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:
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. 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.
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.