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What is happening, and what has happened, when a person becomes demented in later life? In one gestalt configuration — perhaps the prevailing one at present — the central figure is a process of degeneration, or some other physical impairment, in the grey matter of the brain; psychological and social factors fade into the background, at least for the purposes of research. Another gestalt, however, equally valid, can emerge; in this the figure becomes an existential crisis of a person, of an embodied, social and sentient being, and indeed a crisis of an interpersonal milieu; neuropathology, of whatever degree of severity, becomes part of a whole range of peripheral considerations.
The main thesis of this paper is that if the dementias of old age are to be understood and responded to in a way that does justice to our humanity, the second gestalt must have a central place; not to the exclusion of the first, but in a dialectical tension with it. This is acknowledged, if tacitly and common-sensically, by many people who are involved in practical care-giving, whether as family members or professionals. Geriatric care is not easy, at the best of times; it is doubly difficult when resources are cut to the bone and there is a prevailing climate of resentment and demoralization. Nevertheless, a respect for demented persons continually emerges: a belief in their capacity to feel, relate and respond — and even to recover to some degree. Among care-givers there is often a deep reluctance to accept that the demented are merely the victims of a crippling neurological affliction; and there is a reaching out — expressed in praxis rather than in theory — towards a fuller understanding of their predicament.