Physiopathology of Dementia From the Perspective of Traditional Persian Medicine

Abstract

The most common cognitive disorder that is disabling is dementia. During the medieval period, traditional Persian medicine was an outstanding source of medicine that was used as standard references in medical schools of in the West and Middle East. In ancient manuscripts of traditional Persian medicine, a condition has been introduced similar to dementi (raoonat and homgh). In this article, by collecting materials of traditional medicine texts on dementia, we aim to provide theories for further studies on this topics, as there is an obvious difference between traditional Persian medicine and modern medicine with regard to dementia; however, since modern medicine has not found a suitable response to treatment for all diseases, reviewing traditional Persian medicine for finding better treatment strategies is wise. Use of all medical potentials approved by the World Health Organization beside classic medicine like traditional medicine and considering the availability and acceptability among people is recommended.

Introduction

Age increase is associated with higher prevalence of cognitive disorders including forgetfulness and dementia. ^1,2 In cognitive disorders, attention, memory, language, direction finding, performance, judgment, and problem-solving skill are disturbed and memory injury is the most major factor in these conditions. ³ Normal cognitive status is dependent on perfect performance of different brain systems; therefore, as age increases, atrophic and functional changes happen that cause brain dysfunction and cognitive disorders. The severity of these disorders varies greatly and causes a broad spectrum of problems in the elderly. ⁴ The most common cognitive disorder that is disabling is dementia. There are 24.3 million with dementia around the world, and with annual increase of 4.6 million, the number of affected people becomes twice every 2 years. ⁵

With increase of world population age, Alzheimer’s disease is becoming more prevalent. According to statistics, there are 44 million people affected by Alzheimer’s disease dementia, and it is estimated to become 100 million by 2050. ^6,7 Therefore, it is essential to find efficient medicines for Alzheimer’s disease symptoms. ⁸

During the medieval period, traditional Persian medicine was an outstanding source of medicine, and most of its written materials, including the canon by Avicenna was the most important manuscripts that had been used as standard references in medical schools of the West and Middle East until the 16th and 19th century, respectively. ⁹

In ancient manuscripts of traditional Persian medicine, a condition has been introduced similar to dementi (raoonat and homgh) and has been discussed in brain function. They are diseases in which brain function disturbs and the affected person finds problems in doing household work and relating with friends and relatives. ¹⁰ In this article, through collecting and presenting materials of traditional medicine texts on dementi (raoonat and homgh), we aim to provide theories for further studies on this topic.

Materials and Methods

In this qualitative study, medical databases including PubMed and Scopus, some Iranian databases like SID and Magiran, as well as a number of well-known traditional medicine texts including Al Havi (The Liber Continent, written by Rhazes in the 10th century CE), Qanun fi al-Teb (The Canon of Medicine, written by Avicenna in 1025 CE), and Exir Azam (Great Elixir, written by Azam Khan in the 18th century CE) were searched based on the selected keywords (dementia, raoonat, and homgh) to collect all materials on dementia. Through comparison of traditional and modern materials, we tried to find a disease in traditional texts that has symptoms similar to clinical presentations of dementia. Several discussion sessions were held to read and review original data and clarify and interpret those extracted materials that were not clear. All members of research team were involved in the process of discussing and analysis of data, and we tried to follow the trustworthiness criteria of qualitative research. In regular continuous sessions, research team members tried to discuss about ambiguities and to label themes through selecting the most precise words and phrases.

Results

Definition and Symptoms of Dementia in Modern Medicine

The definition of dementia has undergone many changes since its introduction about 300 years ago. In this standardized criteria century, the 4th edition of the DSM (DSM-IV-TR) ¹¹ is more commonly used for the definition and symptoms of dementia:

Development of several cognitive deficiencies including memory deterioration and at least one of the following items:

language disturbance (aphasia)

Inability in doing prelearned tasks (apraxia)

Cognitive disorder (agnosia)

Performance disorder

Cognitive deficiencies should include the following features too:

They should be as severe to disturb professional or social performance

They should show decreased performance

The diagnosis should not be made when cognitive deficiencies happen mainly in the delirium period.

Dementia etiology can be related to a general medical disease, permanent effects of substance abuse, or a combination of them. ^12,13

The age at onset of this disease is mostly the seventh decade of life or later, but in rare cases it might start in the fifth or sixth decades of life, which is known as early dementia. ¹⁴

Traditional Persian Medicine Definition and Classification of Dementi (Raoonat and Homgh)

In traditional Persian medicine, body functions have been classified into 3 categories:

Psychic actions (afal-e-nafsani)

Vital action (afal-e-heyvani)

Physical action (afal-e-tabiei)

Functions related to the brain (afal-e-nafsani) are classified as follows:

Solution-seeking functions (afal-e-modabere) known as political activities

Perception functions (afal-ol-hasase)

Voluntary movement (afal-e mohareke-bel-erade)

Solution-seeking functions (modabere) that are well known as politic functions include imagination (takhayol), thinking (fekr), and remembering (zekr). All these are called brain functions. The location of each function is part of the brain but not all of it; therefore, after injury to one part, only the function of that part is disturbed. Dysfunction to the anterior part of brain disturbs imagination (takhayol), while damage to the middle part of brain disturbs thinking (fekr) in a way that the person does not know what to do and what not to do. Similarly, Jalinoos has mentioned a case wherein a person threw away dishes and other things from the house-top and did not think they should not be thrown away. This condition is called homgh in which thinking is disturbed. ¹⁵ In traditional Persian medicine texts dementi (raoonat and homgh) have been dealt with in brain discussion.

Etiology and Diagnosis of Dementi (Raoonat and Homgh)

Traditional Persian Medicine is a collection of knowledge on prevention, diagnosis, and treatment of diseases in ancient times in Iran. Traditional Persian medicine is a theory of 4 humors and accordingly 4 specific temperaments of balgham or phlegm (cold and wet qualities), dam or blood (hot and wet qualities), safra or yellow bile (hot and dry qualities), and sauda or black bile (cold and dry qualities). Humor is produced from digestion of foods in the gastrointestinal system. ^16–18

The first step toward understanding the etiology of dementia is recognizing its signs and symptoms. This subject was explained in details by traditional Persian physicians based on the kind of brain dystemperament. According to traditional Persian medicine physicians, there are 2 types of temperament: one called general temperament that governs the whole body and is determined by body humor and the other called organic temperament that is related to a specific organ. For example, in normal conditions, brain temperament is naturally wet and cold. As brain dystemperament causes dementia, anything that disturbs the normal brain temperament can be considered as dementia etiology.

Traditional Persian medicine physicians expressed causes of dementi (raoonat and homgh) as follows:

Simple coldness (boroodat-e-sazej)

Coldness and dryness in middle brain ventricle

The presence of phlegm (balgham) in middle brain ventricle

In this disease, brain functions are disturbed and the person finds problems in doing household works and contact with friends, children, and relatives. Indeed, the person does useless things. Avicenna shows raoonat and homgh to be the same. ¹⁰ But there is a difference between raoonat and homgh in the other traditional medicine books. In raoonat, the person sees nobody like himself with regard to wisdom and knowledge. Homgh is deficiency in thinking and recognizing realities and is, in fact, the origin of raoonat. In homgh the patient has no problem in easy issues, while difficult and mathematical issues are problematic. ^19,20

When the cause is coldness with dryness, symptoms are insomnia and inability remembering present events. When the cause is coldness with wetness, symptoms are drowsiness and the person forgets past memories completely. When the cause is coldness alone, symptoms are numbness and vertigo. ^10,19,20

Prevention

Based on the opinions of traditional medicine healers, the main task of the healer is maintaining health before disease occurrence. In traditional medicine, balance of 6 required principles named sete zarooriye causes health, while their imbalance causes disease. The first step of treatment is intervention for balancing these 6 principles ^16–18 : (a) climate, (b) foods and drinks, (c) sleep and awakeness, (d) body movement and repose (harkat-o-sokon), (e) psychological status (aaraz-e-nafsani), and (f) keeping necessary substances and exerting unnecessary substances (Ehtebas-o-estefragh). ¹⁸

Useful Nonmedical Orders

Balancing the brain and body temperament through eating less and light foods and consuming special soup (shourbaj) containing meat, salt, and spinach; a sweet drink prepared with starch (faloode) is useful.

There are some recommendations like avoiding drinking cold water and ice and eating vapory vegetables like garlic, onion, leek, peppergrass and cold substances such as lentil, milk and everything like green apple and coriander. Eating bean, broadbean, onion, and mushroom; oversleeping; and drinking wine causes forgetfulness.

Avoiding nucha cupping (hijamat-e-noghre), evacuation (estefragh), intercourse, sorrow, and anger are recommended. ^15,19–21

Discussion and Conclusion

Traditional Persian medicine, as a holistic school, has a special approach toward the diagnosis and treatment of diseases. Therefore, it seems that, through modifying life style, climate, foods and drinks, sleep and awakeness, body movement and repose (harkat-o-sokon), psychological status (aaraz-e-nafsani), keeping necessary substances and exerting unnecessary substances (Ehtebas-o-estefragh), and consequently balancing these (in accordance with general temperament, age temperament, season temperament, job, habit, and place of living), ^16–18 dementia can be prevented to a great extent, and in the case of disease occurrence, treatment is possible through intervention in these items and if required through treatment processes that are easier and more cost-effective and have less complications. As it is clear, there is an obvious difference between traditional Persian medicine and modern medicine with regard to dementia; however, since modern medicine has not found a suitable response to treatment, reviewing traditional Persian medicine for finding better treatment strategies is wise, even though this requires a broad and careful observation of symptoms and fixing them in the framework of traditional Persian medicine. Use of all medical potentials approved by the World Health Organization beside classic medicine like traditional medicine and considering the availability and more acceptability among people and having less side effects (especially in chronic diseases like dementia wherein long-term consumption of medicines causes several complications) is recommended.