Dementia in the Ancient Greco-Roman World Was Minimally Mentioned

Abstract

Background:

The possibility that Alzheimer’s disease and related dementias (ADRD) is a modern disease arises from the minimal mention of advanced cognitive decline by ancient Greeks and Romans, who were mainly concerned with the physical frailties of older ages.

Objective:

Because standard medical histories of elderly health lacked mention of cognitive decline, we examined texts by Greek and Roman authors that mentioned memory loss and dementia.

Methods:

Primary texts of Greco-Roman authors, 8th century BCE into the 3rd century CE, that mentioned cognitive decline were identified and critically evaluated. Secondary sources were excluded.

Results:

No ancient account of cognitive loss is equivalent to modern clinical data. The term dementia was occasionally used in antiquity, but not invariably linked to old age. Ancient Greeks and Romans expected intellectual competence beyond age 60. While some memory loss was acknowledged, we found only four accounts of severe cognitive loss that might represent ADRD. The possibility of modest ADRD prevalence in ancient Greece and Rome is consistent with its low prevalence in the Tsimane of Bolivia. These contemporary Amerindians live under conditions of high mortality from frequent infections and minimal cardiovascular disease with physically demanding lives. Tsimane after age 60 had increased mild cognitive impairment; the few cases of dementia were not clinically consistent with AD.

Conclusions:

The modern ‘epidemic level’ of advanced dementias was not described among ancient Greco-Roman elderly. The possible emergence of advanced ADRD in the Roman era may be associated with environmental factors of air pollution and increased exposure to lead. Further historical analysis may formulate critical hypotheses about the modernity of high ADRD prevalence.

Keywords

Aging Alzheimer’s disease dementia lead memory

INTRODUCTION

We explore the possibility that the modern high prevalence of Alzheimer’s disease and related dementias (ADRD) are diseases of modern environments and lifestyles that were uncommon in the ancient Greco-Roman world. The prevalence of ADRD increases after age 65 in most modern populations [1, 2]. The Alzheimer’s Association estimated lifetime risk at age 65 in 2022 of 11.6% for men and 21.1% for women [3]. In several populations, the prevalence of ADRD increases exponentially with age after 60 [1, 4].

A challenge to assumptions that high prevalence of ARDA is normative is given by the Tsimane, indigenous Ameriandians of Amazonian Bolivia; with high, life-long mortality from accidents and infections [5, 6]. After age 60, mild cognitive impairment (MCI) was increased, but clinical grade advanced AD was not found up to the oldest age of 93 [5, 6]. This divergence motivated our inquiry about the cognitive status of elderly in ancient Greece and Rome, where, like Tsimane, survival to advanced ages was limited by mortality from accidents and infections. Few other modern populations share these characteristics.

Most ancient medical writers, including Galen [7], considered aging as a natural and irreversible process, although ideas about its impact on the elderly varied. Research into the early history of the concept of ADRD requires care in the use of ancient sources. There is no data in the modern clinical sense. Another issue is that some prior studies mistakenly attributed the theory that severe mental decline was connected with aging by Pythagoras, Greek philosopher of the 6th century BCE [8 –11]. However, no primary text for this supposed text of Pythagoras is known. These authors cited secondary sources, which cited a misreading of a passage in an early 19th century textbook on the human life cycle [12]. Our analysis sought primary texts to appraise the awareness and scope of mental decline during aging in ancient Greece and Rome.

We focus on ancient Greece and Rome because some other ancient literatures have few known references to memory loss in old age. Examples include an Egyptian papyrus and a Talmudic text. The Instruction of Ptahhotep, from the Egyptian Middle Kingdom (ca. 2000-1750 BCE), makes the following observation in a long list of the afflictions of extreme old age, supposedly 110 years:

The heart, void, recalls not the past [13].

The heart was considered the seat of consciousness in Egyptian thought. Similarly, the early Medieval Jewish Talmudic tractate Berakhot gives the following instruction:

“Rabbi Joshua ben Levi advised: And be careful to continue to respect an elder who has forgotten their Torah knowledge due to circumstances beyond their control [14].

Although both passages probably refer to severe memory loss in the elderly, unlike the Greek and Latin texts, these unique examples do not allow diachronic analysis of the awareness and incidence of ADRD in ancient Egyptian and Jewish societies.

METHODS

Four decades ago, the historian M.I. Finley observed “I can find hardly any reference specific to mental illness in old age ... .I do not conclude from this silence that senile dementia was non-existent in antiquity, but I know of no way to penetrate the almost total silence.” [15]. Consistent with Finley’s observation, we found few primary citations of a connection between the aging process and memory loss in Greek and Roman medical texts. Nor was memory loss mentioned in authoritative summaries of ancient medicine: Scarborough 1970, Roman Medicine [16]; Philips 1973, Greek Medicine [17]; Majno 1975, The Healing Hand: Man and Wound in the Ancient World [18]; Nutton 2013, Ancient Medicine [19]; Fox 2020, The Invention of Medicine: From Homer to Hippocrates [20].

Our study carefully researched standard editions of Greek and Latin texts, primarily, but not only, ancient medical and philosophical texts that discussed the human life cycle from the 8th century BCE into the 3rd century CE. There are no statistical data for the incidence of mental illness; moreover, technical terms matching contemporary terminology for mental disorders are lacking for antiquity. Therefore, we searched for passages providing detailed descriptions of the physical, medical, and mental characteristics of the elderly. We note the historical shift in writings from ancient Greece to Rome in the prominence of advanced memory loss, indicating awareness of that condition.

RESULTS

Demographic gaps

A challenge to this analysis is the lack of reliable demographic data for ancient Greece and Rome. Lucian’s On Long Lived Men describes reputed ages of elite Archaic and Classical age Greeks, who were politically, militarily, and intellectually active in extreme old age. While Greeks kept birth year records for many elite males, there was no birth record for women and the lower classes. Nonetheless demographic models used by current historians of ancient Greek and Roman populations [21] closely approximate the demographics of pre-industrial Sweden in 1750 [22, 23] and the modern Tsimane [24], where accidents and infections were the main cause of mortality, as prevailed in the ancient world. The Tsimane Health and Life History Project (THLHP) has assessed health and lifestyles since 2002 [25]; co-author Finch joined this project in 2012. Individual Tsimane lifespans are based on birth records and corroboration of self-statements by kin interviews [24]. Both populations shared high mortality from infections and shortened life expectancy of adults relative to the modern, which support use of Tsimane data as comparanda with ancient and other pre-industrial populations. For Tsimane [24, 25], like Sweden 1750 [22, 23], the high mortality of childhood declined by age 20 to a lower young adult mortality, followed by exponential increased mortality rates by age 40, as in modern populations. The modal age at death was about 72 years for Tsimane, like other premodern populations versus 85 years for the US [24]. While <10% survived to age 80, one-fourth still lived to become grandparents.

Ancient Greece

The city-states of Sparta and Athens required the registration of citizen children shortly after birth [26, 27]. These records gave official age thresholds for public duties: age 18, military service; 30, holding administrative office; 60 for termination of military duty. In Sparta, age 60 was also the threshold for election to the Gerousia or governing council, whose twenty-eight members served for life after election. While Greeks were fully aware of cognitive declines with age, elite elderly were valued for their civic wisdom. Even so, Greek society considered youth and not old age as the prime of life [28]. This age bias was already present in the early 7th Century BCE Homeric Odyssey, which portrayed the old as bent with age, weak, and vulnerable. Solon, the 6th Century BCE Athenian reformer, wrote about both sides of aging.

“As I age, I constantly learn many things” [29].

Contrarily “on reaching old age, speech and thought weakened” [30].

Solon is credited with a law that included old age as grounds for a son to sue his father for incompetence in managing family property [31 –33].

The 4th century BCE Hippocratic text Aphorisms [34], listed ailments of the elderly that included urinary, digestive, and physical disorders; dizziness and insomnia; and deafness and blindness. We could not find any mention of memory loss in elderly in this major body of ancient medical writing, which was continued by unnamed ‘Hippocratic scholars’ for at least a century after Hippocrates died in the early fourth century BCE, allegedly in his 90s.

Aristotle, also 4th Century BCE, described cognitive aging [35].

“Older men and those who have passed their prime have in most cases characters opposite to those of the young ... They live in memory rather than in hope ... talk incessantly of the past, because they take pleasure in recollection.”

Here, Aristotle was illustrating arguments for use by orators to prejudice juries against aged opponents, that represent the Athenian 4th Century BCE stereotype of the elderly. This passage did not include severe memory loss as an aging characteristic, consistent with the two other 4th BCE citations. In the 2nd CE, the grammarian Pollux discussed examples from 4th BCE Greek writing to illustrate proper usage [36]; he included slurred speech among characteristics of the elderly but did not mention memory loss. Similarly, Aristotle’s colleague Theophrastus [37] identifies difficulty in learning new things as typical of old age, but again did not include memory loss. We found one comment by Aristotle that extreme memory loss was a special occurrence, when elderly individuals were near death:

“When this vehicle [the body] decays, memory and love cease” (On the Soul) [38].

The duration of premorbid collapse of body and mind must have been much shorter than the prolonged agonal phase enabled by modern medical technology.

These few references suggest that ancient Greeks recognized that aging commonly brought memory issues we would recognize as MCI. The cognitive losses as described may approach early- or mid-stage AD, but not chronic progressive ADRD-like symptoms with major loss of memory loss, speech, and reasoning. We then encounter a remarkable gap in medical descriptions of old age from ancient Greece to the later Romans.

Ancient Rome

Centuries after Aristotle, in the Roman Era, we found four statements of severe memory loss, suggesting the gradual emergence of more advanced dementia. Baseline age expectations for elite Roman men resembled the prior Greek elites. The Roman requirement for military service ended at age 46; health permitting, former officers were expected to continue political and administrative activity into later ages. Mental decline was recognized but was considered exceptional. As Cicero noted in De Senectute (44 BCE) and the earliest surviving book on this topic, but extreme memory loss was not generally expected:

“Elderly silliness [senilis stultitia], which is usually called dotage [deliratio], is characteristic of irresponsible old men [senum levium], but not of all old men.”

Equally important, Cicero did not include it as one of the four evils ascribed to old age: the end of an active life, physical weakness, the cessation of pleasures, and nearness to death. Apparently, severe memory loss among the elderly was still considered unusual. The first probable advanced case of AD or ADRD comes from Pliny the Elder (died 79 CE), who noted that the senator and famous orator, Valerius Messalla Corvinus, forgot his own name [39].

In the next century, severe memory loss became more noted. The satirist Juvenal included it among the stereotypical evils of old age [40, 41]:

“Greater than all the damage to limbs is dementia, which does not know the names of slaves or the face of the friend with whom it dined the previous night or those whom it engendered and brought up.”

Juvenal’s characterization of ARDA-like memory loss as “dementia”, means literally “out of mindedness”, and is innovative for that reason. Dementia was then a rare general term primarily used in Roman law for various mental impairments, mild to severe, that prevented elderly individuals from responsibly fulfilling their duties as family head [39]. Juvenal’s use of dementia to describe severe elderly memory loss thus suggests greater awareness of that condition among elite Roman in his time.

Later in the 2nd century CE, the Greek physician Galen [42] noted that some of the survivors of both the Antonine Plague (164–165 CE) and the 5th BCE Athenian Plague did not recognize themselves or their friends [43]:

While also one sees some who, owing to extreme age, are overcome by very similar symptoms.

Galen was personal physician to the Roman emperor, Marcus Aurelius, and an eyewitness of the Antonine Plague, possibly the first smallpox pandemic recorded in Europe [44]. Three points are notable in Galen’s account. First, Galen’s reference to dementia in the elderly is incidental to his account of mental problems he observed among victims of the Antonine Plague, AD165–180 and in the earlier Athenian plague, 5th century BCE. Second, these symptoms do not afflict all elderly individuals. Third, they are not characteristic of old age per se, but only of some in extreme old age. In Galen’s schema, extreme old age begins at age 80, when some elderly begin to have difficulty learning new things, also noted in On Hygiene [45], with the first discussion early life factors in later life health. However, this book but did not mention cognitive decline [46]. Nor was cognitive decline included in Galen’s extended list of elderly afflictions [47].

“They readily become chilled, turn black or leaden-coloured and are prone to the cold illnesses: apoplexy, paralysis, numbness, tremor, convulsion, mucus, sore throats. They have lost nearly all the blood in their bodies and with it the redness of complexion. Their digestion, their distribution, blood production, addition, nourishment, appetite, movement, and perception, are all feeble and in a bad state.”

Another indication that Galen’s high age for the onset of mental decline was typical for that time is found in a century later in Censorinus’ encyclopedia of general knowledge, De Diei Natali [48], CE 238. In summarizing the current medical and philosophical views on old age, Censorinus set the age of the onset of memory loss at age 84, later than Galen.

Taken together, these four Roman Era statements suggest the emergence of greater awareness of cognitive loss of memory at advanced ages that would plausibly qualify in modern terms as clinical dementia than had been the case previously. Lacking demographic data, we cannot know if this was because more Romans survived to advanced years than earlier Greeks or not. The modern Tsimane, however, give a calibration for ancient cognitive decline.

Tsimane as a model for ancient aging

The Tsimane Amerindians have attracted attention for diseases of aging because of their minimal cardiovascular disease [49] and dementia [5, 6]. Brain imaging by high-resolution CT showed 30% slower age-related atrophy of cerebral cortex than two population samples from modern economies [50]. Cognition was assessed for 632 individuals ≥60 years from 100 villages by consensus of clinical psychologists and neurologists from the University of Southern California and showed strong evidence of increasing impairment after age 60 [5]. Those with dementia had greater prevalence of APOE E4/E4 carriers; the E4 allele is at upper normative range of 32% [51]. Postmortem brains are not available for histopathological confirmation. Overall, dementia in Tsimane aged ≥60 is 1.2% (crude prevalence), less than one-fifth of the US (8%) or Europe (6.2%) [1, 2]. All dementia cases were ≥80 years and were considered mild. This low dementia rate is also consistent with Tsimane slower cerebral cortex atrophy [50].

Moreover, Tsimane are in the lower range of other indigenous groups: rural India, 1.36% [52] and Nigerian Yoruba, 2.29% [53]. Others are higher: Cree in North America, 4% [54], Chamoros in Guam,12.2% [55], and Australian Aboriginal, 13.4% [56]. Notably, all identified Tsimane dementia cases were mild, and at least age 80 when assessed. In contrast, MCI emerged by age 60, at rates comparable to the US [5]. For Tsimane aged 60, MCI was diagnosed in 8% (35/435). Of those 35 cases, 5 mainly had impaired memory; the majority had impaired executive functions or were impaired in multiple cognitive domains. Movement symptoms included bradykinesia and rigidity that were 50% more common than cognitive impairments. Adult Tsimane are aware that hazards of older age sometimes included cognitive disabilities, but were mainly concerned with spinal pain, arthritis, and sarcopenia, like the ancients. The low Tsimane dementia prevalence and slow brain atrophy may be benefits from their demanding lifestyle of high physical activity for subsistence farming and foraging. Their minimal obesity, low HbA1c, low cholesterol, and low systolic blood pressure comprise low risk factors or cardiovascular disease (CVD) and AD in modern populations. Their high load of parasites and frequent infections may also favor minimal obesity and lower CVD [57].

DISCUSSION

Few primary sources were found from ancient Greece and Rome that described age-related cognitive decline and dementia. We did not find any equivalent to modern case reports of ADRD. None of these ancient accounts of cognitive loss can be considered clinical-grade data in the modern sense. Solon in 6th BCE Athens gave the earliest mention of age-related memory loss that we found, but extreme memory loss was not mentioned by Aristotle or other Greek philosophers in relation to aging, including Galen in 2nd CE. The expanded primary sources we found suggest that advanced dementia was more frequently noticed in the Roman era than ancient Greece.

We suggest that new environmental risk factors for ADRD were present in urban Rome. Air pollution and other environmental factors in ADRD are widely recognized in the AD Exposome [58]. Rome at that time was known for noxious air. In 55 BCE, Lucretius the Roman philosopher noted: “How easily the heavy fumes from charcoal penetrate the brain”. Increased air pollution is strongly associated with ADRD [59, 60]. Besides modern environmental and lifestyle risks of ADRD, our increased survival to later ages inevitably increases ADRD prevalence, with exponential rates after age 60 [1, 4].

Poisoning by lead (Pb) may have been an environmental factor with greater exposure in Rome than in earlier Greece. Severe dementia symptoms first appear in the 2nd CE concurrent with increased exposure to this toxic metal. Upper classes commonly drank wines sweetened with sapa (lead sugar, or white lead), while many drank water from leaded pipes [61]. By chemical analysis, sapa-sweetened wine contained 20 milligrams of Pb per liter of wine [62, 63]. Correspondingly, Roman period skeletons and teeth had high Pb levels [63]. Pliny and others recognized that leaded cosmetics were poisonous [64].

While the specific relation of Pb to later life dementia in ancient Rome can never be known, lead exposure is associated with AD risk [65 –67] supported by experimental studies. Age-related neurodegeneration was accelerated in rhesus monkeys by ingesting lead from ingested from birth to 14 months; at age 23 years, neonatal lead exposure increased brain fibrillary amyloid Aβ₄₂ and P-tau by 35% [68]. Similarly, rats exposed to Pb during nursing and examined at age 20 months later had elevated APP (300%) and Aβ (50%) [69]. The biochemical basis for Pb-induced pro-dementia neurotoxicity includes direct effects on tau fibrillization which is accelerated by Pb interactions with His-330 and His-362 [70]. These direct effects of Pb on tau fibrillization are relevant to adult dementia from wine drinking, while exposure to water from lead pipes may be modelled by early life exposures that increased later life amyloid and tau.

Lastly, we note that CVD predisposes to dementia [71]. Arterial calcification was found in five Egyptian mummies from 350 BC to 45 CE by the Horus mummy research team (Ptolemaic to early Roman era) [72], while chest pain indicative of CVD was noted by Hippocrates in Regimen in Acute Disease XXII [73] and in an Egyptian papyrus from 15th BCE [74].

In sum, we identified Greco-Roman texts that describe memory loss and some form of dementia in the elderly from the 6th BCE to the 2nd CE. The equivalent of MCI was not uncommon in later years, possibly after age 70, like today. Severe cognitive dysfunction was less noted. The few ancient sources we found make clear that some dementias of aging arose in pre-modern times. We cannot know which pathologies were involved. Age-related neurodegeneration extends beyond ‘classical’ neurofibrillary degeneration and amyloid plaques to include vascular amyloid, microbleeds, and aggregates of α-synuclein (Lewy bodies) and TDP-43.

Severe mental deterioration of ADRD clinical grade was more noticed in the Roman era, suggesting greater incidence than in ancient Greece. We suggest that lead toxicity may have been a factor in the occasionally more severe cognitive decline in the Roman era. The 80% lower dementia incidence of dementia in the modern Tsimane than US and Europe gives a rationale for broader historical inquiry. The Tsimane merit further comparison with other indigenous groups cited above with greater dementia and other ancient sources (Assyria, China, India). A broad inquiry could critically formulate hypotheses on environmental factors in ARDA in prior societies that are relevant to the modernity of epidemic-level dementia in many developed economies.

CREDIT AUTHOR STATEMENT

Caleb Finch (Conceptualization; Formal analysis; Funding acquisition; Writing – original draft; Writing – review & editing); Stanley Burstein (Conceptualization; Formal analysis; Writing – original draft; Writing – review & editing).

Footnotes

ACKNOWLEDGMENTS

We appreciate critical reading and comments by Margaret Gatz, Michael Gurven, Hillard Kaplan, Gregory Thomas, and Randy Thompson (THLHP), and Marja Jylhä (Tampere University, Finland).

FUNDING

CEF is grateful for support from the Cure Alzheimer Fund and NIH (P01 AG055367 and R01 AG05442).

CONFLICT OF INTEREST

The authors have no conflict of interest to report.

DATA AVAILABILITY

Data sharing is not applicable to this article. No datasets were generated or analyzed during this study.

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