Margaret, 74, is a retired librarian. Once active and socially engaged, she now skips breakfast, naps frequently, and goes to bed by 7 pm. She has gained 18 pounds, wakes several times at night, and avoids walking due to knee pain. Her PHQ-9 score is 7 (mild depression), but her Apathy Evaluation Scale (AES) score is 42, which indicates clinically significant apathy. She says she doesn’t feel particularly sad—just “blah”—and asks you, “Is feeling flat just part of aging?”

Apathy ≠ depression
Apathy is a motivation disorder with low initiative, reduced interest, and blunted emotions. Unlike depression, it lacks guilt and sadness. It’s also the most common neuropsychiatric symptom in dementia and often precedes cognitive decline (van Dalen JW et al, JAMA Psychiatry 2018;75(10):1012–1021). 

Clinical considerations

• To distinguish apathy from depression, ask:
• “Does anything interest you today?” (apathy)
• “Do you feel sad or down?” (depression)

If you suspect apathy, use the AES (www.tinyurl.com/5fa2t58e); a score of ≥ 42 indicates at least mild apathy in older adults. For more, see “How to Identify and Treat Apathy and Late-Life Depression” in CGPR Oct/Nov/Dec 2022.

SSRIs may worsen apathy. Instead, try behavioral activation or low-dose dopaminergic agents like methylphenidate to help restore drive. 

Why behavioral change matters
Lifestyle interventions are often overlooked in psychiatric care, yet they are foundational for treating apathy, preventing cognitive decline, and improving overall well-being. Behavioral activation can even match the efficacy of medications for late-life depression. A 2022 National Institute on Aging report called sustained behavior change “foundational” to healthy aging (Hughes JM et al, Gerontologist 2023;63(8):1268–1278). Small steps like consistent walking or joining a community class can significantly improve ­well-being. But change isn’t easy. To help make it more realistic, here’s a set of microgoals to improve mood, sleep, cognition, and overall quality of life in older adults.

You ask Margaret to name one thing she might enjoy this week, like watering plants or calling a friend.

The power of microgoals
Behavior change works best when it’s personal. Habits tied to values last longer, and small, specific actions build confidence. A “microgoal” is a goal so small that it feels doable right away, like walking for five minutes after lunch instead of pledging to “exercise more.” At each visit, use the OARS mnemonic from motivational interviewing to turn intentions into action:

Open-ended question: “What’s one thing you’d like to try before our next appointment?”  

• Too big: “I want to exercise more.”
• Microgoal: “I’ll walk to the mailbox after lunch each day.” 

Affirmation: “You already took the hardest step, which is starting the conversation.”

Reflective listening: “You want to feel more energetic so you can keep up with your grandkids, and walking feels like a good place to start.” 

Summary: “So you’re planning a short daily walk and recognize why it matters. What could make it easier to remember?”

At the next visit, ask about the results directly: “How did it go trying that new thing we discussed?” Most patients will follow through because the goal is their own, not yours. Celebrate progress, however small, and build on it. Over time, these microgoals add up to meaningful, lasting change. 

Lifestyle pillars
Start with a Circle of Health wheel, a visual framework of well-being domains like movement, rest, relationships, and spirituality (www.tinyurl.com/4pzp5afj). Ask, “Which domain matters most to you?” That answer guides where to begin (Bokhour BG et al, Altern Complement Med 2020;26(s1):S116–S122).

1. Exercise
Older adults should aim for 150 minutes of moderate aerobic activity weekly, plus strength training twice a week. Group activities like walking or tai chi outperform solo activities because they add structure, accountability, and social support (McMahon SK et al, JAMA Netw Open 2024;7:e240298).

• Clinical considerations: Prescribe exercise like a medication. Suggest a step tracker. If pain limits mobility, try water aerobics or recumbent bikes.
• Microgoal: Walk 10 minutes after breakfast 3 times a week, bonus if with a friend.

2. Nutrition
Malnutrition and poor diet contribute to fatigue and cognitive decline. The MIND diet—leafy greens, berries, nuts, whole grains, fish, olive oil—may reduce AD risk, though trial data are mixed (Barnes LL et al, N Engl J Med 2023;389(7):602–611).

• Clinical considerations: Monitor weight, appetite, and food access. Suggest Meals on Wheels if needed. For chewing/swallowing issues, smoothies and soups can help maintain fiber intake. For tech-savvy patients, photo-based apps like SnapCalorie offer quick feedback.
• Microgoal: Swap one snack this week from cookies to nuts.

3. Social connection
Loneliness raises mortality risk just as much as smoking 15 cigarettes daily. It also worsens depression and speeds cognitive decline.

• Clinical considerations: Ask how many meaningful contacts patients had in the past week. Encourage new interactions via phone, library classes, or virtual groups. Ask family members to help with tech setup if needed. Reassess and celebrate at each step.
• Microgoal: Add one social interaction this week: calling a friend, joining a class, or visiting the library.

4. Novelty
Real-world learning (eg, photography, language, crafts) beats brain games for cognition (Leanos S et al, J Gerontol B 2023;78(8):1305–1317). Choirs, art groups, and classes improve mood and social connection. 

• Clinical considerations: Encourage spending 20–30 minutes daily on a mentally engaging task. Activities that combine novelty with socializing offer extra benefits.
• Microgoal: Spend 20 minutes this week learning something new like a language, a song, or a craft.

5. Sleep
Sleep issues are often early signs of aging-related decline. Older adults still need seven to eight hours nightly. Fragmented sleep increases dementia and depression risk.

• Clinical considerations: Set consistent sleep-wake times and add morning sunlight exposure. Bright light therapy (10,000 lux for 30 minutes) can improve circadian rhythm and mood. Apply CBT-Insomnia principles like sleep restriction. Avoid evening caffeine and review meds that may impair sleep (eg, steroids, decongestants, painkillers).
• Microgoal: Wake at the same time daily and get 10 minutes of morning sunlight.

Margaret starts with two microgoals: twice-weekly senior center yoga and one healthy lunch swap per week. At first, she misses a few classes, but she keeps at it. By her two-month follow-up, she’s lost a few pounds, feels steadier on her feet, and notices she’s sleeping better. She even surprised her grandson with a phrase she learned in her beginner Spanish class.

Carlat Verdict: In late life, behavioral change often works better than medication for apathy, depression, and early cognitive decline. Start with what matters most, set microgoals, and build from there.