Dementia is, and always has been, a substantial social issue. Because it is a cluster of cognitive and behavioral symptoms, the dementia syndrome was technically a mental disorder and was long the purview of the institutionally based alienist, the forerunner of today’s psychiatrist. Before the recognition of mental disorders as a form of illness in the fifteenth and sixteenth centuries, persons with dementia lived in almshouses or wandered the streets when they could no longer be contained by their families. Between the late eighteenth century and the late nineteenth century, individuals with mental illness made a gradual transition to psychiatric hospitals.

Psychiatric hospitals (the first was built in Valencia, Spain, in 1409) (Mora 1980) were originally asylums, places of refuge for persons with diseases of the mind in which the treatments of the day could be administered while the residents were sheltered from the public at large and vice versa. In the United States, these institutions were administered by state governments using state funds.

By the middle of the twentieth century, the proportion of elders in these institutions had increased because of the aging of Americans; in the year ending June 30, 1945, senile or arteriosclerotic psychoses were the diagnoses of 42% of first admissions to the Worcester State Hospital in Massachusetts (Katzman and Bick 2000).

For many years, a substantial portion of individuals housed in these state-run psychiatric facilities were persons with dementia who had been admitted initially for behavioral disturbance but for whom these facilities primarily provided food and shelter, often because there was no family to which these persons could be returned.

Beginning in the 1950s, the use of psychotropic drugs for reducing behavioral disturbance, the increasing concern for civil rights, and the federal stipulation that Medicaid funds may not be used for the care of patients in freestanding state psychiatric facilities all reduced the use of state psychiatric hospitals as asylums, with the result that dependent patients with dementia are now more frequently housed in other types of long-term-care facilities such as boarding homes and nursing facilities.

FIGURE 1-8.  Leon J. Thal, M.D., first head of the Alzheimer’s Cooperative Study.Source.  Courtesy of the Department of Neurosciences,  University of California at San Diego.

Although it is possible to involuntarily confine persons with dementia to psychiatric hospitals by means of court commitment, there is no legal means to restrain these individuals to other facilities, and those who insist on their independence often reside on the streets or in jails, the latter as a result of their impulsivity and poor judgment. Those dementia patients who can accept care by their families will pose an increasing burden to their families as our population continues to age.

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Myron F. Weiner, M.D.
Clinical Professor of Psychiatry and Neurology,
Aradine S. Ard Chair in Brain Science,
Dorothy L. and John P. Harbin Chair in Alzheimer’s Disease Research,
University of Texas Southwestern Medical Center at Dallas, Texas
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