Coping with apathy (low motivation or lack of interest)
Picture a man who wants to walk on his treadmill, has the time, but can’t get himself to do it. He knows he should make a healthy meal, but has a bowl of cereal for dinner instead. He has been told to shower daily, but doesn’t see the need too. He puts off tasks for later… but later never arrives. For some of these tasks, he truly wants to complete them. For others, he’s just not interested.
You might say to yourself, plenty of people have challenges like this, even without a brain injury-- and that is true. Think about various people in your life-- some may be highly motivated while others may be less motivated.
Low motivation or lack of interest can also be called apathy. What causes it? Is it depression, a brain injury or something else? When you are depressed, you may have low motivation and feel sad most of the day, maybe even hopeless. But apathy after brain injury can exist without any sadness.
Some people jump to the conclusion that you are just being lazy or just need to "try harder." If you are a caregiver, it may look like “They’re just being difficult.” But, that is often not the case.
If you look at the brain, there are three important areas that communicate with each other. The brain stem, basal ganglia, and the frontal lobes. In a healthy brain, these areas send messages to one another which allows us to set goals, create an action plan, and carry out the plan. To make things simple, I want you to think of this communication pathway as having a switch. After brain injury, that switch may flip to the off position—What’s the result? You may not be able to think of a goal. Even if you do set a goal, or someone sets the goal for you, you may not feel interested in it or feel like taking the first step.
High effort tasks and low reward tasks are the most difficult to engage in.
What is a low reward task? maybe dusting the shelves? Do you see any reward for yourself? Probably not. What’s a high reward task? If you don’t show up to work you won’t get paid.
What is a high effort task? Believe it or not, showers and cooking meals can feel like a high effort tasks. Think of all the steps involved… You may feel like putting it off for another time… maybe you’ll feel like doing it later. But in reality, you never really “feel” like doing it.
Apathy after brain injury can make life difficult for you and your loved one. It makes it harder to engage in therapy, so rehabilitation progress may be slower. Your days may be unproductive (there’s lots of time yet nothing gets done). Others start to make decisions for you or tell you what to do. You may lose your job or have trouble engaging in volunteer work. You may lose friendships, maybe because you don’t talk as much or you don’t feel like hanging out. Apathy may bring low self-awareness, meaning, you may not be aware of these challenges or the impact these challenges have on others. Emotionally, you may not care much about the tasks. It may not bother you that tasks are not started nor completed. This lack of care can be tough on caregivers and family members. If you are a caregiver, you may feel frustrated because you know your loved one has the ability to do the task, they just can’t get it done. You may feel annoyed by giving frequent reminders. It may be difficult to accept that your loved one is content with doing less.
Treatment is available in two categories: Medication and Behavioral/Environmental interventions
I cannot make any specific recommendations about medication. Medication will vary based on the underlying cause and your specific medical status. Please check with your physician before taking any new medication to avoid interaction or side effects.
You can ask your doctor for more information about: Acetylcholinesterase inhibitors, Gingko biloba, or stimulants
Antidepressants are less likely to improve apathy
Behavioral/Environmental interventions: Success does not rely on your internal motivation or “willing” yourself to do the task. Success depends on external stimulation. Here are some tips:
Set up consistent daily routines and stick with it (to increase automatic habits). If you enjoy reading or listening to audiobooks, I highly recommend Atomic Habits by James Clear
Put the task on your calendar with a start time (don’t wait until you “feel” like doing it)
Work with a provider or family member to set specific goals (a neuropsychologist, speech therapist, or cognitive rehabilitation therapist can help)
Think about past preferences (What did you like? What do you like now?)
Set up rewards for yourself
Reduce the effort required. Remove as many barriers as possible and reduce the number of steps needed. For example, if morning showers are difficult, set out your clothes and towel the night before.
If it is hard to create your own daily schedule, an activity/day program may help.
Use external cues like signs, white boards, checklists, reminders, and alarms. Consider technology like a smart watch or Alexa
Maintain a healthy diet, regular exercise (like walking) and good sleep habits.
If you are a caregiver,
Let your loved one take part in creating the schedule and goals
Praise activities they start and their persistence
Offer verbal or physical prompts for the start of a task
One-on-one personal contact can be helpful. Offer to complete the task together rather than doing it for them.
Lastly, you may need to accept that the person needs less activity to keep them occupied and happy.
