing, energetic woman who had always embraced life with enthusiasm. She took great pride in her appearance, remained well-groomed, dressed elegantly several times each week, and regularly enjoyed social gatherings with three close friends. She had always been independent, socially active, and fully engaged in life.
Following treatment for hypothyroidism, her health stabilised, and she continued living independently for several years.
Approximately two years before her admission to the dementia care centre, however, subtle changes in her memory gradually became noticeable. Initially, these changes appeared minor, but they slowly became more frequent. She began forgetting recent conversations and everyday events while continuing to recall many distant memories with remarkable clarity.
One of the most emotionally significant moments occurred when she could no longer remember that her daughter visited every morning before leaving for work.
After several weeks, she gently said,
“I have missed you. You don’t visit me anymore like you used to. Please don’t forget that I am still your mother.”
In reality, her daughter had never stopped visiting. She had faithfully maintained her daily routine, but her mother’s progressive inability to retain recent memories reflected the deterioration of her short-term memory. What remained beautifully preserved, however, was her deep emotional attachment to her daughter.
Over the following months, both daughters kept their mother under close observation. Although her condition appeared relatively stable, they gradually noticed subtle but important changes in her personality and behaviour.
She became increasingly withdrawn and gradually lost interest in many of the activities she had once enjoyed. Invitations from close friends were frequently declined, and her previously active social life slowly diminished.
Her friends also noticed that she had begun talking to herself during conversations—a behaviour entirely inconsistent with her previous personality.
Concerned by these progressive changes, her daughters arranged a comprehensive psychiatric assessment with a trusted psychiatrist.
Following several weeks of assessment and approximately three months of careful clinical observation, depressive disorders and other affective conditions were systematically excluded.
At that stage, the psychiatrist concluded that her presentation was most consistent with pseudodementia, believing that her previously diagnosed hypothyroidism may have contributed significantly to both her cognitive and emotional changes.
A comprehensive management plan was implemented. This included optimisation of her thyroid hormone replacement therapy, dietary modifications, and ongoing clinical review.
Gradually, her condition stabilised.
Her daughter explained that her mother’s health was now being successfully managed through lifelong thyroid hormone replacement therapy together with regular follow-up appointments with an endocrinologist.
Nevertheless, persistent short-term memory impairment meant that she could no longer remember to take her medication independently. Consequently, one of her daughters visited every day to administer her medication and ensure treatment adherence while also monitoring her mother’s overall wellbeing and safety.
This psychiatrist’s assessment illustrates the critical importance of careful differential diagnosis.
It reminds us that not every episode of cognitive decline in an older adult should immediately be attributed to Alzheimer’s disease or another form of dementia. Medical conditions, endocrine disorders, mood disorders, medication effects, and pseudodementia must all be carefully considered before a definitive diagnosis is reached.
Clinical Reflection
The two cases presented in this article demonstrate that changes in affect, motivation, and behaviour should never be dismissed as a normal consequence of ageing or automatically assumed to represent dementia.
Careful observation, comprehensive clinical assessment, and the systematic investigation of potentially reversible medical conditions are essential for accurate diagnosis and appropriate treatment.
Although I have encountered many similar cases throughout my clinical career, I have intentionally limited this article to a small number of representative real-life examples. My purpose is to highlight the importance of early recognition and person-centred care without overwhelming readers with excessive clinical detail.
I hope these cases encourage families, caregivers, students, and healthcare professionals to appreciate the value of careful observation, compassionate communication, and timely intervention in preserving the wellbeing, dignity, and quality of life of those experiencing cognitive and behavioural change.
I would like to conclude with a reflection that has remained with me throughout my professional journey:
Knowledge teaches us what to do. Compassion teaches us how to do it. When the two walk together, they become wisdom.