REVIEW ARTICLE A systematic review of non‐pharmacological treatments for apathy in dementia Christos Theleritis 1 | Kostas Siarkos 1 | Anastasios A. Politis 1 | Everina Katirtzoglou 1 | Antonios Politis 1,2 1 Division of Geriatric Psychiatry, First Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece 2 Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University, Baltimore, MD, USA Correspondence Antonios Politis, MD, PhD, Division of Geriatric Psychiatry, 1st Psychiatry Dept., University of Athens Medical School Eginition Hopsital, 72-74 Vas. Sofias Avenue, 11528 Athens Greece. Email: apolitis@med.uoa.gr Objective: Apathy is one of the most frequent neuropsychiatric symptoms encountered in dementia. Early diagnosis and timely treatment of apathy in dementia are crucial because apathy has been associated with poor disease outcome, reduced daily functioning, and caregiver distress. Design: Extensive electronic search from the databases included in the National Library of Medicine as well as PsychInfo and Google Scholar for studies which have investigated the effect of non‐pharmacological treatments of apathy in dementia. Quality of the studies was appraised. Results: A total of 1303 records were identified and 120 full‐texts assessed. Forty‐three unique studies were reviewed. A variety of interventions were found to be effective in reducing apathy in demented patients, particularly when provided in a multidisciplinary manner. However, quantification of the effect was limited by the marked methodological heterogeneity of the stud- ies and the small number of studies where apathy was the primary outcome measure. Conclusions: Treatment of apathy in dementia is a complex and underexplored field. Certain studies suggest promise for a variety of non‐pharmacological interventions. Standardized and systematic efforts primarily focusing on apathy may establish a benefit from individualized treat- ments for specific disease groups. KEYWORDS apathy, dementia, non‐pharmacological, systematic review, treatment 1 | INTRODUCTION Applying the Neuropsychiatric Inventory (NPI), Mega, Cummings, Fiorello, and Gornbein 1 found that 88% of subjects with Alzheimer's disease (AD) had neuropsychiatric symptoms, of which apathy was the most frequent, reported to occur in 27% to 72% of patients. 2-6 Apathy is also encountered in several neuropsychiatric disorders; it is present in up to 90% of patients with fronto‐temporal dementia, dementia with Lewy bodies, progressive supranuclear palsy, 40% of those with cortico‐basal degeneration, and 20% of those with Parkinson's disease. 3,7 Some degree of apathy is observed in brain injuries and frontal lobe lesions and is related to lesion location. 7,8 Apathy has been defined as the absence or lack of feeling, emo- tion, interest, concern, or motivation not attributable to a decreased level of consciousness, cognitive impairment, or emotional distress. 8 Starkstein, Petracca, Chemerinski, and Kremer 9 proposed the following core features of apathy: diminished motivation, diminished initiative and interest, and blunting of emotions. Recently proposed diagnostic criteria 10 define “apathy” as a loss or diminution of goal‐directed behavior, cognition, or emotion, which persists and is accompanied by functional impairment. 11 In patients with apathy, the capacity of the frontal cortex to select, initiate, maintain, and shift programs of action is undermined. 12 In dementia, Lyketsos, Rosenblatt, and Rabins 13 proposed that apathy is an aspect of executive dysfunction syndrome and is probably caused by damage to frontal‐subcortical brain circuits. Indeed, apathy is corre- lated with neuronal loss, higher tangle counts, white matter hyperintensities, and hypoperfusion in regions involved in frontal‐ subcortical networks. 2,14 Apathy frequently complicates the course and management of dementia and is prevalent in patients even with milder forms of cognitive impairment in clinic‐based 15 and commu- nity‐based 5,16 samples. Onyike et al 17 proposed that apathy is an early sign of cognitive decline. Consequently, apathy has been associated The authors Christos Theleritis and Kostas Siarkos have contributed equally to the manuscript Received: 14 March 2017 Accepted: 24 July 2017 DOI: 10.1002/gps.4783 Int J Geriatr Psychiatry. 2017;1–16. Copyright © 2017 John Wiley & Sons, Ltd. wileyonlinelibrary.com/journal/gps 1