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.
Generic drugs have gotten a bad reputation in the Caribbean, perhaps because some generics come from India and a lot of people are not convinced that the quality of these drugs is good. Let’s explore the reasons why...
First of all, what is a generic?
So this is what happens: A drug company, a multi-billion dollar organisation, conducts years of clinical trials before a medication receives approval for use by the general public. Because of the huge amount of money they invest, they are granted a patent (a license to produce the drug) which lasts for many years. This means that only that company has the right to make the drug during that time so they can make back their money.
After the patent expires, other drug companies are legally allowed to produce generics, or copies of the drug. This is good news for people who cannot afford expensive drugs and also for countries like the UK which provides free medication for all its citizens. These countries understand that budgeting is key to providing an excellent standard of healthcare.
So for example, Aricept is produced by a company called Pfizer and was the first medication approved to treat Alzheimer’s Dementia. The active ingredient in Aricept is Donepezil Hydrochloride. The patent that Pfizer had for Aricept is now expired, which is good news because now many companies around the world are producing generics such as Palixid (produced in Hungary) and Apo-Donepezil (produced in Canada) at a much cheaper price.
So are the generics just as good as the branded drugs?
In my opinion, yes. But I would definitely choose generics from the US, Canada, the European Union or Australia/New Zealand because their quality standards are rigorous. There are many reports of medications produced in small, unsanitary factories in other countries around the world and even reports of fake medications packaged in fake boxes! So be careful of where the generic is produced.
Why do all medications have two names?
One is the brand name that is used for marketing and the smaller name below is the active ingredient which is the important thing. So always check the small writing below the brand name. For example it will look like this:
ARICEPT or PALIXID
Donepezil Hydrochloride Donepezil Hydrochloride
Another example is:
PANADOL or TYLENOL
They are the same thing, just different brands! (NB: Paracetamol is called Acetaminophen in the US).
As you can see, the active ingredient, in both cases, is exactly the same. If I were you, I would go for the cheaper option, because in the long run you will save yourself a lot of money!
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)
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.
“What is Falls Prevention? Is falling down really that big of a deal?” This was the question asked repeatedly when people heard about the T&T National Falls Prevention Program in March 2017. Hosted by Total Rehabilitation Ltd, the Physiotherapy Association of T&T, Springfield College in Massachusetts and supported by the Ministry of Social Development and Family Services, the program was held at four venues around the country. Age Caribbean Consultants were pleased to speak at the event on the huge impact of falls, the causes of falls and how to prevent falls in older persons. I’ve included a brief overview of the excellent information provided at the program as a reminder, or for anybody who didn’t make it to the program.
Are falls really that big of a deal?
Absolutely. We do not have many figures for falls in the Caribbean, but a Latin America/Caribbean study found that approximately 21% of older adults in Barbados fell each year (more than one in 5 older persons) while in Chile it was as high as 34%, or over one third of older adults. In the UK, the figures are more detailed. Falls represent the most frequent and serious type of accident in people aged 65 and over. They are the main cause of disability and the leading cause of death from injury among people over 75. Falls are also extremely expensive. In the UK, hip injury costs up to 65 million dollars a day 
What happens after a fall?
After a certain age, it’s much harder to get back up and move along after a fall. Falling can cause a decrease in confidence in older persons. They may not want to go out anymore for fear of hurting themselves or being embarrassed. Injury from falls such as hip fractures, broken bones, brain damage and other injuries are very serious when our bodies are frailer. Having a fall over 65 can lead to becoming dependent, especially after a hip injury. Persons who experience a fall after 65 are twice as likely to fall again. So sometimes a fall can lead to many personal and social issues, while the resulting injuries can lead to expensive medical costs.
What causes older persons to fall?
As we get older, the changes we experience may contribute to our risk of falling. Things like increased frailty, reduced stability caused by side effects of medications, poorer vision and hearing, or brain changes can all increase the risk of falls.
Other environmental factors can also increase falls risk, such as having a cluttered space where things can cause you to trip and fall, inappropriate footwear, climbing stairs without proper railings, slippery surfaces like outdoor tile, or even high sidewalks or steep, narrow walkways in public places.
How can we prevent falls?
Physical and Occupational therapists gave some useful advice such as: using non-slip mats in bathrooms, using handlebars to help you get around your home, asking for help with potentially unsafe tasks and ensuring your home is well-lit so you can see where you’re going. But most importantly, they stressed how important exercise was to preventing falls. Going for a walk, dancing, creative, simple exercises at home and strength and balance exercises are key.
The bottom line? FALLS ARE PREVENTABLE. Let’s pay attention and prepare our homes to keep ourselves and loved ones safe.
 (Age UK, Stop Falling: Start Saving Lives and Money; World Health Organisation Global Report on Falls Prevention in Older Age 2007).
Depression in Older Persons- Age Caribbean will host Seminar in San Fernando in recognition of World Health Day 2017
Age Caribbean will be hosting a seminar on ‘Depression in Older Persons’ in recognition of the World Health Day 2017 international campaign called ‘Depression- Let’s Talk.’ Older persons (60+) are one of three target groups of the campaign, (along with adolescents and new mothers). The seminar will take place at the Southern Academy for the Performing Arts, San Fernando, on Saturday April 08 at 9:00am-12:00pm. Members of the public can call 305-3487 or email firstname.lastname@example.org to register. The cost is $195.00 TTD per person.
According to the World Health Organisation (WHO), Latin American and the Caribbean is the fastest ageing region in the world. The American Psychological Association adds that mental health issues among older persons is expected to quadruple in coming decades, as older persons are faced with changes like retirement, the loss of a spouse, illness, or nursing home placement.
As the only Geriatric Psychiatrist in the English-speaking Caribbean, I am thrilled by the decision by the WHO to campaign for a mental health issue for World Health Day, and to target older persons as a vulnerable group. It is a clear message that countries need to finally pay attention to depression in older adults. Depression in later life is not a normal part of ageing; it is a problem which can be treated. Come join us to learn more.
Dr James Bratt, Lead Consultant at Age Caribbean and Geriatric Psychicatrist.