Elsevier

The Lancet Neurology

Volume 2, Issue 11, November 2003, Pages 677-686
The Lancet Neurology

Review
Pain processing in dementia and its relation to neuropathology

https://doi.org/10.1016/S1474-4422(03)00556-8Get rights and content

Summary

Most clinical studies of pain in dementia have focused on assessment procedures that are sensitive to pain in “demented” or “cognitively impaired” elderly patients. The neuropathology of dementia has not played a major part in pain assessment. In this review, the neuropathological effects of dementia on the medial and the lateral pain systems are discussed. We focus on Alzheimer's disease (AD), vascular dementia, and frontotemporal dementia. Lewy-body disease and Creutzfeldt-Jakob disease are briefly reviewed. The results of the studies reviewed show that, although the subtypes of dementia show common neuropathological features (such as atrophy and whitematter lesions), the degree by which they occur and affect pain-related areas determine the pattern of changes in pain experience. More specifically, in AD and even more so in frontotemporal dementia, a decrease in the motivational and affective components of pain is generally present whereas vascular dementia might be characterised by an increase in affective pain experience. Future studies should combine data from experimental pain studies and neuropathological information for pain assessment in dementia.

Section snippets

The medial and lateral pain systems

This review focuses on subcortical and cortical brain areas related to the medial and lateral pain system. For the sake of clarity, we have decided to mention only a few important areas at the level of the reticular formation and the mesencephalon. An extensive review of areas to which the spinoreticular tract and the spinomesencephalic tract project has been made before.15

The medial pain system (figure 1) includes the spinothalamic tract that projects directly to the intralaminar thalamic

The many components of pain

The medial and lateral pain systems are involved in different features of pain. The medial pain system plays a crucial part in the motivational–affective and cognitive–evaluative features, the memory for pain, and the autonomic–neuroendocrine responses evoked by pain, whereas the lateral pain system is particularly involved in the sensory-discriminative features of pain.8, 16

The medial and lateral pain system and neuropathology in dementia

The neuropathology of AD, vascular dementia, and frontotemporal dementia will be discussed exclusively with respect to areas of the lateral and medial pain system. The reason for focusing on these three types of dementia is, as far as we know, that one or more clinical studies with experimental data on changes in pain processing are available only for these subtypes of dementia. The combination of neuropathology and experimental data invites us to propose some cautious theoretical

Vascular dementia

Neuropathology related to the medial and lateral pain system Vascular dementia is a highly heterogenous disorder.32 In contrast to AD, frontotemporal dementia, and Lewy-body dementia, vascular dementia is primarily characterised by white-matter lesions49, 50 and, to a lesser extent, by brain atrophy.33, 51 Consequently, cognitive impairment may result from disruption of corticosubcortical circuits (deafferentiation), specifically frontosubcortical circuits,52 caused by small cortical infarcts

Pain assessment in the nursing home

In the nursing home, in addition to pain assessment tools, assessment instruments can be used that provide insight into the functioning of a pain-related area itself or provide specific information about the processing of sensory stimuli. Those instruments include neuropsychological testing and a brief neurological examination, respectively.

Discussion

Results from the studies reviewed here show that—although atrophy and white-matter lesions are neuropathological features common to all three dementia subtypes—the varying degree by which they occur and affect the different areas of the medial and lateral pain systems determines the pattern of changes in pain processing.

Both the neuropathology and the experimental data suggest the likelihood of a particular pain pattern for AD, vascular dementia, and frontotemporal dementia. Specifically, a

Search strategy and selection criteria

Data for this review were selected from the personal files of the authors and in searches in MEDLINE and Web of Science. The search terms we used were “pain”, “medial pain system”, “lateral pain system”, “pain assessment”, “nociceptive stimuli”, “nociception”, “Alzheimer's disease”, “vascular dementia”, “frontotemporal dementia”, “Lewy-body disease”, “sporadic Creutzfeldt-Jakob”, “variant Creutzfeldt-Jakob”, “atrophy”, “white-matter lesions”, “neuropsychological assessment”, and

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