Pain and apathy

Abstract -In this case report we discuss the lack of emotional reactivity and evasive motor motivation to nociceptive stimuli presented by a patient with frontotemporal degenerative disease and apathy as a predominant behavioral symptom. Key words: pain, apathy, frontotemporal, dementia, anterior cingulate cortex. Dor e apatia Resumo -Neste relato de caso, nós discutimos a falta de reatividade emocional e motora frente a um forte estímulo doloroso apresentada por uma paciente com doença degenerativa fronto-temporal cujo principal sintoma era a apatia. Palavras-chave: dor, apatia, fronto-temporal, demência, córtex cingulado anterior. Pain is an unpleasant sensory and emotional experience associated with real or potential tissue damage, and can be modulated by cognitive factors such as previous experience and attention. 1 There are several scales involving self-report, informant rating and direct observations for assessment of pain in patients with dementia. 2-5 Patients with dementia in early stages are able to complete at least one of the available pain scales but the reliability of these scales decreases with progressive decline in cognitive function which leads to underdetection and undertreatment of pain despite a very high prevalence of pain problems in this population. 9 In patients with dementia, it remains unclear if the difficulty in the management of pain results from impaired communication and memory of pain, or whether the perception and experience of pain is altered as a result of the progressive degeneration of cortical and subcortical regions involved in the transmission and processing of nociceptive information. 10,11 Case report A 52 year-old Portuguese woman, with three years of schooling, presented with a 3-year history of behavioral changes and cognitive impairment. Relatives reported that the disease started with stereotypical movements in the right hand and leg followed by aggressiveness. It was noted that she would keep talking about the same issue, and over time began to speak less and less, developing changes in the pitch of her voice. She was not interested in house chores or family problems and started to overeat. The patient was medicated by a psychiatrist with haloperidol and risperidone due to clinical suspicion of Huntington's disease or psychosis. The medication improved the aggressiveness, but not the stereotyped movements. The deterioration of the clinical picture was progressive and relatively fast. Her father had died with dementia and behavioral changes, but a precise diagnosis was never documented. Her brother had also received assistance at our outpatient clinic for a diagnosed frontotemporal dementia. During the clinical examination at her first evaluation at the Behavioral and Cognitive Neurology Unit, Department of Neurology, HC-FMUSP, she was apathetic. She spoke only after great insistence and was hypophonic. She displayed stereotyped movements slapping her hands on her knees, bringing her legs together, and stood up from the chair several times. She kept her upper limb flexed held to her chest, showing mild hypertonia. Her gait was unstable with a tendency to fall in any direction. No alterations in ocular movement were evident. She was dependent for all activities (Functional Activity Questionnaire 12 scoring 22 out of a maximum 30; controls score 0-2). She could not take food to her mouth and had to be spoon fed