Zusammenfassung
Aus klinischen Studien ist hinlänglich bekannt, dass Patienten mit Morbus Alzheimer im Vergleich zur Altersgruppe deutlich weniger über Schmerzen berichten. Über die zugrunde liegenden Mechanismen des verminderten Schmerzberichtes weiß man hingegen nur wenig. Zu ihrer Aufdeckung sind experimentelle Studien unabdingbar, da hier Noxe und Schmerzerleben unabhängig voneinander zu erfassen sind. Wir berichten deshalb in dieser Übersichtsarbeit über experimentelle Befunde zum Schmerzerleben bei Alzheimer-Patienten. Es zeichnet sich ab, dass die Schmerztoleranzschwelle deutlich erhöht und die vegetative Schmerzreaktion teilweise erheblich vermindert ist. Die Schmerzschwelle und schmerzkorrelierten Hirnpotenziale zeigten sich hingegen weitestgehend unverändert. Wir diskutieren als mögliche Erklärungen hierfür altersbedingte Veränderungen des Schmerzerlebens und neuroanatomische Veränderungen im Rahmen der Alzheimer-Erkrankung. Insbesondere Atrophien im limbischen System könnten einen modifizierenden Einfluss auf das Schmerzerleben nehmen. Auch der Einfluss von alzheimerbedingten Einbußen in der Fähigkeit zur Schmerzkommunikation wird diskutiert.
Abstract
It is well known that patients with Alzheimer's disease report less pain in comparison to their age group. However, little is yet known about the underlying mechanisms causing the decreased pain report. In order to learn more about these mechanisms, experimental studies are indispensable, since only in experimental settings, noxious input and pain experience can be assessed independently. We therefore report on experimental data on pain perception in Alzheimer's disease in this review. The experimental data suggest that the threshold for pain tolerance is markedly increased and the autonomic pain reaction is, at least in part, considerably diminished. On the other hand, pain threshold and pain event-related brain potentials remain largely unchanged. As possible explanations we discuss age-related changes in pain perception and neuroanatomical changes in Alzheimer's disease. Particularly the atrophy of limbic structures may have a modifying impact on the pain experience. We also discuss what influence communicational deficits have on pain report.
Literatur
-
1
Ferrell B A, Ferrell B R, Rivera L.
Pain in cognitively impaired nursing home patients.
J Pain Symptom Manage.
1995;
10
591-598
-
2
Hanlon J T, Fillenbaum G G, Studenski S A, Ziqubu-Page T, Wall W E.
Factors associated with suboptimal analgesic use in community-dwelling elderly.
Ann Pharmacother.
1996;
30
739-744
-
3
Scherder E J, Bouma A.
Is decreased use of analgesics in Alzheimer disease due to a change in the affective component of pain?.
Alzheimer Dis Assoc Disord.
1997;
11
171-174
-
4
Fisher S E, Burgio L D, Thorn B E, Allen-Burge R, Gerstle J, Roth D L, Allen S J.
Pain assessment and management in cognitively impaired nursing home residents: association of certified nursing assistant pain report, Minimum Data Set pain report, and analgesic medication use.
J Am Geriatr Soc.
2002;
50
152-156
-
5
Marzinski L R.
The tragedy of dementia: clinically assessing pain in the confused nonverbal elderly.
J Gerontol Nurs.
1991;
17
25-28
-
6
Feldt K S.
Improving assessment and treatment of pain in cognitively impaired nursing home residents.
Annals of Long-Term Care: Clinical Care and Aging.
2000;
8
36-42
-
7
Huffman J C, Kunik M E.
Assessment and understanding of pain in patients with dementia.
Gerontologist.
2000;
40
574-581
-
8
Parmelee P A.
Pain in cognitively impaired older persons.
Clin Geriatr Med.
1996;
12
473-487
-
9
Morrison R S, Siu A L.
A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture.
J Pain Symptom Manage.
2000;
19
240-248
-
10 Calabrese P. Neuropsychologie der Alzheimer-Demenz. In: Calabrese P, Förstl H (Hrsg). Psychopathologie und Neuropsychologie der Demenz. Lengerich: Pabst Science Publishers 2000: 31-50
-
11
Farrell M J, Katz B, Helme R D.
The impact of dementia on the pain experience.
Pain.
1996;
67
7-15
-
12
Blomqvist K, Hallberg I R.
Pain in older adults living in sheltered accommodation - agreement between assessments by older adults and staff.
J Clin Nurs.
1999;
8
159-169
-
13
Cook A K, Niven C A, Downs M G.
Assessing the pain of people with cognitive impairment.
Int J Geriatr Psychiatry.
1999;
14
421-425
-
14
Chibnall J T, Tait R C.
Pain assessment in cognitively impaired and unimpaired older adults: a comparison of four scales.
Pain.
2001;
92
173-186
-
15
Gibson S J, Helme R D.
Age-related differences in pain perception and report.
Clin Geriatr Med.
2001;
17
433-456
-
16
Cornu F.
Perturbations de la perception de la douleur chez les dements degeneratifs.
Journal de Psychologie Normal et Pathologique.
1975;
72
461-472
-
17
Benedetti F, Vighetti S, Ricco C, Lagna E, Bergamasco B, Pinessi L, Rainero I.
Pain threshold and tolerance in Alzheimer's disease.
Pain.
1999;
80
377-382
-
18
Rainero I, Vighetti S, Bergamasco B, Pinessi L, Benedetti F.
Autonomic responses and pain perception in Alzheimer's disease.
Eur J Pain.
2000;
4
267-274
-
19
Gibson S J, Voukelatos X, Ames D, Flicker L, Helme R D.
An examination of pain perception and cerebral event-related potentials following carbon dioxide laser stimulation in patients with Alzheimer's disease and age-matched control volunteers.
Pain Res Manag.
2001;
6
126-132
-
20
Jonsson C O, Malhammer G, Waldton S.
Reflex elicitation thresholds in senile dementia.
Acta Psychiatr Scand.
1977;
55
81-96
-
21
Willer J-C.
Comparative study of perceived pain and nociceptive flexion reflex in man.
Pain.
1977;
3
69-80
-
22
Porter F L, Malhotra K M, Wolf C M, Morris J C, Miller J P, Smith M C.
Dementia and response to pain in the elderly.
Pain.
1996;
68
413-421
-
23
Hadjistavropoulos T, LaChapelle D L, MacLeod F K, Snider B, Craig K D.
Measuring movement-exacerbated pain in cognitively impaired frail elders.
The Clinical Journal of Pain.
2000;
16
54-63
-
24
Scherder E J, Bouma A.
Visual analogue scales for pain assessment in Alzheimer's disease.
Gerontology.
2000;
46
47-53
-
25
Krulewitch H, London M R, Skakel V J, Lundstedt G J, Thomason H, Brummel-Smith K.
Assessment of pain in cognitively impaired older adults: a comparison of pain assessment tools and their use by nonprofessional caregivers.
J Am Geriatr Soc.
2000;
48
1607-1611
-
26
Basler H D, Bloem R, Casser H R, Gerbershagen H U, Griessinger N, Hankemeier U, Hesselbarth S, Lautenbacher S, Nikolaus T, Richter W, Schroter C, Weiss L.
Ein strukturiertes Schmerzinterview für geriatrische Patienten A structured pain interview for geriatric patients.
Schmerz.
2001;
15
164-171
-
27
Duffy F H, Albert M S, McAnulty G, Garvey A J.
Age-related differences in brain electrical activity of healthy subjects.
Ann Neurol.
1984;
16
430-438
-
28
Goodin D S, Aminoff M J, Mantle M M.
Subclasses of event-related potentials: response-locked and stimulus-locked components.
Ann Neurol.
1986;
20
603-609
-
29
Marsh J T, Schubarth G, Brown W S, Riege W, Strandburg R, Dorsey D, Maltese A, Kuhl D.
PET and P300 relationships in early Alzheimer's disease.
Neurobiol Aging.
1990;
11
471-476
-
30
Filipovic S R, Kostic V S.
Utility of auditory P300 in detection of presenile dementia.
J Neurol Sci.
1995;
131
150-155
-
31
Barrett G, Feinstein A, Jones S, Turano G, Youl B.
Event-related potentials in the assessment of cognitive function in multiple sclerosis.
Electroencephalogr Clin Neurophysiol Suppl.
1999;
50
469-479
-
32
Hadjistavropoulos T, Craig K D, Martin N, Hadjistavropoulos H, McMurtry B.
Toward a research outcome measure of pain in frail elderly in chronic care.
The Pain Clinic.
1997;
10
71-79
-
33 Ekman P, Frieses W V. The Facial Action Coding System. Palo Alto, CA: Consulting Psychologists' Press 1978
-
34
Prkachin K.
The consistency of facial expression of pain: a comparison across modalities.
Pain.
1992;
51
297-306
-
35
Hadjistavropoulos T, LaChapelle D L, MacLeod F K, Hale C, O'Rourke N, Craig K D.
Cognitive functioning and pain reactions in hospitalized elders.
Pain Res Manage.
1998;
3
145-151
-
36
Hadjistavropoulos T, LaChapelle D L, Hadjistavropoulos H D, Green S, Asmundson G JG.
Using facial expressions to assess musculoskeletal pain in older persons.
Eur J Pain.
2002;
6
179-187
-
37
Möltner A, Hölzl R, Strian F.
Heart rate changes as an autonomic component of the pain response.
Pain.
1990;
43
81-89
-
38
Chakour M, Gibson S J, Helme R D.
The effect of age on A delta and C fibre thermal pain perception.
Pain.
1996;
64
143-152
-
39
Chapman W P, Jones C M.
Variations in cutaneous and visceral pain sensitivity in normal subjects.
J Clin Invest.
1944;
23
81-91
-
40
Chapman W P.
Measurements of pain sensitivity in normal control subjects and in psychoneurotic patients.
Psychosom Med.
1944;
6
252-257
-
41
Clark W C, Mehl L.
Thermal pain: A sensory decision theory analysis of the effect of age and sex on various response criteria, and 50per cent pain threshold.
J Abnorm Psychol.
1971;
78
202-212
-
42 Gibson S J, Gorman M M, Helme R D. Assessment of pain in elderly using event related cerebral potentials. In: Bond MR, Charlton JE, Woolf CJ (Hrsg). Proceedings of the 4th World Congress on Pain. Amsterdam: Elsevier 1991: 527
-
43
Hall K RL, Stride E.
The varying response to pain in psychiatric disorders: A study in abnormal psychology.
Br J Med Psychiatry.
1954;
27
48-60
-
44
Harkins S W, Price D D, Martelli M.
Effects of age on pain perception: thermonociception.
J Gerontol.
1986;
41
58-63
-
45
Heft M W, Cooper B Y, O'Brien K K, Hemp E, O'Brien R.
Aging effects on the perception of noxious and non noxious thermal stimuli applied to the face.
Aging Clin Exp Res.
1996;
8
35-41
-
46
Lautenbacher S, Strian F.
Similarities in age differences in heat pain perception and thermal sensitivity.
Funct Neurol.
1991;
6
129-135
-
47 Meliala A, Gibson S J, Helme R D. The effect of stimulation site on detection and pain thresholds in young and older adults [abstract 188]. Vienna: Abstracts 9th World Congress on Pain 1999: p 559-P559
-
48
Procacci P, Bozza G, Buzzelli G, Della Corte M.
The cutaneous pricking pain threshold in old age.
Gerontol Clin.
1970;
12
213-218
-
49 Procacci P. Methods for the study of pain threshold in man. In: Bonica JJ, Liebeskind JC, Albe-Fessard DG (Hrsg). Advances in Pain Research and Therapy (3). New York: Raven Press 1979: 781-792
-
50 Procacci P. A study of the cutaneous pricking pain threshold in normal man. In: Soulairac A, Cahn J, Charpentier J (Hrsg). Pain. London: Academic Press 1968: 223-224
-
51 Scudds R J, Scudds R A. A comparison of hot and cold pain thresholds between young subjects and young-elderly, middle-elderly and old-elderly subjects [ abstract 194]. Vienna: Abstracts 9th World Congress on Pain 1999: p 560-560
-
52
Sherman E D, Robbilard E.
Sensitivity to pain in relationship to age.
J Am Geriartr Soc.
1964;
12
1037-1044
-
53
Sherman E D, Robillard E.
Sensitivity to pain in the aged.
Can Med Assoc J.
1960;
83
944-947
-
54
Schulderman E, Zubek J P.
Effect of age on pain sensitivity.
Percep Motor Skills.
1962;
14
295-301
-
55 Tremblay N, Allard N, Veilette Y. Effect of age on pain perception: Preliminary results [abstract 283]. Vienna: Abstracts 7th World Congress on Pain 1993: p 98
-
56
Birren J E, Schapiro H B, Miller J H.
The effect of salicylate upon pain sensitivity.
J Pharmacol Exp Ther.
1950;
100
67-71
-
57
Harju E-L.
Cold and warmth perception mapped for age, gender, and body area.
Somatosensory & Motor Research.
2002;
19
61-75
-
58 Kenshalo D R. Changes in the vestibular and somesthetic systems as a function of age. In: Ordy JM, Brizzee KR (Hrsg). Sensory systems and communication in the elderly. New York: Raven Press 1979: 269
-
59 Lautenbacher S, Nielsen J, Bär S, Strate P, Arendt-Nielsen L. Pain processing and somatosensation in young and elderly individuals. In: Abstracts - 10th World Congress on Pain Seattle: IASP Press 2002: p 304
-
60
Liou J T, Lui P W, Lo Y L, Liou L, Wang S S, Yuan H B, Chan K H, Lee T Y.
Normative data of quantitative thermal and vibratory thresholds in normal subjects in Taiwan: gender and age effect.
Zhonghua Yi Xue Za Zhi (Taipei).
1999;
62
431-437
-
61
Meh D, Denislic M.
Quantitative assessment of thermal and pain sensitivity.
J Neurol Sci.
1994;
127
164-169
-
62
Pickering G, Jourdan D, Eschalier A, Dubray C.
Impact of age, gender and cognitive functioning on pain perception.
Gerontology.
2002;
48
112-118
-
63
Schumacher G A, Goodell H, Hardy J D.
Uniformity of the pain threshold in man.
Science.
1940;
92
110-112
-
64
Yarnitsky D, Sprecher E, Zaslansky R, Hemli J A.
Heat pain thresholds: normative data and repeatability.
Pain.
1995;
60
329-332
-
65
Jensen R, Rasmussen B K, Pedersen B, Lous I, Olesen J.
Cephalic muscle tenderness and pressure pain threshold in a general population.
Pain.
1992;
48
197-203
-
66
Lasch H, Castell D O, Castell J A.
Evidence for diminished visceral pain with aging: studies using graded intraesophageal balloon distension.
Am J Physiol.
1997;
272
G1-3
-
67
Mertz H, Fullerton S, Naliboff B, Mayer E A.
Symptoms and visceral perception in severe functional and organic dyspepsia.
Gut.
1998;
42
814-822
-
68
Edwards R R, Fillingim R B.
Age-associated differences in responses to noxious stimuli.
J Gerontol A Biol Sci Med Sci.
2001;
56
180-185
-
69
Zheng Z, Gibson S J, Khalil Z, Helme R D, McMeeken J M.
Age-related differences in the time course of capsaicin-induced hyperalgesia.
Pain.
2000;
85
51-58
-
70
Neri M, Agazzani E.
Aging and right-left asymmetry in experimental pain measurement.
Pain.
1984;
19
43-48
-
71
Tucker M A, Andrew M F, Ogle S J, Davison J G.
Age-associated change in pain threshold measured by transcutaneous neuronal electrical stimulation.
Age Ageing.
1989;
18
241-246
-
72
Collins L G, Stone L A.
Pain sensitivity, age and activity level in chronic schizophrenics and in normals.
Br Journal Psychiatr.
1966;
112
33-37
-
73 Harkins S W, Chapman C R. Age and sex differences in pain perception. In: Anderson B, Mattews B (Hrsg). Pain in the Trigeminal Region. Amsterdam: Elsevier Press 1977: 435-448
-
74
Harkins S W, Chapman C R.
Detection and decision and factors in pain perception in young and elderly men.
Pain.
1976;
2
253-264
-
75
Harkins S W, Chapman C R.
The perception of induced dental pain in young and elderly women.
J Gerontol.
1977;
32
428-435
-
76
Laitinen L V, Eriksson A T.
Electrical stimulation in the measurement of cutaneous sensibility,.
Pain..
1985;
22
139-150
-
77
Lucantoni C, Marinelli S, Refe A.
Course of pain sensitivity in aging. Pathogenetical aspects of silent cardiopathy.
Arch Gerontol Geriatr.
1997;
24
281-286
-
78 Mumford J M. Pain perception in man on electrical stimulating the teeth. In: Soulairic A, Cahn J, Charpentier J (Hrsg). Pain. London: Academic Press 1968: 224-227
-
79
Mumford J M.
Pain perception threshold and adaptation of normal human teeth.
Arch Oral Biol.
1965;
10
957-968
-
80
Notermans S LH.
Measurement of pain threshold determined by electrical stimulation and its clinical application. Part I. Method and factors possibly influencing the pain threshold.
Neurology.
1966;
16
1071-1086
-
81 Helme R D, Gibson S J. Pain in the elderly. In: Jensen TS, Turner JA, Wiesenfeld-Hallin Z (Hrsg). Proceedings of the 8th World Congress on Pain. Seattle: ISAP Press 1997: 919-944
-
82
Walsh N E, Schoenfeld L, Ramamurthy S, Hoffman J.
Normative model for cold pressor test.
Am J Phys Med Rehabil.
1989;
68
6-11
-
83
Woodrow K M, Friedmann G D, Siegelaub A B.
Pain tolerance: differences according to age, sex and race.
Psychosoma Medicine.
1972;
34
548-556
-
84
Washington L L, Gibson S J, Helme R D.
Age-related differences in the endogenous analgesic response to repeated cold water immersion in human volunteers.
Pain.
2000;
89
89-96
-
85
Edwards R R, Fillingim R B, Ness T J.
Age-related differences in endogenous pain modulation: a comparison of diffuse noxious inhibitory controls in healthy older and younger adults.
Pain.
2003;
101
155-165
-
86 Melzack R, Casey K L. Sensory, motivational and central control determinants of pain. In: Kenshalo DR (Hrsg). The Skin Senses. Springfield, IL: Thomas 1968: 423-443
-
87
Ishii K.
Clinical application of positron emission tomography for diagnosis of dementia.
Ann Nucl Med.
2002;
16
515-525
-
88 Price D D. Psychological and Neural Mechanisms of Pain. New York: Raven Press 1988
-
89
Braak H, Braak E.
Morphological changes in the human cerebral cortex in dementia.
J Hirnforsch.
1991;
3
277-282
-
90
Callen D J, Black S E, Caldwell C B.
Limbic system perfusion in Alzheimer's disease measured by MRI-coregistered HMPAO SPET.
Eur J Nucl Med Mol Imaging.
2002;
29
899-906
-
91
Chetelat G, Baron J C.
Early diagnosis of Alzheimer's disease: contribution of structural neuroimaging.
Neuroimage.
2003;
18
525-541
-
92
Rüb U, Del Tredici K, Del Turco D, Braak H.
The intralaminar nuclei assigned to the medial pain system and other components of this system are early and progressively affected by the Alzheimer's disease-related cytoskeletal pathology.
J Chem Neuroanat.
2002;
23
279-290
-
93
Scheff S W, Price D A.
Alzheimer's disease-related synapse loss in the cingulate cortex.
J Alzheimers Dis.
2001 Oct;
3
495-505
-
94
Buchel C, Morris J, Dolan R J, Friston K J.
Brain systems mediating aversive conditioning: an event-related fMRI study.
Neuron.
1998;
20
947-957
-
95
Bromm B.
Brain images of pain.
News Physiol Sci.
2001;
16
244-249
-
96
Bornhovd K, Quante M, Glauche V, Bromm B, Weiller C, Buchel C.
Painful stimuli evoke different stimulus-response functions in the amygdala, prefrontal, insula and somatosensory cortex: a single-trial fMRI study.
Brain.
2002;
125
1326-1336
-
97
Tölle T R, Kaufmann T, Siessmeier T, Lautenbacher S, Berthele A, Munz F, Zieglgansberger W, Willoch F, Schwaiger M, Conrad B, Bartenstein P.
Region-specific encoding of sensory and affective components of pain in the human brain: a positron emission tomography correlation analysis.
Ann Neurol.
1999 Jan ;
45
40-47
1 Unter Schmerzbericht wird hier die verbale Äußerung von klinischen Schmerzen jedweder Genese verstanden.
Dipl.-Psych. M. Kunz
Klinik für Psychiatrie und Psychotherapie · Philipps-Universität Marburg
Rudolf-Bultmann Str. 8
35033 Marburg
eMail: kunzm@med.uni-marburg.de
