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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 4-9

Dementia in Indian cinema: A narrative review


1 Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virgina, USA
2 Department of Psychiatry, Government Medical College, Kollam, Kerala, India
3 Department of Psychiatry, General Hospital, Ernakulam, Kerala, India

Date of Web Publication27-Jun-2018

Correspondence Address:
Badr Ratnakaran
611, S. Jefferson Road, Apt #105, Roanoke, Virginia 24011
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_14_17

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  Abstract 


Indian cinema is known for portraying social, cultural, political issues, and this also includes issues in mental health. The objective of this paper is to provide a narrative review of the portrayal of dementia in Indian cinema. The films were identified after discussion with various experts in person, telephone, e-mail correspondence and via social media. Fifteen films portraying balanced and unbalanced versions of dementia and its related issues have been identified. Caregiver issues have also been discussed in the films. However, treatment and other interventions have not been adequately portrayed. It can be concluded that these films can be used as a resource for movie clubs as a part of teaching curriculum during postgraduate and undergraduate training. They can be an excellent medium to understand cultural issues related to dementia in the community.

Keywords: Dementia, Indian cinema, movie clubs


How to cite this article:
Ratnakaran B, Anil SS, Suresh N. Dementia in Indian cinema: A narrative review. J Geriatr Ment Health 2018;5:4-9

How to cite this URL:
Ratnakaran B, Anil SS, Suresh N. Dementia in Indian cinema: A narrative review. J Geriatr Ment Health [serial online] 2018 [cited 2018 Jul 17];5:4-9. Available from: http://www.jgmh.org/text.asp?2018/5/1/4/235361




  Introduction Top


Dementia is a degenerating disease of the brain. As per the estimates based on 2001 global population, the global prevalence of dementia is found to be 24.3 million, with 4.6 million incidence of new cases every year.[1] The prevalence of dementia is expected to double every 20 years with growth being highest in developing countries including India. In 2010, an estimated 3.7 million people of over the age of 60 years in India were considered to have dementia.[2] This estimate is believed to increase by twice and thrice by the year 2020 and 2050, respectively.

In this scenario, the need for awareness of dementia has gained utmost importance. Cinema is an important form of entertainment in India, and Indian films such as Taare Zameen Par (2007) have contributed much to the awareness of specific learning disease in the country.[3],[4] There have been films from other countries with dementia as central theme including A Moment To Remember (South Korea, 2004), A Separation (Iran, 2011), and Still Alice (USA, 2014) with scientific articles discussing the portrayal of various aspects of dementia in films.[5],[6],[7] In this scenario, we decided to review the portrayal of dementia in Indian films.


  Methodology Top


We were not able to find any credible database which lists all Indian films released till date. However, we relied on two sources to gather knowledge on the films which have portrayed dementia in Indian cinema.

  1. The official online group of Indian Psychiatric Society called e-ips present in yahoo groups
  2. The Facebook page called “Minds Maladies in Movies” which discusses portrayal of mental illness including dementia in films.


Both these sources had members including psychiatrists and other mental health professionals belonging to India and also members who were interested in the field of cinema and mental health. During the period from October 2014 to December 2016, we enquired with the members of both the groups on films that could have portrayed dementia, and we included films which met any of the following criteria:

  1. The diagnosis of dementia has been mentioned
  2. Had a character which suffered from or portrayed a characteristic symptom of dementia.


We have been able to identify 15 films with characters suffering from dementia and will be reviewing their portrayal in this narrative review article. The films with their language, year of release, director, and actor portraying the dementia patient have been listed in [Table 1].
Table 1: Indian films portraying dementia

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All films were personally viewed by the authors using CDs/DVDs, legal online sources, or viewing in theater. We would like to note that the films, Dhoosar and Astu, had never had commercial release and had been viewed by the authors while they were playing in the film festival circuit during the corresponding years they had been shown to the public. There are review articles on mental illness portrayed in cinema mentioning one or two Indian films portraying dementia.[6],[8] Our literature search has provided one only review article that exclusively discussed an Indian film with dementia.[9] We have not been able to identify any review articles dedicated to the portrayal of dementia in Indian cinema.


  Indian Films Portraying Dementia Top


The films described in our article have focused mainly on the symptoms of memory loss and the problems created due to it in daily life. Behavioral and psychological symptoms of dementia (BPSD) have also been portrayed in 12 of the films identified by us. We have tabulated them in [Table 2] according to the seven domains of behavioral symptoms of the first part of Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), a two part study tool used to assess BPSD.[10] The portrayal of dementia in the films has been described as follows.
Table 2: Behavioral symptoms as per seven main domains of the first part of Behavioral Pathology in Alzheimer's Disease Rating Scale that have been portrayed in the films

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36 Chowringhee Lane is perhaps one of the earliest films to have portrayed dementia in one of its main characters. The character appearing in a couple of scenes in the movie is the lead protagonist's brother who is being confined to an old age home. An Anglo Indian, he is depicted to be irritable in nature, frequently swearing and has affinity to chocolate biscuits which he keeps demanding. He believes to be still living in the era when King George ruled India.

Black had the lead character portrayed by Amitabh Bachchan depicted to gradually develop forgetfulness. In a scene, he had shown to forget for whom he had purchased ice creams and also collecting the remaining change after the purchase of it. When reminded of his recent mistakesdue to lapses in memory, he realizes that he is not his old self. Apart from this, the film did not depict the progression of his disease and it is only in the end, we see his tall figure stooped along with tremors and apathetic face not able to recognize anyone.

In the story segment, The Bridge of Kerala Café, we are shown the story of an old lady who is forced to be abandoned by her son. Belonging to a low socioeconomic class, she is shown to have difficulties in dressing herself, holding her bowels, and forgetting when she had food and her son's name. She is seen to be frequently preparing herself to go to visit the beach which had been promised by her son, probably before her disease had set in. The family is unaware that her behavior is a part of a disease. However, her son is shown to depict the patience and tenacity to take care of her. Unfortunately, due to the frequent complaints by his wife of the burden of taking care of her, he is forced to abandon his mother in the streets, an act causing much remorse in him.

ListenAmaya depicted the protagonist coming in terms of her widowed mother's relationship with a male companion of the same age. The companion is shown to be suffering forgetfulness and getting lost while venturing outside his home suggestive of early signs of dementia.

O Kadhal Kanmani had one of its pivotal female characters suffering from dementia. She is seen to have difficulty in remembering people and events and gradually she is depicted to forget her way home. She is shown to retain her skills to play the Tanpura, knows she is suffering from Alzheimer's dementia, and fears the day she forgets her husband. Her husband is shown to take care of her, taking charge of the household activities while also including her in it. The character arc is used in the film to depict an older generation teach a younger couple on being with each other in the ups and downs of life.

Utopiayile Rajavu, Pavada, and Red Wine are recent films which have had a scene mentioning Alzheimer's dementia in a legal context. In Utopiayile Rajavu, we see a witness being examined by the court who keeps repeating his answers and thus portraying symptoms of perseveration. In Pavada, the protagonist's mother is mentioned in the court to be suffering from dementia although the depiction has been found to be deficient for a diagnosis. The symptoms have been described as occasional remote memory loss and somatic complaints of loss of energy and difficulty in walking. Both these films have attempted to portray the problem of competency as witness for dementia patients as per the section 118 of Indian Evidence of 1872.9 which states, “All persons shall be competent to testify unless the Court considers that they are prevented from understanding the questions put to them, or from giving rational answers to those questions, by tender years, extreme old age, disease, whether of body or mind, or any other cause of the same kind.”[11] In Red Wine, the antagonist attempts to malinger to evade being arrested by the police by showing signs of being oblivious one's surrounding and devoid of expressions. A neurologist is shown to be in cahoots with him in the devious scheme by describing him of suffering from Alzheimer's dementia and fabricating medical records.

These films had dementia as a theme as a part of its story lines or portrayed by one of its side characters. There have been Indian films where the central theme or the central character portraying dementia. Thanmatra perhaps has the most balanced portrayal of dementia in the films listed in this review. It depicted its lead protagonists, a middle-aged government servant, gradually developing symptoms of dementia. He is initially shown to misplace his things including his files and toothbrush and is irritable and in denial when informed of his forgetfulness. Later, in the film, we see him buy groceries, excess of one's household consumption, to his office and behaving inappropriately there by being in a state of undress. He is mistaken by his colleagues to be drunk. He is diagnosed to be suffering from presenile Alzheimer's dementia. As his disease progresses, he is shown to have speech difficulties of paraphasia, bradyphasia, and writing difficulties. We witness his gradual loss of capabilities of taking care of himself, not identifying his son and misunderstanding him for a thief and later on his sudden death while asleep. The film also depicted how much the disease had affected his family. Being the only bread earner in the family, he is forced to take premature retirement from work; his family has to relocate from the city to his ancestral home where caregiving support is better and the eldest son sets his career ambitions aside to look after his family.

U Me Aur Hum also portrayed presenile dementia, with its heroine diagnosed as dementia at the age of 28. She is shown to confabulate when she is not able to recall events or people from her past and is diagnosed to have the disease when she is unable to find her way home. She is pregnant when diagnosed and the film also informs us that her pregnancy is capable of worsening her symptoms, a fact which has not been scientifically proven. She is showing to forget her baby in the bathtub and becomes agitated when she does not do recognize her husband. She is institutionalized in the film but later is taken back by her husband when he decides to look after her. Apart from these symptoms, she is not shown to develop any loss of skills, language deficits, etc., as the film progresses. She is later seen with her husband and grown up son, well alert, groomed, and cheerful, showing no symptoms of progression of her disease.

Maine Gandhi Ko Nahin Mara, Astu, and Godhi Banna Sadharana Mykattu had its leading men suffering from the disease. They have been portrayed to be retired from their profession, implying they have the appropriate age of onset. In Maine Gandhi Ko Nahin Mara, the protagonist forgets he has retired or his wife has passed away. A Hindi professor, he is shown to gradually forget the lines of favorite poems and develops persecutory ideas of his maid poisoning his food. He is later seen in a state of delusion where he believes he is the reason for Mahatma Gandhi's assassination, a scenario he had encountered during a role play game in his childhood. Along with this delusion, he also starts hallucinating his deceased father reprimanding him for killing Mahatma Gandhi.

Astu had its lead protagonist in addition to memory loss, shows personality changes initially with irritability and stubbornness. We see post-it notes used to label family photographs so that he could identify his relatives including himself. While traveling with his daughter, he wanders away, following an elephant with a childlike curiosity. Being unable to find his way back, he is taken care of by the elephant's mahout and his wife. We gradually see him regress in his behavior, identifying the mahout's wife as his mother and behaving in a childlike manner. He is later found by the police and reconciles with his family. The film has a narration that goes back and forth between the protagonist's current and premorbid state to portray how a highly respected and knowledgeable person deteriorated due to the disease process. The predicament of the family witnessing the deterioration of their patriarch and the role reversal in taking care of their father who once took care of them when they were children is also an important narrative of the film.

Godhi Banna Sadharan Mykattu also has a similar premise to Astu. A widower who suffers from Alzheimer's dementia is seen to be taken care in a nursing home. His only son, a software professional, is unable to take care of his father due his career plans and busy schedule. He also wanders away during an outing in the city with his son and ends up with another family who takes care of him in spite of the troubles they face. The character is shown to have problems with short term memory and learning, but his remote memory appears to be intact and retains his skills while playing caroms. On screen, he is shown to have a vacant look with restricted emotions. The narration like Astu also depends on flashbacks to show the deterioration in memory.

Dhoosar and Mai portrayed its leading women with dementia. In Dhoosar, we see the protagonist, a spirited and dignified lady who had gone through an abusive marriage, gradually realize that she is suffering from memory loss when she starts forgetting names and her address. Her daughter is working abroad, and during this time, she befriends a drifter who ultimately becomes her caretaker. She has made her caretaker swear not to inform her daughter about her condition. All this while, the only communication the daughter has had with our protagonist was the letters and cheques she had sent to her. The daughter returns after 2 years to find her mother having difficulties in taking care of herself including swallowing food and cutting toe nails. She has a vacant and expressionless face and cannot recognize her daughter. When the daughter goes through the protagonist's diaries, we get glimpses of the progression of her disease state which started with her having doubts of whether her personal items such as blouse and sandals belonged to her, difficulty in recognizing names and words, etc.

In Mai, the protagonist's son is seen to give the charge of taking care of the protagonist to the daughter. He does this with excuse of his family relocating out of the country when in reality his family finds it difficult to take care of her behavior symptoms unaware of her disease state. While staying with her daughter, we get to see her behavior changes with her difficulty in recalling names, misplacing her expensive jewelry, hoarding behavior, and not being able to dress properly. She is seen to become irritable and aggressive behavior without provocation during nonlucid periods where she believes that she is in a time of her past. The family is ashamed of her behavior. However, later on upon knowing she is suffering from Alzheimer's dementia, they are able to cope and accommodate in taking care of her.


  Discussion Top


These films have successfully been able to portray the various faces of dementia and the fact that dementia is not just about loss of one's memory. The symptoms depicted ranged from forgetfulness, wandering behavior, agitation, psychosis, depression, regression in behavior and difficulties in activities of daily living. Films such as Mai and Maine Gandhi Ko Nahin Mara, have been able to show BPSD being mistaken for behavior associated with senility rather than an organic mental disorder. This is a situation prevalent in the country due to lack of awareness and these films have been able convey the message that these symptoms are much beyond the behavior expected with aging.[10]Thanmatra and U Me Aur Hum also depicted that dementia earlier than the usual and their spouses taking care of them; however, U Me Aur Hum had portrayed a rare age onset of 28 years without much disease progression being depicted. Literature has shown that the majority of the caregivers in India are females.[12] Except for The Bridge, U Me Aur Hum, and O Kadhal Kanmani, the rest of the films had the immediate loved ones and caregivers of the dementia patients are depicted females.

The main themes of the films have been the relationships between the caregivers and their loved ones suffering from dementia. Thanmatra, Mai, Maine Gandhi Ko Nahin Mara, Astu, and Dhoosar have portrayed how the caregivers initially find it difficult to understand the patients but are later willing to accommodate and take care of them in their homes. Apart from Black, The Bridge, and 36 ChowringheeLane, the films have depicted the preference of caregivers to look after the patient's by themselves in their homes. This echoes literature from India where caregivers prefer home care rather than institutions.[13],[14],[15] The importance of addressing caregiver burden of dementia patients have been portrayed in Thanmatra. Studies from India have shown majority of the caregivers suffering from mild to moderate dementia.[16],[17]Thanmatra, The Bridge, Mai, O Kadhal Kanmani, and Godhi Banna Sadharan Mykattu have shown the caregivers struggling to care of the patient due to poor social support including from the family members who fail to understand the symptoms of dementia. Shaji et al. have found that lack of support from local health services including family members add to the caregiver burden of patients with dementia in India.[18]O Kadhal Kanmani, Thanmatra, U Me Aur Hum, Maine Gandhi Ko Nahin Mara, Astu, and Godhi Banna Sadharana Mykattu have shown delusions, hallucinations, aggressive and wandering behavior of the dementia patients as most troubling to the caregiver. These symptoms have been shown to contribute much to the caregiver burden as per literature from India.[16],[18],[19]

Alzheimer's dementia has been the diagnosis mentioned in Utopiayile Rajavu, Pavada, Red Wine, Thanmatra, U Me Aur Hum, Maine Gandhi Ko Nahin Mara, Astu, Godhi Banna Sadharana Mykattu, Dhoosar, and Mai. However, other types of dementias find no mention. Thanmatra, U Me Aur Hum, Maine Gandhi Ko Nahin Mara, Dhoosar, Astu, and Mai had the caregivers and the patient visits the doctor and the diagnosis mainly made on the basis of history of the patient. In Mai, we witness the doctor conduct an assessment of cognitive functions and the protagonist confabulates the answers. Staging of the severity of dementia has been mentioned in Maine Gandhi Ko Nahin Mara, Mai, and O Kadhal Kanmani, but it is not known which type of staging has been used.

These films also have not portrayed management of dementia patients adequately. That there has been no cure discovered yet has been addressed in Thanmatra, Maine Gandhi Ko Nahin Mara, Astu, Mai, and U Me Aur Hum, which adds pessimism on the prognosis of the disease on the audience. In Mai, the message that pharmacotherapy can only slow the progress of the disease has been conveyed. None of the other films do not mention the need for pharmacological management. However, in U Me Aur Hum, describes medications as “neurodilators,” a nonexistent group of medications.

The films have depicted the tendency of dementia patients to wander away from home; however, how this could be managed has not been addressed. Black depicted the protagonist restricted by being chained to the hospital bed to prevent him from wandering, which could send a wrong message to the audience. Maine Gandhi Ko Nahin Mara also portrays psychodrama as means to cure the protagonist's delusion, which is rarely used means of therapy. Important measures to be taken by the caregiver such as informing neighbors of the chances of the patient to wander away and nonpharmacological therapies such as validation therapy and reminiscence therapy have not been portrayed.

The portrayal of dementia in Indian films has been mainly pessimistic amidst a moribund setting with the themes focusing on the decline in functioning of the patient, the ill-fated prognosis and the burden on the caregiver. The nihilistic portrayal of dementia, the popular theme of wandering, the lack of adequate pharmacological and nonpharmacological interventions are also findings in majority of the films portraying dementia in cinema from western countries.[20] However, films such as Happy Tears ( 2009) and Barney's Version (2010) are films belonging to the comedy genre while Notebook (2004) and Aurora Borealis (2004) have been dealt in a romantic setting.[6],[7],[21] Films on famous personalities who suffered from dementia including Iron Lady (2011) which depicted the life of the former British Prime Minister Margret Thatcher and Iris (2001) based on the life the author Iris Murdoch along with literature reviewing these films are also present.[22],[23]

We would like to conclude that these films can be used in cinemeducation and psychiatry movie clubs which are effective means of teaching about psychiatric disorders to medical students.[24],[25] With the help of a guided discussion or a structured curriculum, these films can be used to illustrate symptoms and course of the disorder, facilitate role play, and discuss transcultural issues and impact of the portrayal of dementia by the Medican.[26] This can help them in identifying patients suffering from dementia while they encounter them in career.

The characters have been portrayed by eminent and recognizable actors of Indian cinema, and apart from 36 Chowringhee Lane, Astu, and Dhoosar, the remaining films belong to commercial cinema which has far wider audience. Such films can help raising awareness of the disease in the community. Gerritsen et al. and Segers have opined about bringing a collaboration between doctors and various other stakeholders in dementia care with the movie industry for an improvement in the portrayal of dementia.[6],[7] Such sensitization measures might help the print and visual media in filling the void in the portrayal of persons with dementia.


  Acknowledgements Top


We would like to thank the members of the Facebook group “Psychiatry and Cinema”and members of “e-ips”, the official yahoogroups of Indian Psychiatric Society, Dr. Jayaprakashan KP, Secretary, Kerala State Mental Health Authority; Dr. Jomon Joy, Assistant Professor, Travancore Medical College, Kollam; Dr. Lallchand Anilal, Assistant Professor, Government Medical College, Thiruvananthapuram for their valuable contributions to our article.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Badr Ratnakaran would like to declare to have worked as Consultant Psychiatrist for the Alzheimer's and related disorders society for India from May 2014 to April 2015, as a potential conflict of interest.



 
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Prince M, Wimo A, Guerchet M, Ali GC, Wu YT, Prina M, et al. World Alzheimer Report 2015: The Global Impact of Dementia. An Analysis of Prevalence, Incidence, Cost & Trends. Alzheimer's Disease International, London, U.K; 2015. p. 22.  Back to cited text no. 1
    
2.
Shaji KS, Jotheeswaran AT, Girish N, Bharath S, Dias A, Pattabiraman M, et al. The Dementia India Report: Prevalence, Impact, Costs and Services for Dementia. New Delhi, India: Alzheimer's & Related Disorders Society of India; 2010. p. 22.  Back to cited text no. 2
    
3.
Green MC, Garst J, Brock TC. The power of fiction: Determinants and boundaries. In: Shrum LJ, editor. The Psychology of Entertainment Media: Blurring the Lines between Entertainment and Persuasion. Mahwah, NJ, USA: Lawrence Erlbaum Associates Publishers; 2004. p. 161-76.  Back to cited text no. 3
    
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Sathyanarayana Rao TS, Krishna VS. Wake up call from 'Stars on the Ground'. Indian J Psychiatry 2008;50:2-4.  Back to cited text no. 4
    
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Capp R. Dementia on the silver screen. Gerontologist 2013;5:172-3.  Back to cited text no. 5
    
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Gerritsen DL, Kuin Y, Nijboer J. Dementia in the movies: The clinical picture. Aging Ment Health 2014;18:276-80.  Back to cited text no. 6
    
7.
Segers K. Degenerative dementias and their medical care in the movies. Alzheimer Dis Assoc Disord 2007;21:55-9.  Back to cited text no. 7
    
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Kumar K, Gupta A, Gupta R. Mental illness in India: A cinematographical review. J Ment Heal Hum Behav 2012;17:95-100.  Back to cited text no. 8
    
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Keshavan MS. Film review - Astu: So be it. Asian J Psychiatry 2015;15:90.  Back to cited text no. 9
    
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Reisberg B, Auer SR, Monteiro IM. Behavioral pathology in Alzheimer's disease (BEHAVE-AD) rating scale. Int Psychogeriatr 1997;8:301-8.  Back to cited text no. 10
    
11.
The Indian Evidence Act, 1872 [Internet]. Kerala Medico-Legal Society; [cited 2017 Sep 9]. Available from: https://sites.google.com/site/keralamedicolegalsociety/the-indian-evidence-act-1872.  Back to cited text no. 11
    
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Prince MJ. The 10/66 dementia research group - 10 years on. Indian J Psychiatry 2009;51:S8-15.  Back to cited text no. 12
[PUBMED]  [Full text]  
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Emmatty LM. In: An Insight Into Dementia Care in India. USA: SAGE Publications Ltd.; 2009. p. 26-7.  Back to cited text no. 13
    
14.
Brijnath B. Why does institutionalised care not appeal to Indian families? Legislative and social answers from urban India. Ageing Soc 2012;32:697-717.  Back to cited text no. 14
    
15.
Dias A, Dewey ME, D'Souza J, Dhume R, Motghare DD, Shaji KS, et al. The effectiveness of a home care program for supporting caregivers of persons with dementia in developing countries: A randomised controlled trial from Goa, India. PLoS One 2008;3:e2333.  Back to cited text no. 15
    
16.
Shaji KS, George RK, Prince MJ, Jacob KS. Behavioral symptoms and caregiver burden in dementia. Indian J Psychiatry 2009;51:45-9.  Back to cited text no. 16
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Emmatty LM, Bhatti RS, Mukalel MT. The experience of burden in India: A study of dementia caregivers. Dementia 2006;5:223-32.  Back to cited text no. 17
    
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Shaji KS, Smitha K, Lal KP, Prince MJ. Caregivers of people with Alzheimer's disease: A qualitative study from the Indian 10/66 Dementia Research Network. Int J Geriatr Psychiatry 2003;18:1-6.  Back to cited text no. 18
    
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Wessely S. Dementia and Mrs Thatcher. Lancet 2012;379:210.  Back to cited text no. 22
    
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24.
Alexander M, Hall MN, Pettice YJ. Cinemeducation: An innovative approach to teaching psychosocial medical care. Fam Med 1994;26:430-3.  Back to cited text no. 24
    
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