Mrs Audrey’s unwillingness to visit the community health centre may prompt her daughter to reach out to Mrs Audrey’s General Practitioner (GP) located at the community health centre or family doctor working on the day of visit/contact. These healthcare professionals are likely from the same community and would be the preferred choice due to familiarity and trust developed over the years. This outreach may be done secretly due to the strained relationship between Mrs Audrey and her daughter, along with her overall unwillingness to explore her symptoms. In this regard, the GP, who is likely not trained in dementia diagnosis, care or management, would make a house visit to assess Mrs Audrey’s condition under the disguise of a regular doctor’s visit. The GP’s lack of training may result in either no diagnosis, a misdiagnosis, or being told that her symptoms were a normal part of ageing. As a result, Mrs Audrey’s dementia-related symptoms will be left untreated, with her most likely supports being her husband, GP, and daughter. To note, given the resource constraints of public healthcare settings in Jamaica, home visits, though possible, will be infrequent and dependent on the community health centre’s resources including available doctors and/or nurses and the severity of Mrs Audrey’s condition.

Mrs Beverley’s location in an urban area will likely offer her more opportunities to receive a dementia-related diagnosis. However, she will likely seek assistance from the General Practitioner (GP) who is currently treating her other health challenges. Though there is a possibility that Mrs Beverley will receive either no diagnosis or misdiagnosis, given the location and increased awareness of mental health within urban areas, Mrs Beverley may be referred to a psychiatrist, who will most likely aim to provide a diagnosis. If Mrs Beverley receives a diagnosis, professional support will be provided by the family doctor and or the psychiatrist, particularly if she is prescribed dementia-related medication. However, given the low rate of Jamaicans insured (less than 20%) and Mrs Beverley’s son and daughter-in-law being self- employed, it is likely that these additional medical expenses will be paid out-of- pocket and will further strain the family financially.

Additionally, the Caribbean Community for Retired Persons (CCRP) currently boasts a membership of approximately 11,000 persons 50 years and older, and have been identified as a key source of information for age-related issues. Should Mrs Beverley’s family reach out to CCRP for her dementia-related symptoms, the organisation will likely recommend them to STRiDE Jamaica. Through this referral, the family will likely access free memory care consultations that provide guidance and support to carers of persons with dementia by empowering them with strategies in dementia care and management as well as providing culturally appropriate resources. Despite this, STRiDE Jamaica – better known among urban areas- is not well-known and is limited in its current capacity to meet the demands of persons desiring care consultations. As such, many persons are likely not able to benefit from this support.

Furthermore, changes in the family arrangement are inevitable. The family is likely to seek a paid carer, possibly not trained in dementia care and management, or a practical nurse. Sourcing these resources will be facilitated through word-of-mouth, along with perusing the newspaper classifieds. The paid carer will assist with managing Mrs Beverley’s symptoms and overall care. The assistance will afford Mrs Beverley’s son and daughter (primary unpaid carers) the time and mental space needed to refocus on their business and children. However, Mrs Beverley’s daughter-in-law will still spend at least three times more time caring for her mother- in-law than Mrs Beverley’s son as women are likely to assume the caring role within the family (CaPRI, 2018). Alternatively, paid care may come from a domestic worker who is untrained in dementia care management. Based on the family’s preference, the domestic worker will likely assist with household chores such as cleaning, cooking and helping out with childcare and or care of Mrs Beverley. Again, these options come at additional expenses that the family may be unable to shoulder.

Mrs Carol will likely visit her General Practitioner (GP) as primary care providers are usually the first point of contact within Jamaica. At this stage of her illness, as evidenced by difficulty swallowing, there is a high possibility that Mrs Carol would have already visited her GP, but either did not receive a diagnosis, received a misdiagnosis or received a provisional diagnosis of dementia and was referred to a psychologist or psychiatrist to assist in providing care.

Based on the type of dementia, Mrs Carol may be prescribed medication, which is very costly in Jamaica and must be paid out of pocket (ranging from JMD9,244.88 to JMD35,653.60 or USD68 to USD264, as of October 2020). As such, dementia-related treatment may strain the financial resources of the family as Mrs Carol’s daughter is also dealing with her health challenges. Professional support, at a cost, may be provided by a psychologist, psychiatrist, mental health professional with possible knowledge in dementia care, nurse or paid carer (untrained in dementia care).

Changes have already occurred in the family arrangement, with Mrs Carol now living with her daughter – who on average will spend 7-8 hours maintaining the house and caring for her mother – and will continue to occur. As a result of the advanced stage of Mrs Carol’s condition and the need for support with activities of daily living (ADLs), the responsibilities may become too great for Mrs Carol’s daughter in the context of being primarily responsible for her mother, her daughter and her health challenges. As such, she may be inclined to place her mother in a palliative care facility. However, there is only one government-operated palliative care facility in Jamaica which many believe only caters to persons coping with cancer. The other two palliative facilities are privately operated.

Should there be no available accommodation in the government-operated palliative care facility, Mrs Carol’s daughter may need to hire a live-in paid carer to assist with managing Mrs Carol’s symptoms, care needs and to allow Mrs Carol’s daughter to leave the home confidently knowing that her mother will be taken care of.

Having noticed his father’s declining ability to take care of himself and his household, Mr Donovan’s son is likely to take his father to the clinic (around 5 miles away from Mr Donovan’s residence) within Mr Donovan’s community for a GP to assess the nature of his health decline. The GP is likely to monitor Mr Donovan for some time given the early stages of his illness and will remain his primary source of professional medical support. Mr Donovan will likely have several missed appointments as he may forget, and his son may be unable to travel from the city to the rural community where his father resides due to time constraints. It will also be challenging for Mr Donovan to travel the distance on his own, given his current health condition, as this would involve waiting at the “bus stop” or a “taxi-stand” for a privately operated public passenger vehicle (PPV), such as a car or bus as the government-operated transportation system is not provided outside of the capital city, Kingston and surrounding urban areas. Should Mr Donovan’s symptoms worsen due to lack of appropriate interventions, he will likely be referred by his GP to a psychologist or psychiatrist. Though psychologists are located throughout Jamaica, the majority are within the Kingston and St Andrew region, a predominantly urban region with the highest population density. As a result, Mr Donovan will likely need to travel with his son to meet these professionals.

Though the first point of contact, regardless of location, is typically the General Practitioner (GP), Mr Errol may have direct access to a psychologist or psychiatrist without needing a referral from a general practitioner. However, culturally, men are less likely to seek medical help until their medical condition becomes unbearable. Further, if he is unaware of the possible nature of his challenges, the visits to his GP will likely be general check-ups. Through these check-ups, if the GP notices any changes in Mr Errol’s cognitive skills, he will recommend a cognitive assessment to provide a provisional diagnosis. A referral may be made to a psychologist or psychiatrist who will instruct Mr Errol to do diagnostic tests to rule out alternative explanations of symptoms and identify an accurate diagnosis.

Mr Errol is unlikely to follow up on the referrals to conduct these tests if left up to him. However, Mr Errol is likely to have a romantic partner who visits frequently and may encourage him to follow up on the referred tests; unfortunately, her efforts will be met with much resistance. His GP will be Mr Errol’s primary professional support. The GP, having observed Mr Errol’s cognitive decline, may contact Mr Errol’s listed emergency contact. Mr Errol’s deceased wife is likely to still be listed as his emergency contact. At this point, the GP may request to update this information, in which the contact information of his current romantic partner will be provided. Mr Errol, however, may ask the GP to refrain from contacting anyone out of feelings of embarrassment and will likely deny any changes in cognition.

Being estranged from his children and the loss of his wife, Mr Errol’s support will come from his romantic partner, along with trusted friends, co-workers or his extended family members. His extended family members, having observed Mr Errol’s cognitive decline, may, on their own, attempt to contact his children to encourage them to attend to their father’s needs. Unfortunately, due to limited contact, the children’s numbers and addresses may have changed. To note, though estranged from his children, under the Maintenance Act (2005), his children are obligated to look after Mr Errol. Specifically, Part V, section 10.1, states that “every person who is not a minor has an obligation, to the extent that the person is capable of doing so, to maintain the person’s parents and grandparents who need such maintenance by reason of age, physical or mental infirmity or disability.” Failure to do so can result in criminal charges; however, this law is not enforced. In fact, Jamaica’s public hospitals are faced with challenges of family members neglecting their loved ones, further indicating that the Act is not enforced. Though abandoning Mr Errol into a public facility is an unlikely scenario given Mr Errol’s mild symptoms, it may become a reality as the disease progresses. Additionally, living wills and power of attorney that can buffer this reality does not apply to persons with cognitive deficiencies in Jamaica. As such, if there is no reconciliation or favourable response from Mr Errol’s children, Mr Errol is not left with many options to handle his affairs on his behalf.

Mrs Gloria, a stalwart in her community and who more than likely has taught many of its members, would likely continue to trivialise and attribute her symptoms to “old age”. She will continue to avoid seeking professional help due to feelings of embarrassment, pride and fear of being thought of differently (stigmatised) by those who admire her. Her feelings of embarrassment and guilt may also arise due to Mrs Gloria’s heavy reliance on her 15-year-old granddaughter.

Despite the minimisation of her symptoms, Mrs Gloria is likely to still have regular check-ups at her General Practitioner (family doctor, GP). These check-ups would be minimally subsidised by the NI Health Gold, which is a national health plan for pensioners under the National Insurance Scheme (NIS) which retired teachers have access to. Her doctor may notice changes in her behaviour and recommend that s/he administer a cognitive test.

It is customary that GPs with a longstanding relationship with their patients, especially in rural settings, will retain the client instead of referring them to a neurologist or psychiatrist. However, there is the possibility that the GP will seek guidance from a colleague in psychiatry or neurology in considering the course of treatment. The GP may also consider Mrs Gloria’s financial situation and instead prescribe non-pharmacological treatment, including dietary changes, the use of herbal treatment, and support Mrs Gloria’s family providing her with herbs such as ginseng, guinea hen weed, coconut oil, peppermint, etc. In addition, even if the GP would like to refer Mrs Gloria, she will not follow up on the referral out of fear of being diagnosed with dementia and what others may think. Regardless, though Mrs Gloria has health insurance, the coverage from public health insurance is significantly lower than private insurance, and as such, she may encounter difficulties financing such services. Due to these factors, professional medical support will be provided by Mrs Gloria’s family doctor.

Mr Frank’s reluctance to visit the doctor and comply with the suggested changes put forth by his son will make it very difficult for his symptoms to be adequately addressed. Mr Frank’s wife and sons are likely to contact Mr Frank’s general practitioner, without him knowing, about these challenges and to seek advice. Mr Frank’s doctor will offer to contact Mr Frank on their behalf; however, Mr Frank will likely become upset with his family going behind his back and speaking about his condition. The family may then enlist the closest family member or friend of Mr Frank, someone he has listened to in the past, to encourage him to visit the doctor. Mr Frank, also noticing a decline in his functionality, will likely be in denial and will do as much as possible to avoid revealing his condition to his social network and other family members. Within Jamaica, men generally display poor help-seeking behaviour due to being socialised to think that they are “strong enough” to overcome health or general adversities and seeking help may be a sign of weakness, particularly health challenges without a clear physical origin.

The changes in the family arrangement and responsibilities include Mr Frank’s wife and children taking control of collecting rental income and managing the properties; however, this will be met with much resistance from Mr Frank. Additionally, given the safety concerns, the family may offer to drive Mr Frank to his desired destinations. However, this is likely to be met with much resistance, and as such, the family will likely hide the car keys. Unfortunately, Mr Frank is likely to locate these keys and possibly get into a motor vehicle accident. At this point, the authorities will then rule him to be a danger to himself and others. This decision will be supported by collateral information from his family. The family may also resign Mr Frank to one residence, more likely the home in St Andrew (predominantly urban), where the resources to support Mr Frank is accessible.