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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 Paracetamol Paracetamol 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!
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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 [1]  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. [1] (Age UK, Stop Falling: Start Saving Lives and Money; World Health Organisation Global Report on Falls Prevention in Older Age 2007). 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 info@agecaribbean.com 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.   This is a tricky one, especially when looking after a parent. It may be very uncomfortable to talk or think about, but persons with dementia may experience an increase or decrease in their sexual feelings. It’s a sensitive topic and due to the effect of dementia on the brain, changes in sexual behaviour may be unpredictable. I’ve included some useful advice to help discuss this issue from a brochure ‘Sex and Intimate Relationships’; published by the Alzheimer’s Society UK. If there is an increase in sexual feelings and behaviours or ‘sexual disinhibition’, bear in mind that it may be caused by a few things that you may have not already thought about:
Caregivers should take a sensitive approach towards turning down sexual demands by persons with dementia to help prevent aggression and maintain the person’s dignity. Try not to make accusations or be offended by their behaviour; instead talk to them calmly and in private to avoid embarrassment. Another option that I have seen work in the past is to get male caregivers. This is hard to do because most carers are female, and also it may be that you like the ones you already have. Sometimes distracting or redirecting the person is enough. Also, once the female caregiver is aware of the illness, and it's explained to them, they can better approach sexual advances in a more understanding way. However, sexual disinhibition can become out of control and we may have to resort to medication. Usually we start with SSRI antidepressants which can have the side effect of decreasing libido. If that is ineffective there are stronger meds like antipsychotics, or even anti-androgens (androgens are the male hormones like testosterone). On the other hand, if you have a spouse with dementia, it’s important to know that a decreased interest in sex should not be taken personally. Some persons may be more comfortable with other forms of intimacy and affection instead. It is important to find other ways to feel close to your partner and to reduce your own frustration. If you are able to continue your sexual relationship with your partner who has dementia, this is great, as long as both parties are:
It may be worth talking to a professional about this issue if you are having problems, feeling unappreciated or neglected. Or if you are feeling guilty or uncomfortable regarding your loved one’s sexual needs, or lack thereof. Most times with some consideration, sensitivity and professional input, sexual issues in dementia can be resolved while maintaining the dignity of all parties. 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...  When your husband has dementia... 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.  Spending time with a pet is also a form of therapy for dementia patients. 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! Think about risks to the person's safety and put things in place to protect them. 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. Ask yourself:
 Older persons, even if ill, need to feel included. When visiting the home, look for reading material or any other evidence of activity 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. Christmas time is here again. Treat yourself or your loved one with a gift that will make ageing a bit easier. If you know someone who is struggling with daily tasks because of reduced mobility or athritis, then one of these 5 items can really make their life, and the life of their family members, much easier. Scroll to the bottom of the page to complete the order form for any of these 5 items via our partners at Care Safety Solutions Ltd. (All prices provided are inclusive of VAT and shipping.) #1.- Self-Standing Cane with Light - from SteadyCane ($385.00 TTD) I hurt my foot recently and used crutches for a while. It's extra dangerous to walk into a dark room if you have a walking stick or crutches. Not to mention, it can be hard to find somewhere to lean them up when you're not using them. This walking stick: stands up by itself, is foldable for easy transport, has a wrist strap to help you hold it easily, is height adjustable for short people like me and has a bright LED Light to help you see where you're going.  #2- Automatic One Finger Can Opener ($400.00 TTD) If you have athritis, a shoulder injury or if you are just fedup of struggling with big, heavy can openers, this one is for you. Just place the Automatic Can Opener on top of the can, press the button and the can will be open in seconds. A little extra help in the kitchen is always useful.  #3- Car Caddie- to help you get in and out of the car easily ($485.00TTD) Seniors who may not move as briskly as they used to might need a little extra support to get in and out of a vehicle. The Car Caddie is a sturdy and easy to reach device to help get you to a standing or sitting position. It can help reduce the likelihood of pain and falls when entering or leaving the car.  #4- Portable Fall Alert for Cane, Walker or Wheelchair ($750.00TTD) Falls are serious business. They can lead to head injuries, broken bones and a decrease in somebody's confidence. Help prevent falls with an alert which attaches to a walker, wheelchair or cane. If the walker, cane or wheelchair tips past a 30 degree angle, the alarm sounds. This can also be used as a PANIC alert system that is in easy reach if someone is in danger.  #5- Door knob Gripper (pack of 2) ($350.00TTD) Only when we get older do we realise how difficult little things like opening a door can be. But for people with limited dexterity or mobility, turning a smooth, round door knob can be very frustrating. The door knob grip cover gives you something to hold on to and makes it easier to use slippery doorknobs. It's also quick and easy to install and even easier to use.  So there you go. 5 gift ideas for mom or dad, granny or grandpa, or even just for you. Remember, there are many useful gadgets specially designed to make getting older safer, easier and more enjoyable. Follow Age Caribbean for more updates and advice on age-friendly services. |
AuthorDr James Bratt, Lead Consultant at Age Caribbean and Geriatric Psychicatrist. Archives
November 2017
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