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.
There are 3 licensed medications for the treatment of the above types of Dementia: (for more info on the different types of dementia, visit our dementia page)
1. Donepezil (brand names in T&T: Aricept, Palixid and Yasnal-Q)
2. Rivastigmine (brand name Exelon)
3. Galantamine (brand name Reminyl)
These medications have been proven to do several things:
They are not wonder drugs, but they are the best we have to treat these illnesses.
These medications, like all medications, have side effects. They can make people feel sick, nauseous, dizzy, vomit, have diarrhoea or they can interfere with sleep. However most of the time they do NOT cause any side effects at all. Also, if the side effects are mild they usually go away in 1-2 weeks and so it is best to persist and not give up too easily.
What to do if the side effects are intolerable?
If the person is on Donepezil 10mg daily here are some suggestions:
1. Ensure that the person is taking the medication after a full meal if they are having gastrointestinal side effects (stomach problems). This type of medication tends to be harsh on the stomach, so taking it after a meal is helpful.
2. Sometimes that's not enough and we have to add in a medication called a ‘proton pump inhibitor’ (e.g. Nexium, Prilosec, Omeprazole) to protect the stomach, and that can sometimes work very well to solve the problem. Omeprazole is available for free on CDAP.
3. Sometimes lowering the dose from 10mg to 5mg daily works, and so that is an option that you can try. If that works then we leave the person on 5mg daily indefinitely.
4. If the person is getting nightmares from taking the medication at night, then you can have them take the medication in the morning/lunchtime instead and that may get rid of the problem.
5. Sometimes none of this works and I have to change it to an alternative medication such as Reminyl or Exelon which are both available in T&T but are more expensive (over $1000 per month). Exelon also comes in patch form so the medication bypasses the stomach and goes directly into the bloodstream, therefore avoiding any side effects affecting the stomach. Exelon patches are applied to the person’s back and have to be changed every 24 hours.
6. Finally, sometimes some people do not tolerate any of these medications and we have to accept that. There is a second line treatment however, called Memantine (brand name Namenda or Ebixia), that is not available in T&T but is available in Barbados, the US, UK and Canada.
Getting a formal diagnosis from a qualified psychiatrist or neuropsychologist is a step in the right direction. (For information on what dementia is and signs of the disease, click here.) As a geriatric psychiatrist, I make dementia diagnoses often. Many times families feel overwhelmed. So I've come up with 10 steps you should take after a dementia diagnosis to help you cope. A sense of humour can also help...
Ten Steps to take after a Dementia Diagnosis:
1. Ask your doctor for clear directives on the type of dementia diagnosed, what medication is used to treat it, the size of the doses and how to take the medication. Have it all written down in case you forget. It's important to ask your doctor these questions, or find a doctor who is qualified to answer them. Once you know what type of dementia your family is coping with, do some research on it.
2. Call a family meeting to inform close relatives and friends to help make everyone aware of the changes that your loved one is experiencing and will continue to experience. The most common form of dementia is Alzheimer's disease, so advise them to visit reputable websites such as www.alz.org or www.alzheimers.org.uk to learn more about the disease. If they offer, let them know that you will call on them for help as it is needed.
3. Research available kinds of care that are extremely useful like Nursing, Occupational Therapy, Music Therapy or Art Therapy that cater to Dementia patients. Age Caribbean offers Seminars to help you and your support system go about this step. Some forms of care may not be available in your country, but ask around for freelance professionals who may be able to help. Care can be expensive, but can make a big difference for dementia patients and you, the caregiver. Start discussing and preparing finances early on.
4. Investigate Support groups and take advantage of the free groups in your country. Click here for a list of the Alzheimer's Associations in the Caribbean. Joining a support group is a vital part of understanding the illness and how best to approach difficult situations. Do not be ashamed. You may be surprised at how many families are also coping with dementia.
5. Make a detailed care plan- In most families, one relative will be the main caregiver of the dementia patient- maybe a spouse, a child or a sibling. That person needs to get a break every now and then. Make a plan to hire help or get other relatives to help. Age Caribbean offers Seminars to help you and your support system go about this step.
6. Think about risks to the person's safety and put things in place to protect them. Think about the "4 F's" - fire, floods, falls and fraud and try to prevent them. For example, all bank accounts should be joint with a trusted person to avoid financial abuse. Invest in electrical appliances that turn off automatically. Install a handlebar in the bathroom. And don't forget to stop them from driving if they are too dangerous on the road!
7. Remember, DO NOT take anything personally when there are behavioural symptoms (e.g. aggression or violence), or personality change (e.g. being abrupt or rude). This is part of the illness and the person cannot help it. They are not just being 'miserable'. They are not well. Getting upset might just make the difficult behaviour worse. Be patient, calm and have a plan on how to cope.
8. Remember to put the patient first- we can forget that dementia patients are still people with thoughts and feelings. They are often totally dependent on us, so try to involve them as far as possible in their own care and help them maintain a sense of independence and normalcy. For example, let them choose their own clothes when dressing and try to give them food they enjoy. Age Caribbean offers Seminars to help you and your support system go about this step.
9. Encourage activities! Persons with dementia usually don't want to go out or be social, for many reasons. But there are other ways to keep them active and engaged. For example, ask for help with easy chores, even though they may not be able to do it very well. (See 100 Caribbean activities for persons with dementia). Ask them what they would like to do rather than telling them what to do. And remember to be patient!
10. Remember that you may start grieving for the person while they are still alive - they are no longer the person you have always known. This grief can be prolonged as the person may live for many years, but dementia only gets worse over time. You will have to come to terms with this change. Feelings of guilt, frustration, anger and confusion are normal for most grieving caregivers. Be sure to seek emotional support from close friends and family or from a professional to help you through this change.
Making the decision to place your loved one in a Nursing Home can be very stressful. You may feel guilty about the decision, but you may also feel like you have no other choice. For persons suffering from difficult diseases which require 24-hour care, it can be necessary. There is no shame in making this decision if it is your best or only option for your loved one.
In the Caribbean, Nursing Homes are a recent trend. With the increase of older persons across the region, they have been popping up to fill the need for elder care. However, it's happened very quickly and Caribbean governments have not yet implemented policies to govern nursing homes. This means that they are widely unregulated and unfortunately, many are not appropriate or well-run.
For example. in Trinidad, there is no legal requirement for homes to provide a certain number of staff to patients. There is also no legal requirement that Nursing Home Staff have adequate qualifications. It is therefore very important to do your own research when choosing a home. The guidelines below are meant to help you make the best decision available to you and have been adapted from a UK organisation, Unforgettable.org.
But bear in mind that the Caribbean still has a long way to go in providing formal, holsitic care for older persons. You are unlikely to find an ideal, affordable care home but you can find a home that is appropriate and well suited to your loved one.
'...they are widely unregulated and unfortunately, many are not appropriate or well-run. It is therefore very important to do your own research when choosing a home'
Visit more than one home
Treat each visit as if you’re shopping around for a new house and choosing a good school for your children – at the same time. You're not only looking for a sturdy, safe building and convenient location, but for warm, qualified, caring staff to look after someone you love and who may, in many respects, be as vulnerable as a child.
Questions to ask the manager/staff:
'If the manager hesitates, is unable to provide first and last names, or clear roles for staff, this is a sign of a home with an inadequate care team...'
Before making a decision:
• If possible, take the person, especially if thay have dementia, to see the home before hand. Ask any other friends or relatives, whose opinion you’d value, to visit, too.
• Drop in again – this time unannounced and at a different time of day if possible. Staff should still welcome you if they have nothing to hide.
After making your decision:
Understand that moving your loved one to a care home can be a difficult transition at first. They will need time to adjust and settle in. Once you choose a home, try to work with staff to ensure that your loved one is comfortable as far as possible. Your job as a loving caregiver to your relative does not end when you place them in a home. Instead, you are now part of a bigger team to help care for your ageing relative.
As a psychiatrist, I get questioned about the medications I prescribe all the time. People often Google and research the medication I give them. What they find might really worry them.
First of all, doing your research and asking questions about your medication is an excellent practice, once you use a reputable website such as www.mayoclinic.org or www.alzheimers.co.uk. It is important to know what a drug is being prescribed for, what the side effects are, if there are any risks, and how long you should take the medication for.
It's easy to think that drugs prescribed by a psychiatrist that effect your brain can be more dangerous than drugs perscribed by another specialist or GP. But this is not true. Some GP's prescribe psychiatric drugs. Other doctors might not properly explain what they are prescribing or why. It is up to you to make sure that you ask the right questions before you leave their office. Taking too many medications at the same time can be dangerous, unnecessary and expensive. So make sure that you and your doctor agree that each and every medication prescribed is absolutely necessary.
It is important to know what a drug is being prescribed for, what the side effects are, if there are any risks, and how long you should take the medication for.
But just because a medication is necesary does not mean that it will be perfect. So you need to look at the benefits over the risks and understand that it might be the best decision for you or your loved one, despite what you might find in your research,
For example, Antipsychotics have been shown to increase the risk of many things in people with Dementia including stroke, pneumonia, falls, sedation and death in extreme cases. Sounds terrifying, I know. But as a psychiatrist, it is my job to find the best and safest antipsychotic to treat extreme agitation and agression in persons with Dementia. In many cases I choose a drug named Risperdal because it works well and is specifically santctioned to help people with dementia.
Whenever I have Dementia patients with aggression or agitation, I recommend other tactics first, such as paying attention to any physical health problems that may be causing their agitation. Apart from this, the person's environment should be calm, peaceful, comfortable and cool. Most importantly, they should be receiving good nursing care. This is a real challenge in the Caribbean because many of the nurses or caregivers have very limited experience or training with Dementia patients. But in my opinion, when it comes to Dementia, having an excellent nurse is far better than any medication.
Whenever I have Dementia patients with aggression or agitation, I recommend other tactics first, such as paying attention to any physical health problems that may be causing their agitation...and the person's environment.
But the reality is that often I get calls from families saying that they simply cannot cope. Often times, local Nursing Homes threaten to throw Dementia patients out if their aggressive behaviour cannot be controlled. This is not pleasant, but this is what happens. So when the agitation is severe enough, I take on the risk of prescribing low doses of Risperdal (0.5mg to 1 mg daily) which in my experience helps with aggression and agitation, but are unlikely to cause harm at such a low dose. (The maximum dose of Risperdal is 16mg, or 32 times the dose I prescribe).
So in the end, sometimes antipsychotics, although dangerous in large doses, can be safely given to persons with Dementia who absolutely need it. But first, be sure to talk to your doctor, try to improve your loved one's behaviour by attending to their physical needs and environment and ask your doctor for the lowest possible dose to start off with in order to decrease the risks of the medication.
Remember- these guidelines apply to any medication for any condition- not just dementia. For our T&T clients, Age Caribbean will be hosting a seminar on Medication Management in January 2017. Check our Seminars page to learn more and keep educating yourself about elder care.
Dr James Bratt, Lead Consultant at Age Caribbean and Geriatric Psychicatrist.