Importance Apathy is a common and disabling syndrome in aging and neurodegenerative disease. Existing assessment tools rely on subjective reporting, limiting their accuracy in cognitively impaired individuals or in individuals with otherwise impaired insight.

Objective To identify behavioral subgroups relevant to apathy using gaze-based metrics in an emotionally salient virtual reality (VR) setting, and to characterize their clinical and physiological profiles.

Design, Setting, and Participants Cross-sectional study of 85 older adults (mean age 74 ± 5.7 years) with varying cognitive abilities, recruited from a memory clinic. Participants completed a naturalistic VR task while gaze and physiological signals were recorded.

Exposures Positive, aversive, and neutral images were presented within a 3D VR environment. Gaze features included time to first fixation, total fixation duration, and fixation variability. Physiological signals included heart rate variability (HRV), galvanic skin response, and respiration.

Main Outcomes and Measures Unsupervised clustering (K-means) was applied to gaze metrics to derive behavioral engagement profiles. Between-group differences in apathy severity (LARS), cognitive function (MoCA), and physiological reactivity were examined using linear mixed-effects models.

Results Two distinct behavioral subgroups emerged: “engagers” (n = 48) and “non-engagers” (n = 37). Non-engagers were older, showed higher apathy scores, and had lower MoCA scores. Physiologically, they exhibited lower baseline HRV but showed a selective increase in HRV during exposure to positive stimuli. No group differences were observed in response to aversive stimuli or in other physiological signals.

Conclusions and Relevance This study introduces a novel, nonverbal approach for identifying apathy through naturalistic gaze behavior in VR. The findings highlight a physiologically responsive yet behaviorally disengaged subgroup, suggesting that emotional reactivity may persist even when outward engagement is diminished. Gaze-based phenotyping in immersive environments may offer a scalable tool for detecting motivational impairments in aging and can be further tested in individuals with poor insight to inform future personalized assessment strategies.

The authors have declared no competing interest.

This study was funded by the Alzheimer's Disease Discovery Foundation (ADDF)-grant number 201906 and by Tel Aviv University Brecher Banner and Ofer Mordechai grants  

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The study did not use openly available human data. All data were collected under institutional IRB approval (Sheba Medical Center, IRB #4436-17), and contain identifiable behavioral and physiological information. Due to ethical and privacy restrictions, the data are not publicly available. However, access to de-identified, encrypted datasets may be considered upon reasonable request and subject to approval by the corresponding author and institutional ethics board.

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All data produced in the present study are available upon reasonable request to the authors