After a stroke, which is usually confirmed with a CT Brain Scan, persons might be left paralysed, may have speech and swallowing problems or psychiatric problems such as depression or anxiety. Complications from stroke can also include pneumonia, impaired vision and loss of independence. It can be scary for the patient and their family, but recovery is possible with proper support. (Check out this quick guide to a stroke to learn more about what a stroke is, the symptoms and what happens afterward).
For many recovering stroke patients, short term goals would be to improve mobility and functioning, and to make sure that swallowing and speech problems are addressed. Long term, most persons wish to get back to their regular lives as much as is actually possible.
How can stroke patients and their families achieve this? The answer is stroke rehabilitation as well as physical aides to help the person function.
Unfortunately, many hospitals in the Caribbean lack the resources to provide proper rehabilitation support to stroke patients in the weeks, months or years after a stroke. However, private resources are available if you are willing to seek them out.
Good healthcare requires a multi-disciplinary approach which means that a team of people is needed to help the person. Stroke rehabilitation is no exception. This kind of team may include a Physical Therapist, Occupational Therapist, Neurologist or Psychiatrist. Family members will also need to get involved to arrange visits, assessments, ensure finances are managed, and offer insight on the patient to the health professionals. We have some highly qualified professionals in T&T and the Caribbean. For example, Total Rehabilitation Centre TT or the Stroke and Diabetes Centre in Trinidad may be a good start. Check out our post about the different kinds of professionals available, and scroll down on our 50+ Resources Page for useful contact info in T&T, Barbados and St Lucia.
You may also need to use physical aids like a wheelchair, a walker, foot brace, or grab rails. These are available from medical equipment companies, or you can find out if you qualify for it from your local social welfare department via a grant. Some stroke patients with communication problems can also use technological devices like the T&T made Communicare app, which allows patients to communicate with their family members and caregivers via a smart phone or iPad.
Other options are assistive technology devices which allow people to be more independent and to live safely. They include a wide range of devices which help persons to do everyday tasks which may now be a bit difficult for them, such as cooking safely, making a phone call, turning door handles or getting in and out of a car. These devices are available for sale on Amazon.com.
But these devices often require professionals to help persons learn how to use them successfully. Even things like a walker, which might seem simple, requires knowledge on how to use it properly and avoid accidents or falls. In this case, you can consult with an Occupational Therapist or a Physical Therapist who can help the recovering stroke patient to improve balance, mobility and independence and reduce their risk of falls. Lastly, if there are speech or swallowing problems, you can consult with a Speech and Language therapist.
A stroke can be a traumatic, life changing event for the patient and their family members. Seeking out appropriate healthcare providers for stroke recovery and rehabilitation, as well as investing in appropriate aides and devices to help the person remain independent is therefore key for the long term well-being of stroke patients and their loved ones.
Medications are sometimes necessary, but if used recklessly they can also cause a lot of harm.
First of all, they should be prescribed cautiously by a qualified doctor in that field, reviewed regularly and reduced or stopped where possible. You should be in contact with both your doctor and pharmacist to ensure that this is done. Be careful who you accept medication from. Just as a Psychiatrist should not be prescribing heart medication, Cardiologists should not be prescribing psychiatric medication. GPs are able to prescribe all medications but will seek specialist advice when they are not sure. Be careful because medications don't always make things better!
Secondly, please, no matter what Dr Google says, NEVER self-medicate, take medication against your doctor's advice or alter doses on your own. If you think you are on too much medication talk to your doctor and get specialist advice as needed. People these days think that the internet is the answer to everything (and free too!) but this is simply not true. There is a reason why we doctors need to study pharmacology for years and years and why only a doctor can prescribe. I cannot tell you how many patients I have had who have made their illness worse by taking matters into their own hands.
Thirdly, choose your pharmacist wisely and seek advice from them and not your friend who is playing doctor. Even if you are going for over the counter (OTC) drugs, remember they can cause harm too and can interact with other medications you are taking. For e.g some people take St. John's wort for depression which is a 'natural' antidepressant. However did you know that it interacts with the contraceptive pill? So women of child-bearing age run the risk of becoming pregnant thanks to this so-called harmless natural medicine. That is only one example of many. Lastly, strict pharmacists are not trying to make your life more difficult. They just take their work seriously and understand how dangerous medication can be and so will not give you medication if they think it will harm you, or without a prescription. This is the type of pharmacist you should go to!
Dementia by definition is a deteriorating illness with no cure, meaning that it will get worse over time no matter what we do. So the only thing we can do is manage the situation as best as possible.
However, if you live with the person you will unfortunately witness the deterioration right in front of your eyes, which is extremely difficult and heartbreaking to witness. No matter how much you resist, there is unfortunately no way to stop this deterioration.
Different psychiatric medications have varying degrees of success. Once the proper medication is decided for the patient, it might help ease the symptoms or slow the progress of the disease, but it will not stop the deterioration altogether.
There are also several other treatments that I often suggest, yet few people listen as everyone is hoping for a miracle pill which does not exist. These treatments are always beneficial physically and emotionally:
1. Occupational therapy to ensure your loved one remains independent and active as possible
2. Psychological therapy for family members to help to accept the situation and to learn strategies to deal with day-to-day situations
3. Psychological therapy for your loved one to help him/her deal with his diagnosis in the early stages
4. Music therapy or art therapy to help your loved engage and enjoy life as much as they can.
5. A comprehensive nursing assessment looking at the day-to-day aspects of the person's life, in order to identify and solve difficulties (e.g. eating, bathing, dressing, sleeping, behavioural problems)
6. Attending a support group to get ideas on how to manage situations or just so that you don't feel alone and isolated
Other experts that also help with Dementia care are Dietitians, Physiotherapists, Social Workers and of course other doctors such as GPs/Neurologists. To learn more about each of these, click here.
The idea when treating a person with Dementia is that it should be a team effort. We unfortunately do not have big centres such as in Canada or the US/UK where everything can be found in one place, but we are lucky in T&T to have excellent, well-trained healthcare professionals that one can go to privately. The problem of course is that it is so expensive. This is why careful planning for retirement, and investing in insurance plans are so important! There are also excellent healthcare professionals in the public sector, but you may have to ask around to make sure you get the best qualified, most suitable person available.
We should never give up on loved ones with dementia, as there is so much that we can do to make their lives (and yours) better. But acceptance of the reality of the situation is the first step. Also, acceptance of the fact that it will be very very difficult and will require a lot of work on your part might make things easier in the long run. I know dealing with dementia is hard, but don't give up!
If you have mental health concerns, you should seek help. But where do you go? How do you know what type of doctor you should talk to? Do you look for a psychiatrist or a psychologist?
If you’re unsure what the difference is, you’re not alone. What you see on TV is not reality. There are similarities, but there are important differences, too. Here’s what you need to know to decide which is right for you.
How They’re Alike: Psychiatrists and psychologists are different types of professionals trained to help you deal with mental health issues. Both are there to get you through problems. Both Psychiatrists and Psychologists look closely at your behaviour such as not getting out of bed, your sleep patterns, eating habits, and negative thoughts that might be causing or contributing to depression for example.They aim to provide you with the means to manage the issues in your everyday life.
How They’re Different:
Education: Psychiatrists are medical doctors who graduate from 4-6 years of medical school, and then go through anywhere from 4-8 years of post graduate training in the assessment and treatment of mental health disorders depending on where they train (US = 4 years, UK = 8 years, so a total of up to 14 years of training). A doctor who graduated in the British system like we have in the Caribbean has the letters MB BS, or MB BCh or MB ChB after their name. A doctor who graduated from the American system has the letters MD after their name. They all mean the same thing: a basic medical degree. Then there may be other letters after that, for e.g. in the UK the letters MRCPsych mean that the person is a qualified Psychiatrist and CCT means they have completed their training. West Indian Psychiatrists may have the letters DM after their name, which is the local equivalent of MRCPsych.
On the other hand, psychologists have a doctorate degree in an area of psychology, which is the study of the mind and human behaviour. They are not medical doctors and so can’t prescribe medication. A psychologist can have a PhD or a PsyD in clinical or counselling psychology, for example. Typically, they have gone through 7-9 years of training in total. Unlike psychiatrists, psychologists are also trained in giving psychological tests (like IQ tests or personality tests). In most countries, only a person who has a doctorate degree can call themselves a psychologist.
The Approach: Psychiatrists are medical doctors and have studied the workings of the body (physiology, biochemistry) and mind (psychology) and how medications work (pharmacology). They focus on the medical side of things. They might ask you to do blood tests, or get a brain scan or to get an ECG to check your heart. For instance, before a psychiatrist calls someone depressed, they will make sure they don’t instead have a vitamin deficiency or a thyroid problem. Once they’ve excluded physical illness and they make a mental health diagnosis, psychiatrists often prescribe you medicine. People are often afraid of medications like antidepressants, However they have been proven to work and can improve your quality of life significantly. They will also advise you to make lifestyle changes to help you to help yourself (exercise, eat healthy, get good rest, don't drink too much alcohol, don't smoke etc.). Sadly most people do not listen to this advice as they don't want to take responsibility for their health!
Psychologists on the other hand are trained to practice different forms of psychotherapy (talking therapy) -- i.e. talking with their patients about their problems and using highly specialised ways to treat their problems and to give the person the tools to manage their daily problems. It is not just talking or getting advice as you would from a friend or family member, but it is a form of treatment that is equal to medication and it takes years of training to be competent. Only some psychiatrists are trained to do this in addition to their medical treatment, but not all. It depends on their training. It is important to know whether the person you are seeing is actually trained in psychotherapy before you do talking therapy. Don't be afraid to ask!
Both are highly important professionals in treating mental illness and both medication and talking therapy have been proven to work, and to work even better when combined!
For more info on this topic, check out this interview I did with a local podcast on mental health issues in T&T:
As a Geriatric Psychiatrist, I am sometimes asked to determine if a patient is able to manage his/her own financial affairs. Concerned family members often want to help put things in place so that their loved one's financial needs are met and their assets are kept safe. If this is the case a request from the person's lawyer is necessary to ensure that all proper legal proceedings are followed.
However, there is often some confusion about how psychiatrists determine whether or not someone is able to manage their own financial affairs. Here are some things you should know:
Determining someone's financial capacity can be complicated
If you have ever considered taking over the financial affairs of an older, loved one, you would know that power of attorney often does not apply to dementia patients in T&T, and so local banks will often not accept a power of attorney as a means of giving a relative control over bank accounts. It is just the way the law works here.
Consequently, people come to mental health specialists like myself to determine a person's financial capacity, or their ability to manage their financial affairs. I often get requests for 'a letter to the bank' saying that mummy/daddy/tanty has dementia and can't manage their money anymore... Sometimes I get this request before mom/dad/tanty has even been formally diagnosed with dementia!
Family members may notice that their loved one is not able to keep track of bills anymore, or maybe they can no longer visit the bank or ATM and need help to pay for doctor's visits, medication and nursing care.
However, family members should also understand that it is not right to take away a person's control over their assets unless it is deemed absolutely necessary by a mental health specialist and a court of law.
This process can take several months, and starts with a diagnosis. Following a diagnosis, of Alzheimer's disease for example, a separate financial capacity assessment is needed. This is a private interview in a quiet, comfortable, safe space where a specialist can determine, through a series of questions, whether someone is able to make decisions about their assets, what kind of decisions they are able to make and how this may affect them, their financial security and their family members .
An older person may not trust others with their assets, and with good reason
Many family members are often just trying to help and protect their older loved ones. However, if there are substantial assets involved, some relatives may be tempted to secretly 'pay themselves' by keeping money, property, jewellery, vehicles or other valuables belonging to the older person.
Financial abuse is something I often mention, but some relatives believe that taking from a parent or someone who is dependent on them is acceptable.
So it can be difficult for older persons to figure out who is trustworthy and who is not. Understandably, they may want to be extra careful about who they give up control of their finances to. Or maybe they are very private and possessive about their assets and do not want to give up control at all.
Considering someone outside of the family, like a trusted lawyer, can be an option in this case. Also, if the person is in the early stages I always recommend that they add a trusted person onto their bank account(s) and that will negate the need for the entire legal process in the first place.
However, if that is not a possibility and the person lacks the capacity to manage their financial affairs and property then families need to apply to the High Court for 'Committee' status, which is the legal term under our law to obtain Legal Guardianship of the person.
Ultimately, it is a judge who will decide who can be allowed to take over this person's affairs. The financial capacity assessment plays a big role in this decision. So it needs to be done carefully.
Dementia does not always mean that a person lacks financial capacity.
Like I said earlier, a financial capacity assessment can be complicated. There are many factors which need to be considered, such as the diagnosis and if it's dementia, the stage of dementia the person is in (early, middle or late), the person's extent of understanding and judgement, the size of their estate and their relationship with persons who are willing to help.
It is important to note that just because a person has dementia, this does not always mean that they are not capable of making some financial decisions. For example, a person may not be able to keep track of their bills or visit the bank anymore, but they may know exactly who they trust and do not trust.
They may remember exactly how many properties and bank accounts they own and while they may not remember what they had for breakfast, they may very well remember what money they set aside for their old age, and how they would like to have that managed.
Financial capacity therefore goes beyond the dollars and cents and cannot be determined with one quick letter to the bank.
This challenge is best done along with Age Caribbean Consultants, following a staff training program.
Each week for 4 weeks, the staff at the home is asked to watch one of the below videos by US Dementia expert, Teepa Snow, and discuss the questions posted under it. These questions are directly related to the training sessions that have been completed by staff. (These videos are not sufficient on their own to train staff or improve the quality of care homes).
After the 4 weeks are over, an Age Caribbean consultant will speak to management about the next steps.
Week 1: How to Approach Patients with Dementia
Can you state 3 key things to remember when approaching a patient?
Week 2: De-escalating a Crisis
Has there been a dramatic incident or event similar to the one described in your care home?
How was it handled?
How could it have been handled differently?
Week 3: Bathing a patient with Dementia
Did you find the above advice practical?
Are there ways you can change your current approach to bathing patients to make it more comfortable and dignified for both you and your patient?
Week 4: Getting patients to do things
How can staff better engage with patients at your home?
How can staff support each other when trying to engage patients?
There are many different healthcare professionals available to Caribbean people that we may not have known about 20 years ago. Sometimes older people are uncertain of how different therapies or treatments can really help them. Below is a list of some common healthcare professions and how they can work for you. Many times, using one of these other professionals (besides your regular doctor) and can save you money in the long run and improve your quality of life. Here's how:
Psychiatrists- Psychiatrists are doctors who have specialised in the treatment of mental illness. First, we go to medical school. This is why we can prescribe medications- we are trained firstly as doctors. Then we spend some time specialising and training in psychiatry. Some psychiatrists like myself decide to spend even more time training, so we sub-specialise in a certain kind of psychiatry, like addiction or geriatric psychiatry.
Speech & Language Pathologists- These professionals are very useful for stroke and dementia patients. They are trained in helping people with communication issues or swallowing problems.
Physical Therapists (also known as Physiotherapists) Physiotherapists are specially trained to help persons recover from muscle injuries and strengthen their body. They can assist with mobility and balance issues. They are useful for persons who have had a fall or who have had a stroke.
Occupational Therapists- Occupational Therapy is very important for persons who have fallen ill and can no longer go about their daily tasks the way they used to. This includes dementia patients, stroke patients, or people with mobility challenges like Parkinson’s disease. Occupational Therapists assist with increasing a person’s independence and confidence by helping them to adapt and learn how to do day to day tasks such as bathing, dressing and hobbies even though they are ill or injured.
Cognitive Stimulation Therapy- In the UK, this is the only other approved treatment for dementia patients, in addition to medication. This therapy is like ‘exercises for the brain’ that can take place within a group session. It can help persons with orientation, confidence and socialisation.
Psychologists – sometimes people become depressed or anxious after they have retired from a job they loved, or received a scary health diagnosis. Very often, family members who are looking after an older, ill person can become depressed as well! Psychology is a very healthy way of addressing these issues and uses talking therapy to help persons cope with difficulties. Psychologists are not doctors and cannot prescribe medications, but they often work with doctors and psychiatrists to help a person get through a difficult time.
Dieticians – A dietician is different from a nutritionist. They have had specialist training in what kind of nutrition persons need to maintain a healthy weight, or to manage illness like diabetes or high blood pressure. Sometimes eating is a huge problem in Dementia patients and family members become concerned that their loved one is not getting their nutritional needs. A Dietician is an expert in this area and can help.
Social workers – Social workers can be extremely helpful in situations where there are serious social issues that a family needs help with. Some social workers might assist with government financial aid, or refer a family to government counselling or legal aid. Many social workers in the public sector are stretched thin because there are not too many of them. So it may take some time before you receive assistance.
Neurologists- Both Geriatric Psychiatrists and Neurologists can treat Dementia. A Neurologist treats disorders affecting the brain, spinal cord and nerves. For example, they are the specialist you will go to if you have had a stroke or to get tested for dementia.
Your GP- A general practitioner is probably your family doctor and is a good first stop if you suspect anything is wrong. Your GP will then refer you to a specialist depending on the circumstances. Your GP should say why you are going to a specialist if you are referred so you can fully understand your situation.
Learn more about finding these resources on our 50+ Resources page.
If you are confused or uncomfortable, ask whoever you go to about their training and qualifications. Many of the professionals listed are available both publicly and privately, so you may have options once you do your research. When you choose to see a professional, try to listen and follow their instructions as closely as possible. Remember, they have likely trained for many years in their field. If you are still uncertain, you are free to ask questions or get a second opinion.
Yes, I'm talking about falls again. I have to! Falls can be extremely dangerous for older persons and can result in broken bones, head injury, shaken confidence and immobility. As I mentioned in the review on the Falls Prevention Programme, it is extremely important to do what we can to prevent falls in older persons. The most important change to make includes doing regular strength and balance exercises. In addition, below are 10 tips to help you take necessary action in preventing costly, potentially traumatic falls:
"Falls can be extremely dangerous for older persons and can result in broken bones, head injury, shaken confidence and immobility..."
1. Check your eyesight - your vision plays an important role in your sense of balance and movement. It is a good idea to check your eyes at least every 2 years. Remember that bifocal glasses can make objects appear closer than they really are and could cause you to trip or lose balance. Ask your Optician for advice. And if the cost is a problem, call your local social services division and ask if you qualify for any relevant grants or assistance.
2. Manage your medications - some medications can make you faint, unsteady or light-headed on your feet. These include tablets for high blood pressure, diabetes and insomnia. Talk to your doctor about it and ask if the dose can be reduced, or the medication changed.
3. Ensure good lighting around the house, especially on the stairs. If you need to get up in the middle of the night to use the bathroom, use a night light or switch on the light first before doing anything else.
4. Have handrails fitted in the bathroom or on the stairs to make it safer and easier to get in and out of the shower, or to climb the stairs. Remember it's better to be safe than sorry and handrails cost very little compared to the cost and pain of breaking your hip.
5. Keep your house clear - rearrange your furniture to help you move around or to prevent you from bumping into things. Keep the floor clear of anything that might make you trip, such as carpets, boxes, cords or anything else.
6. Remember pets can cause you to fall as well as they tend to scurry under your feet! Put a bell on their collar to alert you of their presence or use a brightly coloured collar so you will see them better (e.g. red).
7. Use a non-skid mat in the bathroom or if you already have a mat that you like, you can stick a rubber sheet underneath to prevent it from moving. Alternatively, if you are re-doing your bathroom, put in non-skid tiles. Wet tiles are notorious for making people fall!
8. Avoid standing on a chair to change light bulbs or to hang up curtains. Ask someone else to do this or if you have to, use a stepladder.
9. In the garden or yard watch out for uneven paths, sharp stones and slippery surfaces after it rains. Keep foot paths clear. Put in railings or a ramp as needed.
10. Use proper footwear and clothes - it is important to choose suitable shoes that fit you well. Buy shoes with a good grip, low heels and high sides. Inspect your shoes. Think about what problems you have with respect to walking. Let's take Diabetes for example. People with Diabetes over time can develop a loss of sensation in their feet. You might often wear sneakers which tend to be well-cushioned and are very comfortable, but tend to have thick soles. Therefore, because you cannot feel the floor this may make you more unsteady. Avoid rubber slippers as they invariably make people fall. Avoid flared pants or clothing that trails to the ground. Avoid walking in slippery socks or tights. You can buy special socks that have a grip underneath.
AND ABOVE ALL
Continue to exercise regularly to improve your strength and balance.
Caregivers are often concerned that their loved ones don't get enough sleep. If you have noticed a change in sleeping patterns of an older person, do not panic. As we get older, we tend to sleep less. We may get up during the night more frequently due to aches or because we need to use the washroom.
Some older persons find that instead of getting 8 or 10 hours of sleep each night, they are only getting 4 or 6 hours of sleep. This is a common change and is nothing to be alarmed about. Do not turn to sleeping tablets right away. They can be addictive, and many more people (in T&T for example) end up taking sleeping pills for several decades, which is not healthy.
"As we get older, we tend to sleep less."
Sleeping tablets should be your last resort, after consulting with a trusted doctor. Some more creative, healthier ideas to improve sleep quality for older persons are suggested below, as adapted from Philip T. Hagen, M.D. of the Mayo Clinic, USA:
Memory loss is a common concern in persons over 50. If you are over 50 and find it harder to remember details, don't panic. Many factors may affect your memory, including stress, multi-tasking or a lack of interest in details. Here are 10 proven strategies you can try to help you recall information better:
1. Develop a routine and stick to it. Many persons have a morning routine, but what about an after work routine or weekend routine?
2. Advanced planning can help reduce the risk of forgetting. Keep a large, easy to read calendar nearby with important dates and events clearly marked.
3. Create a place for everything and store everything in its place. This is useful for smaller items like your phone, keys and wallet.
4. Use a back pack or handbag. Place things in the bag that you will need for the day ahead. Pack whatever you think you might need- better to be safe than sorry!
5. Use a to-do list and remember to take it with you when you leave the house! For your home, consider keeping a small blackboard or whiteboard in the house to list things as you remember them, which you can then go back to.
6. Use a Journal to keep track of important plans, impressions, ideas, and appointments. Keep it on you at all times.
7. Develop schedules for different time periods. Plan by the day, week and month, especially during hectic months like Christmas time and August vacation.
8. Use a network of reminders – it doesn't hurt to have several methods to remind you of one important event. Use post-its in easy to see places, or an alarm on your phone, or ask someone you trust to call you to remind you. Get a talking alarm clock to keep better track of the time or a talking pill box to remind you to take your medication.
9. Use tricks to help your memory like repetition or association. For example, associating your medication with your lunch might make it easier for you to remember to take it at lunch time.
10. Focus on one thing at a time. Paying attention to one thing at a time will help you to remember more details. Besides, trying to do too much at once might cause you to feel rushed and stressed out, which can then affect your memory.
The bottom line? Get organised! Your memory will work better if you give it some help by being proactive and making things as clear as possible.
Dr James Bratt, Lead Consultant at Age Caribbean and Geriatric Psychicatrist.