Part II | Vascular risk factors for depression and apathy 131 7 First, can we make unequivocal distinctions between vascular apathy and other clinical presentations of CSVD? It is not too difficult to discriminate between vascular apathy and Binswanger’s disease 80, vascular parkinsonism 81 and subcortical vascular dementia 82, since patients with these conditions present with other distinctive symptoms (gait disturbances in vascular parkinsonism), more symptoms (not only apathy, but also gait disturbances, MCI and bladder dysfunction in Binswanger’s disease), or more andmore severe symptoms (severe cognitive impairment affecting overall daily functioning in subcortical vascular dementia). However, subcortical MCI and the depressive-executive subtype of depression are more difficult to discriminate from vascular apathy. Neuropsychological testing will help to establish subcortical MCI, as in MCI one of the cognitive domains is affected, -in subcortical MCI often semantic memory, executive/attentional functioning, visuospatial functioning or perceptual skills 82 - without problems in daily functioning. When only apathetic symptoms are present the criteria for a depressive disorder are not met (DSM-5; 2013). Still, discriminating between apathy as part of a depressive disorder, or apathy as an independent syndrome remains difficult in individuals coping with a depressive disorder, since anhedonia, loss of interest, indecisiveness and psychomotor retardation are symptoms that characterize both disorders 83 (see Table 2). Interestingly, in a CSVD study investigating the process of effort-based decision making, a high resistance to efforts and a low response to rewards was seen in the patients with apathy, while the depressed CSVD patients showed a different decision-making pattern, with a higher decision making boundary, reflecting a need for more information before making a decision 28. In the future behavioral tests might help to discriminate between apathetic and depressed CSVD patients, but to date these new behavioral paradigms have only been applied in apathy studies 25.
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