In Living with Lost Time (3)(2025)

3. The History of Dementia

That the disease called dementia increases in likelihood with advancing age, and that this tendency appears with particular clarity in the modern era — an age of extended longevity — is not especially difficult to understand. Yet, when history is traced back — that is, when the memory of humankind is followed — faint traces concealed within old records make it possible to confirm that, even in times when life expectancy was short, the germ of this disease was by no means entirely absent. Such traces may be glimpsed in literary expressions that move between reality and imagination, as in one of the enduring tragedies left by William Shakespeare, namely King Lear. In that work, three daughters stand in relation to a father; and although the matter of gender differs, in another place a mother also stands in relation to three children.

In this work, the figure of King Lear — advancing in age and at times exhibiting behavior as though reason were failing — through erratic conduct and contradictory speech gives rise to anxiety and suspicion within the relation binding father and daughters, among whom are Goneril and Regan, figures who, though cold, remain attentive to the words and actions directed toward them. In a certain scene, where two daughters speak together of the strangeness of a father, the words that are heard cannot but be received as voices resounding from a distant past, bearing not only the inscrutability brought about by this disease, but also the confusion and inner conflict that arise within the relation of witnessing. Within the resonance of such voices, the universality of the phenomenon called dementia — and the profound effects that unfold within the relations surrounding it — can be discerned, faintly yet unmistakably.

GONERIL

You see how full of changes his age is; the observation we have made of it hath not been little: he always loved our sister most, and with what poor judgment he hath now cast her off appears too grossly.

REGAN

’Tis the infirmity of his age: yet he hath ever but slenderly known himself.

GONERIL

The best and soundest of his time hath been but rash; then must we look from his age to receive not alone the imperfections of long-engraffed condition, but therewithal the unruly waywardness that infirm and choleric years bring with them.

In this play, said to have been composed between 1605 and the following year, the fact that the daughters — Goneril and Regan — regard the eccentric conduct of father King Lear, together with the wavering of reason that at times appears, as part of the phenomenon of aging, may be said to reflect a perception of old age that was nearly universal within the premodern world. This is because, in an age when the concept of neurodegenerative disease was not yet known, it was widely accepted to regard human aging as a single continuous process, one understood to include within it mental decline as well. Such an understanding is scarcely to be doubted, given that it is the result of people having uniformly witnessed the physical and mental changes that an individual inevitably experiences with advancing age.

However, for people of the present age, the blind spot lurking within this simple understanding — the subtle yet significant difference existing between the general phenomenon of aging that accompanies advancing years and the onset of the specific disease known as dementia — offers, rather, an occasion to reconsider the very essence of dementia itself. What the statistical phenomenon whereby the probability of developing dementia increases with advancing age suggests is not merely an increase in disease as a result of human lifespan having lengthened, but rather how complex and delicate a balance the brain depends upon in maintaining its function. When this balance collapses, what comes into relief is the manner in which the universal phenomenon of aging and the specific disease of dementia become entangled in ways difficult to distinguish, at times binding so closely together that the very distinction itself seems impossible.

Moreover, the point that the very understanding of mental illness has itself influenced the perception of dementia cannot be overlooked. Given that dementia, while being regarded as part of the phenomenon of aging, at the same time often exhibits symptoms suggestive of mental illness, the dominant perception toward it has acted profoundly upon the interpretation and attitude of those who have witnessed this disease. In considering such a phenomenon, it is difficult to speak of it apart from the background of the premodern age. In this era, wherein the unity of religion and governance functioned as a fundamental principle of society, the religious and ethical norms shared by the community greatly constrained the cognition and conduct of individual people, while at once confining the understanding of disease within that same framework. The circumstance whereby the disease itself, prior to being grasped in medical and scientific terms, is first evaluated from a moral standpoint, determines how the suffering of the afflicted comes to be situated.

Dementia too is drawn into this framework, interpreted in relation to the community’s norms and belief system before ever being grasped as a mere physical or biological phenomenon. For this reason, those who experience dementia cannot but be affected, even more profoundly than by the concrete difficulties the symptoms themselves bring, by the gaze of the community — that is, by the prejudice and misunderstanding shaped according to the values of the age. In this way, dementia comes to be bound not only to an understanding as part of the phenomenon of aging or of mental illness, but to the very representation of the age itself, as something prescribed by social and religious values.

Now, when one traces the shelves of history, however minutely the progress of medicine may be recorded there, one comes to notice that books turning their attention to the transformation of the disease called dementia itself are, in both East and West, surprisingly few — scattered, rather, throughout the vast domain of psychiatry, as though lost within the shadow of old age, such that tracing its history as a singular entity proves difficult. Although the phenomenon called dementia has been visible to human eyes since antiquity, vaguely accepted as one among the fates of aging, it had to await the arrival of the scientific spirit of the nineteenth century before being clearly recognized as a single disease and becoming an object of systematic study. Prior to that, it was treated merely as a sign of aging, or as a distant echo of madness, never becoming an object of individual inquiry; this very circumstance, it would seem, is the reason why, even today, books weaving an independent history of this disease remain surprisingly few.

In the age extending from antiquity to the Middle Ages in the West, the phenomenon called dementia is grasped as a natural consequence of aging and, at times, as a mysterious occurrence. In ancient Greece, Hippocrates, the sage of medicine, turns attention to the decline of mental function among the elderly, attributing its cause to old age. According to the medical theory of Hippocrates, it is the balance of the bodily humors that governs human health; dementia, too, is explained from the standpoint of a disturbance among these humors. This thought is carried forward into the age of Galen in ancient Rome as well; Galen likewise records the decline of cognitive function as part of the process of aging. The interpretation of this consolidator of ancient medicine, however, seeks not to grasp this as a pathological phenomenon, but rather to understand it as the working of nature’s own order.

However, when one turns one’s gaze to medieval Europe, the understanding of dementia undergoes a complete transformation. Rather than seeking its cause and nature within the order of nature, the tendency to speak of it as a mental illness or as a religious matter grows stronger. Under the influence of Christian theology, dementia comes to be bound to the intervention of evil spirits or curses; the mental changes of the elderly are often viewed negatively, as an object of fear. Through this, the notion of a gentle process of aging — such as the Greco-Roman tradition presents — comes to be reinterpreted within a religious context of guilt and punishment. As a result, the elderly who experience such changes at times become objects of exclusion or persecution by the community, the very existence of those afflicted with dementia being treated as a factor that stirs social unrest.

In this way, in whichever age one looks, the mental changes of the elderly are spoken of, more often than not, not as a mere biological phenomenon but as a disturbance of temperament or a religious occurrence. Given this, no concept exists whereby dementia itself is identified as an independent disease or systematically classified; rather, cultural norms and religious convictions are deeply implicated in such a background.

The understanding of dementia in China differs subtly from that of the West, being grasped as part of the phenomenon of aging and, at the same time, as its symbol. From ancient times, within Chinese thought, the decline of mental function among the elderly has been regarded not merely as the result of advancing age, but as arising from a depletion of vital energy or a disharmony of yin and yang within the body. This view bears resemblance to the understanding found in the Greco-Roman world, such that one glimpses a commonality between the two civilizations of East and West in their reverence for the order of nature. However, even as the general understanding that attributes the cause of dementia to aging is shared, the interpretation surrounding it undergoes subtle change from age to age.

In the medical texts of the Tang dynasty, it is explained that the cause lies in a pernicious influence called “wind,” which invades from without through the skin and disturbs the harmony within the body. This grasps the decline of cognitive function within a connection between natural phenomena and external factors, suggesting the thought that the human body is affected through its interaction with the environment. By the Yuan dynasty, on the other hand, it comes to be thought that the decrease of vital essence and blood in old age — that is, a condition of “deficiency” — gives rise to symptoms such as forgetfulness, stupor, and even incoherent speech and delusion. What is to be seen here is the recognition that the biological phenomenon of aging is deeply bound to mental change and confusion, beneath which lies the foundation of traditional Chinese medicine, namely that body and mind are one and inseparable.

In this way, within China, dementia is incorporated into the broad framework of the phenomenon of aging and of mental illness, never arriving at a recognition formed as an independent disease. What this signifies is that the changes of human body and mind were not severed as discrete events, but rather understood within a grand cosmology of harmony and disharmony as a whole; such a view, even while speaking of the same phenomenon of aging, offers a cultural perspective differing from that of the West.

The understanding of dementia in Japan shows a pronounced tendency, in comparison with that of the West or of China, to be grasped within the broader expanse of aging phenomena and mental illness; this ambiguous boundary suggests that, since ancient times, it has been deeply rooted within the consciousness of the people. For instance, in one poem collected in the seventh-century Man’yōshū, the act of a falconer letting a hawk escape is depicted within words that evaluate this very person as “a mad and wretched old man.” That this may be understood as pointing toward dementia owes to the fact that the poem’s figurative expression hints at a mental decline and abnormality lying behind it.

Moreover, in the eighth-century Shoku Nihongi, there exists a description of the conditions under which a district magistrate — an official governing a district as a local administrator — comes to retire; therein, the case is expressed wherein “one reaches advanced age, the mental faculties fall into derangement, thus giving rise to deranged speech.” What is to be seen here is evidence that signs of mental confusion or delusion were recognized as something arising naturally within those who have passed beyond a certain age. Within such a description, the distinction between the phenomenon of aging and dementia remains ambiguous; rather, it may be said that both were grasped within one and the same continuous change.

What is common to these examples is that, within ancient Japanese society, mental decline and abnormality were received not as something cut out as an individual pathology, but rather as the inevitable fate that a human being traces along with advancing age; behind this, one glimpses a thought seeking to enfold the relation between nature and humankind within harmony. Such a manner of grasping things, bound up with the cultural background of Japan, bears the peculiarity that the very concept of dementia raises its outline only dimly, within the larger framework of aging.

Premodern medicine in Japan, at its very root, is deeply inscribed with the influence stemming from China; the concept of dementia, too, is formed upon this cultural foundation. From antiquity through the medieval period, people strive to understand disease and the disturbances of body and mind on the basis of cosmic principles originating in China, such as the theory of yin-yang and the five elements, or the flow of qi. Amid this, during the Heian period, Chinese-derived medicine comes to be placed at the center of court medical practice, its knowledge undergoing systematization while simultaneously achieving development; however, no particular attention comes to be directed toward dementia, such that the understanding concerning it remains ambiguous.

The decline of cognitive function accompanying aging, too, is for the people of that age enfolded within the broad concepts of “old age” or “foolishness,” never severed as an individual pathology in itself. Even symptoms such as the decline of memory or mental confusion — symptoms that, from a present-day vantage, might be regarded as dementia — are accepted as changes naturally visiting old age.

Furthermore, as Buddhism spreads widely, many mental problems come to be explained within the religious framework of karma or earthly desire. People situate the decline of memory or the disturbance of spirit brought by old age within the Buddhist worldview of impermanence and the cycle of rebirth, understanding it as personal fate or the transmigration of the soul, finding therein a kind of metaphysical meaning. This is an attempt to sublimate the reality of suffering and decline into a universal truth transcending the individual; within it breathes the perspective of Japanese culture, ever seeking to harmonize the relation between nature and humankind, between spirit and flesh.

Within the classics, descriptions surmised to be dementia are scattered here and there, beginning to appear under the expression hoke from the Heian period onward. This hoke is a word that, with the passing of time, is carried into the present as boke; its earliest instances are confirmed within The Tale of Genji. For instance, the mother of Lady Akashi is described as “an utterly hoke person,” while, regarding the mother of the Bishop of Yokawa, it is recorded that “the years had accumulated upon this person, who had become hoke.” These descriptions hint at how the people of that age received the mental changes of the elderly.

Moreover, in Yoru no Nezame (“Awakening at Night”), written in the latter half of the eleventh century, there appears a passage — “the hoke-hoke-ness accumulated through old age, how regrettable that things should come to this” — depicting concretely the mental transformation brought by aging. As the age shifts toward the Kamakura period, within the Genpei Jōsuiki, in a description concerning Itō Nyūdō Suketaka, who plotted rebellion against Minamoto no Yoritomo, there occurs a scene in which Sukekiyo, the son of this very Suketaka, states: “given that the lay-priest, my father, has fallen to excess into old-age madness, this conduct gives rise only to matters that bring inconvenience.” Also to be seen is a depiction wherein one who seeks to seize, through contention, a gift bestowed by Yoritomo, is evaluated as “perhaps the doing of old-age madness”; room remains to interpret this expression “old-age madness” as pointing toward dementia.

The expressions hoke and “old-age madness,” repeated throughout these records, show that, within the cultural and religious background of that age, the distinction between the phenomenon of aging and dementia was grasped ambiguously; moreover, given that these phenomena are depicted not as mere physical change but as an aberration within the dimension of spirit and society, such expressions bear a significance of their own.

The examples raised, much as that seen within King Lear, can hardly be called, any of them, a positive expression. Behind this, despite the deeply rooted custom of revering elders, there drifts something resembling no small antipathy, whereby the people of that age did not regard the phenomenon called dementia with much favor. In such an age, it seems that these records vividly reflect how the disease called dementia did not remain a mere phenomenon of aging, but was rather an existence accompanied by fear and avoidance. Rather, within myth and legend, those bearing dementia or mental illness are often depicted as an object of reverence, while at the same time as a threat. It is as though this tells of how a complex feeling, in which fear and reverence intermingle at once, crossed back and forth within the hearts of the people of that age.

With the advent of the Edo period, references concerning the physical and mental changes accompanying aging increase; among these comes to be seen expressions suggesting the necessity of what might be called prevention or caregiving. This stands as evidence that, as though advancing age were part of an unavoidable transformation, awareness of it gradually came to permeate every corner of society. In this process, the term rōmō (senility) comes into wide use, settling into place as a concept pointing toward the mental decline of the elderly. However, interestingly, this word rōmō does not necessarily coincide with the present-day concept of dementia; its category includes mental problems in a broad sense as well as physical changes accompanying aging, such that one senses it inevitably contains a good many parts differing from today’s framework of the concept of dementia.

In the medical texts of that age, descriptions concerning the decline of memory or change of character brought about by aging are scattered here and there; however, all of these are spoken of within the framework of Eastern medicine, such as the stagnation of “qi” or “blood” composing the body, or the decline of function of the “kidneys.” For instance, despite Kaibara Ekiken, in the Yōjōkun (“Precepts for Health”), speaking of the importance of maintaining health and peace of mind in old age, no discussion comes to focus upon dementia itself. In the eyes of this very Ekiken, maintaining harmony between body and mind is, above all else, of importance; the wavering of memory or thought is grasped, to the very last, as nothing other than the natural course of things. Such a view suggests that the people of that age regarded the changes visiting along with old age as something to be accepted, in some measure.

In Kinsei Kijinden (“Biographies of Eccentrics of Recent Times,” 1790), the collection of biographies from the mid-Edo period composed by Ban Kōkei, there is reference made to the prevention of dementia and to caregiving. Nourishing life, that is, as a means of delaying rōmō, points toward a path of modesty and diligence, such as “eating but little, never taxing the heart and mind, severing oneself from carnal indulgence.” However, contrary to what such words might evoke, toward the illness of the mind including rōmō, Kōkei lets drift a stern sense of helplessness, stating that “even a divine physician possesses no remedy”; this signifies that, once such a thing has occurred, its repair is no longer possible. Moreover, while there is also a description concerning caregiving, those bearing rōmō are said, after death, to be elevated to ancestral spirits, becoming guardian deities watching over the family’s later generations; the caregiving of such persons is held to be a duty belonging to the family — within this resounds something distinctly East Asian, namely that caregiving forms part of the obligation of ancestral rites.

With the advent of the modern age, as Western medicine sets its steps upon this path, the understanding concerning dementia undergoes a great transformation. Unlike the obscure viewpoint formerly seen toward mental change, such change accompanying dementia comes to be grasped clearly, having obtained the framework of new concepts such as “chihō” or “senile chihō”; this is, precisely, a matter dating from the time modern Western medicine came to be imported into this land.

After the Renaissance, the development of anatomy and physiology begins to reveal one corner of the once-mysterious relation between brain function and mental state. For instance, the seventeenth-century development of body-mind dualism by René Descartes makes reference to the brain, situating its existence within the framework of thought. However, during this period, the phenomenon called dementia has yet to reveal its form. Upon entering the eighteenth century, the understanding toward mental illness gradually deepens, such that its abnormality comes to be considered as perhaps originating in brain function; the day, however, when the decline of cognitive function accompanying old age comes to be clearly grasped as a disease, remains yet ahead.

As the historical figure most widely known to have developed dementia, Immanuel Kant stands foremost. Born in 1724, Kant, weak in health from childhood onward, pays the most scrupulous attention to health. Through a regular life, a daily walk, meals considered for nutritional balance, moreover gatherings of society wherein topics of the day are discussed together, Kant — rare for the age — lives out a long life, passing into eternal rest at the age of seventy-nine. However, in the very last years of this life, as dementia advances, Kant comes to eat cheese and butter repeatedly, in time develops gout; the famous walk most renowned in the history of thought, together with the rhythm of life long preserved, collapses, quarrels with friends increasing — though many imagine that, had there been no dementia, this life would have continued longer still, pursuing even deeper contemplation.

When one looks back upon the transformation of understanding concerning dementia, one is led, inevitably, to the epoch-making discovery made, at the dawn of the twentieth century, by a physician bearing the name Alois Alzheimer. This report casts new light upon an age in which the forgetfulness of old age had been accepted as a vague fate; given this, it is rather to be considered natural that this disease was first recorded as a youthful-onset dementia. In order to define dementia as a disease unto itself, severed from the irreversible flow of aging, clinical cases occurring in none other than the young prove indispensable; therein alone can one find both the dilemma that medical progress bore at that time and the dawning of a new age brought by its overcoming.

The German psychiatrist Alois Alzheimer carries out, within a laboratory of the University of Munich, the research destined to inscribe this name into the history of medicine — together with Frederick Lewy, a name later to be bound to “dementia with Lewy bodies”; both come to study under the towering figure of psychiatry, Emil Kraepelin. Kraepelin builds a grand system of classification dividing mental illness broadly into schizophrenia and manic-depressive illness, a figure who thereby redraws the map of psychiatry thereafter; Alzheimer’s inquiry, too, proceeds within such a framework. However, on a certain day in 1901, the encounter with Auguste Deter, a fifty-one-year-old woman examined by Alzheimer, becomes the turning point that changes this very life, thus medicine itself.

Despite that age, the suffering of Auguste Deter — afflicted by symptoms such as memory impairment and delusions of jealousy, until life comes to an end at fifty-six — proves something the conventional framework of medicine cannot fully grasp; Alzheimer estimates the onset of symptoms to trace back to around the age of forty-six. Following death, Alzheimer investigates this very brain in detail, discovering, outside the nerve cells, abnormal spots — what comes to be named the Alzheimer “senile plaque.” With this epoch-making discovery, Alzheimer presents, in 1906, at the Southwest German Society for Psychiatry held in Tübingen, the case concerning Deter, publishing the paper the following year. At that time, the theory attributing dementia to syphilis holds sway as the dominant view; Alzheimer, however, raises objection to this, presenting a new category as a disease characterized by onset in early old age, progressive memory impairment, delusion, accompanied by senile plaques as well as neurofibrillary tangles.

This case comes to be taken up at great length within the textbook of psychiatry composed by Kraepelin, in time becoming widely known under the name “Alzheimer’s disease.” Moreover, the “senile plaque” named by Alzheimer is revealed, through later research, to be a mass of protein called amyloid beta. However, although Alzheimer’s disease was at first distinguished from senile dementia as a dementia of early old age, clinicopathological research in the 1960s arrives at the conclusion that both are one and the same disease. In this way, medicine, by reuniting a pathological condition once divided, by inscribing the name of Alzheimer into the very name of the disease, traces the path whereby this physician’s research becomes a thing immortal.

In premodern Japan, dementia, regarded as one part of the old age that belongs to the order of nature, even when conduct grew abnormal, was not necessarily cast out from the community; however, once modern Western medicine came to be imported, this very phenomenon, taken as a kind of mental illness, comes to be placed under the management of medicine and police, such that not only is protection by the family enforced, but, in cases difficult to manage, confinement within a private home or forced commitment to an asylum for the insane is also carried out. At that time, as terms of Western medicine were being translated into Japanese, for “dementia,” words such as “chikyō,” “fūten,” “chihō” come to be proposed; at the close of the Meiji era, Dr. Kure Shūzō, grieving over the circumstances of the mentally ill in Japan with the words, “beyond the misfortune of having received this disease, one must say that this compounds the misfortune of having been born in this country,” advocates avoiding the characters for “madness” and “derangement,” proposing instead the use of “chihō.” Yet, in society at large, the distinction between dementia and the phenomenon of aging remains ambiguous still, those with dementia who wander being called “kyōten” or “fūten.” Not only in Tanizaki Jun’ichirō’s Diary of a Mad Old Man, but Natsume Sōseki too, within I Am a Cat, records those afflicted with fūten as “madmen.” As the name of the disease, “chihōshō” comes into use, continuing in use until, in 2005, the Long-Term Care Insurance Act is revised, the term changed to “ninchishō” — this, too, the fruit of efforts by a social movement contending that the former term brings about a stigma founded upon speculation and prejudice.

That the response toward people with dementia holds many elements in common with that toward people bearing mental disability is a matter easily imagined; however, when one comes to know the fact — as Miyazaki Wakako’s Shall We Learn the History of People with Dementia? (2011) tells — that even in the postwar era, antiquated methods such as confinement within a room or physical restraint persisted stubbornly, continuing to be tacitly permitted where the eyes of society could not reach, one is brought once again face to face with an instance in which humanity becomes captured by a certain idea, thereby, through blind adherence to it, comes to lose its very humanity. Dementia, in the first place, is something that appears through individual human beings, never existing severed from human activity in itself; nevertheless, at some point, attention comes to be drawn solely toward “dementia,” such that the irreplaceability of the very person standing before one is overlooked, the ideals of respect for human rights and humanitarianism being lost from the attitude with which one comes into contact. Even so, in recent years, given changes in political and medical recognition — in particular the influence of a new current symbolized by a “new perspective on dementia” — treatment that ought to be called a manifest violation of human rights, such as once existed, has vanished from open scenes; this, however, does not immediately mean that people with dementia have come to be treated with dignity in whatever environment they may find themselves, for, each time a case of abuse by facility staff or family is reported as news, one is made to realize anew how incomplete, how fragile, such change remains. I myself, too, harbor doubt — more than once — as to whether my conduct toward my mother is indeed appropriate, as to whether my own actions might not, somewhere, unknowingly wound my mother’s dignity; on such occasions, I cannot but consult with the doctor or the care manager.

This history of dementia is, so to speak, a path tracing the process known as “medicalization”; when we look back upon this course, it is as though we are watching the transformation whereby a problem, a behavior, or a condition once severed from the outside comes, by degrees, to be newly defined within the framework of medicine, emerging as an object of diagnosis and treatment. This is nothing other than the process whereby what was once regarded as a non-medical existence, as part of the phenomenon of aging, is suddenly reconstructed as a medical problem, revealing its form before our eyes. Peter Conrad and Joseph W. Schneider, in Deviance and Medicalization: From Badness to Sickness (1980), discuss this divided into three dimensions, as though, quietly yet steadily with the passing of time, the very form of the thing were changing. It is as though, with the flow of time, what was once nothing in particular suddenly turns, within people’s perception, into something called illness, such that one is asked how much change must be accepted, how much understood, in step with such a progression.

In the first stage lies the medicalization of the conceptual dimension, whereby deviant behavior or problems come, before one knows it, to be spoken of within a medical framework. Behavior or conditions once regarded as part of aging, or as moral deviance, come gradually to be conceptualized as “illness,” arriving at last at being made an object of treatment. This is much like the sensation of walking along a road not yet seen, such that what lies ahead at last comes gradually into view.

Proceeding further, one arrives at institutional medicalization, whereby society, within its institutions and policies, incorporates medical responses, selecting a method of dealing with deviant behavior. Problems of daily life come to be defined as illness, the institutional structure of medical bodies corresponding to this becoming established. The scope of medicine gradually expands, extending even into domains once borne by religion, law, or other social institutions. Within such a process, it is unavoidable that not merely the birth of new authority but, at times, fierce friction too should arise. Therein countless relations of power become entangled, such that one sees figures desperately striving to understand this framework, lest anyone be left behind by its current.

In the third stage lies the medicalization of the dimension of the doctor-patient relation, whereby, defined as illness, the corresponding medical institution is established, the patient receiving examination by the physician. In step with such stages, the management of deviance, too, expands; as a means of managing behavior that society regards as undesirable or destructive, various organizations, on the grounds of medical explanation, press upon society the necessity of medicalization, until, at last, medicine comes to be made use of. When such behavior comes to be defined within the framework of medicine, the approach taken toward it shifts from a punitive one toward treatment; the intervention of medicine, in the course of such a process, gradually expands its scope. Into depths once unreached, the hand of medicine extends; before one knows it, this becomes part of daily life, a situation arriving, somewhere, inevitably, that must be accepted. This, like a fate from which there is no longer any escape, comes to show people a new path — the so-called “self-restraint police” at the time of the COVID pandemic stand as one example of an ill-intentioned exploitation of medicalization.

Even granting that the concept of medicalization is, as its very name suggests, the process whereby illness or disorder is taken up into the framework of medicine, this is not always met with praise; it is at times mocked with critical terms such as “disease mongering” or “pathologization.” Such criticism is founded upon a viewpoint that regards the expansion of medicine as nothing other than the justification of a kind of “medical imperialism”; even granting that this aspect is, indeed, difficult to deny, what proves interesting is that there exists a movement running, as it were, counter to this current — namely, the phenomenon called “demedicalization.” Demedicalization refers to behavior or conditions once made the object of medicine being released from that framework, redefined as something requiring no application of medicine; the history of homosexuality in the West may be cited as one such example. As this example shows, medicalization and demedicalization are not formed purely from medical knowledge alone; one must not overlook that they are influenced by social movements as well.

Against this, when one confronts, in Japan, the task of truly medicalizing dementia, what cannot be avoided is the new stage of medicalization known as “pharmaceuticalization.” This pharmaceuticalization points to a tendency to grasp human conditions or behavior as problems requiring treatment or improvement by means of drugs; within such a process, drugs come to occupy the very core of medicine — at the time of the COVID-19 pandemic, the conspiracy theories of anti-mask and anti-vaccine sentiment that ran rampant did nothing more than exploit, in extremist fashion, the problems of medicalization and restriction, rather than questioning them so as to improve matters. What proves epoch-making from this vantage is the approval, in Japan in 1999, of “Aricept”; this event clearly positions dementia as an object of medicine, becoming the occasion for “truly” medicalizing it within Japanese society.

The drug called Aricept (also known by the name donepezil) comes to be widely known as a presence offering a faint guidepost within a brain turned into a labyrinth of memory, or, again, as a drug casting new light upon the landscape of the disease called Alzheimer’s-type dementia. Its development is the fruit of collaboration between two enterprises bearing differing cultural backgrounds — the Japanese pharmaceutical company Eisai, the American pharmaceutical company Pfizer; in 1996, approval is granted by the United States Food and Drug Administration — or rather, the abbreviation FDA, more familiar from having been heard so often during the pandemic — as a treatment for patients with mild to moderate Alzheimer’s-type dementia. From this moment as a starting point, Aricept spreads beyond geographical boundaries, becoming, throughout the world, one of the standard options in the treatment of Alzheimer’s disease.

The mechanism of action of Aricept lies in its very essence as an acetylcholinesterase inhibitor. In Alzheimer’s disease, acetylcholine, a neurotransmitter within the brain, gradually decreases; this is one cause giving rise to the decline of cognitive function, such as the loss of memory or difficulty of thought. This drug, by suppressing the action of the enzyme bearing the role of breaking down acetylcholine — that is, acetylcholinesterase — increases the concentration of acetylcholine within the brain, aiming, as a result, at the smoothing of neural transmission. Through such action, the possibility is suggested of an improvement in memory or thinking ability, or, alternatively, a slowing of the progression of the disease. However, such action does not overcome the disease of Alzheimer’s itself; rather, it resists its progression, becoming a support for the patient’s “quality of life (QOL)” within a limited span of time.

Aricept, bearing such properties, may temporarily ease the symptoms of Alzheimer’s-type dementia, possibly slowing its progression; however, the fact that this never possesses a dramatic effect such as a magic wand must likewise not be overlooked. Nevertheless, the advent of this drug brings a decisive turning point to the very manner of medicine surrounding dementia. Compared to the chlorpromazine revolution of 1952 in the treatment of schizophrenia, even granting that its effect may be limited, the very fact that a possibility of treatment exists leads to dementia being positioned not merely as a problem for specialists alone, but as a disease that a greater number of medical practitioners ought to confront. Such change is not confined merely to the spread of a single drug; it opens new doors within the medical system as well as in patient care.

That the undertaking of medicine aims, as its original purpose, at healing illness or injury goes without saying; however, one must recall the fact that, given that, at the time, no effective treatment exists for the disease called dementia, physicians other than specialists lack the motivation to gain deep knowledge concerning this disease, such that, even when a patient crosses the threshold of the examination room, the physician has no choice but to respond without fully understanding the symptoms, in a state of not quite knowing. As a result, when a patient’s condition worsens, taking on the aspect of abnormal behavior, the measure of forced commitment to a mental hospital is at times taken; whether such an act truly considers the benefit of the patient is exceedingly doubtful. Among such physicians, there are, it is thought, some who push the response to dementia patients outside the bounds of professional responsibility, reasoning, “there is no prospect of a cure in any case, nor, to begin with, is this my domain.” Medicine’s true calling lies in treatment; however, given that this proves impossible for dementia, for which no effective drug exists, it follows that no motivation exists, for the non-specialist, to learn knowledge concerning this disease.

Meanwhile, there exist specialists who continue to confront this problem in earnest; with the introduction, through the 1982 Health and Medical Services Law for the Elderly, of a fixed-amount burden on elderly medical expenses, dementia policy as a measure of mental health care for the elderly comes to be undertaken on a national scale. Through this policy direction, from 1984 onward, many new initiatives are unfolded: training programs in techniques of response for the demented elderly, the establishment of a headquarters for promoting policy toward the demented elderly, moreover the development of health facilities for the elderly, treatment wards for dementia-related illness, day-care facilities, dementia-disease centers. Given the present circumstance in which an effective treatment drug remains still lacking, specialists proceed by placing emphasis upon “care” aimed at improving the patient’s quality of life, beginning with rehabilitation.

Under such circumstances, the advent of a drug recognized as effective, even if limited, marks the moment at which the landscape of the disease called dementia begins to be newly redrawn. As this new drug, named Aricept, becomes available for prescription, physicians other than specialists too come to be called upon to bear diagnosis and prescription; this gives rise, among physicians in general, to a current of relearning knowledge concerning dementia, beginning with training sessions. Given that non-specialists, too, come to bear prescription for patients, diagnosis becomes necessary; while detailed examination and treatment are carried out by specialists, literacy concerning dementia comes to be demanded of general physicians as well. Through the spread of such knowledge into the medical community, interest toward this disease rises; given that the administration of Aricept aims at slowing the speed of progression, physicians too come to reconsider how to confront this disease, the gap between specialist and non-specialist concerning dementia coming to be filled, such that physicians of neighboring fields too come to take part in treatment. However, the use of this drug demands the utmost care. Administration to patients bearing heart disease, to those with problems of the stomach and intestines, to those suffering from asthma, must be carried out with caution; moreover, attention must be paid to interaction with other drugs. In particular, concurrent use with drugs possessing anticholinergic action ought to be avoided. Whether specialist or non-specialist, when carrying out drug treatment for dementia patients inclusive of other illness, one is pressed toward the necessity of possessing comprehensive knowledge and judgment, deciding policy only after confirming medical history as well as drugs being taken. In this way, medical knowledge concerning dementia comes to be shared widely throughout the medical world, advancing toward the new stage called “medicalization.” Now, having passed through such a history, the very drug used in the treatment of my mother is this Aricept.

In 2004, the appellation “chihōshō,” long in use, brings down the curtain upon its own history, being revised into the more neutral and scientific name “ninchishō” (cognitive disorder). Behind this lies the spread of an awareness as to how grave a psychological burden the derogatory and discriminatory resonance lurking within the word “chihō” had brought upon the afflicted as well as the family; moreover, this had become, by then, a demand of the age no longer to be overlooked. This change is not confined merely to the act of replacing a word; amid an aging population accelerating ever further, it stands also as an ethical attempt to alter the gaze that society directs toward those with dementia, ever increasing in number, removing, even if only somewhat, the prejudice and misunderstanding toward the disease itself.

Within the new name chosen, “ninchishō,” is embedded a scientific, dispassionate connotation — that of impairment of cognitive function; this, while expressing accurately the very essence of the disease, holds also the significant intent of softening the sense of stigma borne by the afflicted as well as the family. In this way, the Ministry of Health, Labour and Welfare formally adopts “ninchishō” as the recommended term, the expression “chihō” gradually vanishing as well from the medical community and clinical practice. Given that this new name comes to be used in education and research too, a social consensus comes to be formed, an occasion built whereby understanding toward the disease called dementia evolves into something deeper, more comprehensive. It may be added that other countries, too, are shifting from “dementia” toward “cognitive decline.”

The renaming into “ninchishō” carries a meaning that, far from merely focusing upon impairment of cognitive function, proves truly fitting, bearing, in a certain sense, an inclusive connotation. Inferring from several traits exhibited by my mother — namely, a poverty of the capacity to view her own thought and conduct objectively, my mother’s manner of always acting with her own viewpoint set at the center — this name “ninchishō” suggests that, beyond cognitive function itself, the disease includes within it what might be called metacognition, that is, the decline of the capacity to recognize and control one’s own cognitive process. Metacognition is none other than the capacity to objectify oneself, to know what one is thinking and how, adjusting one’s conduct on that basis; this is, indeed, the very foundation enabling the higher cognitive activities of human beings, such as memory, attention, or problem-solving. However, that this capacity is eroded, little by little, with the progression of dementia, is something I am made, willy-nilly, to understand through the conduct of my mother witnessed day by day.

Metacognition holds, broadly, two aspects. One is called “metacognitive knowledge,” pointing to knowledge concerning one’s own cognitive function, that is, an understanding of how one remembers, learns, or pays attention. The other is called “metacognitive control,” meaning the capacity to adjust the cognitive process, adapting it toward the achievement of a goal. These capacities are said to be related, in particular, to the frontal lobe of the brain; once impairment extends there, a person may come to lose awareness of memory impairment in herself, find difficulty in devising an appropriate strategy for problem-solving, in time even become unable to recognize the very fact of being ill. Such change appears markedly in the conduct of my mother, my mother’s behavior often taking on a quality such as might be described as “a child possessed of an adult’s pride.” This is because what appears lacking is the capacity to relativize the self — that is, self-reflexive cognitive behavior itself.

As this expression “a child possessed of an adult’s pride” suggests, there is no doubting that a firm pride remains within my mother; how delicate, how difficult a task it is to interact without wounding this very pride, I come to realize anew, day by day. That the words and conduct of my mother at times provoke irritation within me arises, too, from this: that, even as I myself strive to respect this pride, I come near to being crushed beneath it; this very conflict is, no doubt, the cause of the ambivalent feeling I bear toward my mother.