Behavioral and Psychosocial Treatments of Dementia in the Caribbean: Cuba, Dominican Republic, and Puerto Rico

  • Ivonne Z. Jiménez-VelázquezEmail author
  • Juan Llibre-Rodríguez
  • Daisy Acosta
  • Christian E. Schenk-Aldahondo
  • Mackenzie T. Goertz


Cuba, the Dominican Republic, and Puerto Rico, otherwise known as the Spanish Insular Caribbean, comprise a subgroup of insular territories that have similar cultural, historical, and colonial backgrounds. The Spanish Insular Caribbean population faces a particularly high risk for dementia, and only steadily emerging, albeit unique behavioral and psychological approaches for treatment. Comprehensive efforts to provide adequate and culturally congruent treatment are complex and characterized by social, economic, political, and public health influences. This chapter begins contextualizing the treatment of dementia by describing the cultural and historical landscape of the Spanish-speaking islands in the Caribbean. Prevalence rates of dementia in these regions are also discussed along with the current strategic, national guidelines for comprehensive care and the systems of healthcare provision in each country. Furthermore, cultural considerations for dementia management are discussed, including a summary of the psychological strengths exemplified within the Cuban, Dominican, and Puerto Rican communities. The chapter concludes with a review of treatment practices and interventions for individuals with dementia and their caregivers.


Aging Alzheimer’s Disease Behavioral Psychological Symptoms in Dementia Cuba Dementia Dominican Republic Puerto Rico Spanish Caribbean 


  1. Abraha, I., Rimland, J. M., Trotta, F. M., Dell’Aquila, G., Cruz-Jentoft, A., Petrovic, M., … Cherubini, A. (2017). Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open, 7(3), e012759. Scholar
  2. Acevedo, G. (2004). Neither here nor there: Puerto Rican circular migration. Journal of Immigrant & Refugee Services, 2(1–2), 69–85.CrossRefGoogle Scholar
  3. Acosta-Belén, E., & Santiago, C. E. (2006). Puerto Ricans in the United States: A contemporary portrait (p. 84). Boulder, CO: Lynne Rienner Publishers.Google Scholar
  4. Adames, H. Y., & Chavez-Dueñas, N. Y. (2017). Cultural foundations and interventions in Latino/a mental health: History, theory, and within group differences. New York, NY: Routledge.Google Scholar
  5. Adames, H. Y., & Chavez-Dueñas, N. Y. (2018). The drums are calling: Race, Nation, and the complex history of Dominicans. In P. Arredondo (Ed.), Latinx immigrants: Transcending acculturation and xenophobia (pp. 95–109). New York, NY: Springer. Scholar
  6. Adames, H. Y., Chavez-Dueñas, N. Y., Fuentes, M. A., Salas, S. P., & Perez-Chavez, J. G. (2014). Integration of Latino/a cultural values into palliative healthcare: A culture centered model. Journal of Palliative & Supportive Care, 12(2), 149–157. Scholar
  7. Adames, H. Y., Chavez-Dueñas, N. Y., & Organista, K. C. (2016). Skin color matters in Latino/a communities: Identifying, understanding, and addressing Mestizaje Racial Ideologies in clinical practice. Professional Psychology: Research and Practice, 47, 46–55. Scholar
  8. Alzheimer’s Association. (2016). Alzheimer’s disease facts and figures. Alzheimer’s & Dementia. The Journal of the Alzheimer’s Association, 12(4), 459–509.Google Scholar
  9. Alzheimer’s Association. (2017, August 7). Global efforts. Retrieved from
  10. American Cancer Society. (2015). Cancer facts & figures for Hispanics/Latinos 2015–2017. Atlanta: American Cancer Society.Google Scholar
  11. Ames, D., O’Brien, J. T., & Burns, A. S. (2017). Dementia (5th ed.). Boca Raton, FL: CRC Press. Google Scholar
  12. Anauati, M. V., Galiani, S., & Weinschelbaum, F. (2015). The rise of noncommunicable diseases in Latin America and the Caribbean: Challenges for public health policies. Latin American Economic Review, 24(1), 11. Scholar
  13. Azermai, M. (2015). Dealing with behavioral and psychological symptoms of dementia: A general overview. Psychology Research and Behavior Management, 8, 181–185. Scholar
  14. Baez, S., & Ibáñez, A. (2016). Dementia in Latin America: An emergent silent tsunami. Frontiers in Aging Neuroscience, 8, 253. Scholar
  15. Banerjee, S., Hellier, J., Dewey, M., Romeo, R., Ballard, C., Baldwin, R., Bentham, P., Fox, C., Holmes, C., Katona, C., KNapp, M., Lawton, C., Lindsey, J., Livingston, G., McCrae, N., Moniz-Cook, E., Murray, J., Nurock, S., Orrell, M., O'Brien, J., Poppe, M., Thomas, A., Walwyne, R., Wilson, K., & Burns, A. (2011). Sertraline or mirtazapine for depression in dementia (HTA-SADD): A randomised, multicentre, double-blind, placebo-controlled trial. The Lancet, 378(9789), 403–411. Retrieved from Scholar
  16. Basauri, V. A. (2008). Cuba: Mental health and community participation. In J. M. Caldas De Almeida & A. Cohen (Eds.), Innovative mental health programs in Latin America and the Caribbean (pp. 62–78). Washington, D.C.: Pan American Health Organization. Retrieved from
  17. Black, B. S., Johnston, D., Rabins, P. V., Morrison, A., Lyketsos, C., & Samus, Q. M. (2013). Unmet needs of community-residing persons with dementia and their informal caregivers: Findings from the maximizing independence at home study. Journal of the American Geriatrics Society, 61(12), 2087–2095. Retrieved from Scholar
  18. Borrell, L. N. (2005). Racial identity among Hispanics: Implications for health and well-being. American Journal of Public Health, 95, 379–381. Scholar
  19. Bosch-Bayard, R. I., Llibre-Rodríguez, J. J., Fernández-Seco, A., Borrego-Calzadilla, C., Carrasco-García, M. R., Zayas-Llerena, T., Moreno-Carbonell, C. R., Reymond-Vasconcelos, A. G. (2016). Cuba’s strategy for Alzheimer disease and dementia syndromes. MEDICC Review, 18(4), 9–13.PubMedGoogle Scholar
  20. Bupa. (2015, October 7). The Americas: Leading the way in dementia policy. Retrieved from
  21. Capielo, C., Schaefer, A., Ballesteros, J., Monroig, M. M., & Qiu, F. (2018). Puerto Ricans on the U.S. mainland. In P. Arredondo (Ed.), Latinx immigrants: Transcending acculturation and xenophobia (pp. 187–210). New York, NY: Springer.CrossRefGoogle Scholar
  22. Capielo Rosario, C., Adames, H. Y., Chavez-Dueñas, N. Y., & Renteria, R. (2019). Accultuaiton profiles of Central Florida Puerto Ricans: Examining the influence of skin color, perceived ethnic-racial discrimination, and neighborhood ethnic-racial composition. Journal of Cross-Cultural Psychology, 50(4), 556–576. Scholar
  23. Caplan, S., Little, T. V., Reyna, P., Sosa Lovera, A., Garces-King, J., Queen, K., & Nahar, R. (2018). Mental health services in the Dominican Republic from the perspective of health care providers. Global Public Health, 13(7), 874–898. Scholar
  24. Castellanos, J., & Gloria, A. M. (2018). Cuban Americans: From golden exiles to dusty feet–freedom, hope, endurance, and the American dream. In P. Arredondo (Ed.), Latinx immigrants: Transcending acculturation and xenophobia (pp. 75–94). New York, NY: Springer.CrossRefGoogle Scholar
  25. Central Intelligence Agency. (2015, October 30). The world factbook. Retrieved from
  26. Cerejeira, J., Lagarto, L., & Mukaetova-Ladinska, E. B. (2012). Behavioral and psychological symptoms of dementia. Frontiers in Neurology, 3, 73. Scholar
  27. Chavez-Dueñas, N. Y., Adames, H. Y., & Organista, K. C. (2014). Skin color prejudice and within group racial discrimination: Historical and current impact on Latino/a populations. Hispanic Journal of Behavioral Sciences, 36, 3–26. Scholar
  28. Chien, L. Y., Chu, H., Guo, J. L., Liao, Y. M., Chang, L. I., Chen, C. H., & Chou, K. R. (2011). Caregiver support groups in patients with dementia: A meta-analysis. International Journal of Geriatric Psychiatry, 26(10), 1089–1098. Scholar
  29. Clay, R. A. (2015). Getting to know Cuba. Monitor on Psychology, 46(6), 30. Retrieved from Scholar
  30. Comas-Díaz, L. (1981). Puerto Rican espiritismo and psychotherapy. American Journal of Orthopsychiatry, 51(4), 636–645.CrossRefGoogle Scholar
  31. Country Reports. (2016). Dominican Republic facts and culture. Retrieved from
  32. Coyula March, M. (2010). Havana: Aging in an aging city. MEDDIC Review, 12(4), 27–29.Google Scholar
  33. Custodio, N., Wheelock, A., Thumala, D., Slachevsky, A., Cogram, P., Caramelli, P., & Pe, N. (2017). Dementia in Latin America: Epidemiological evidence and implications for public policy. Frontiers in Aging Neuroscience, 9, 221. Scholar
  34. De Jesus Llibre Rodriguez, J. (2013). Aging and dementia: Implications for Cuba’s research community, public health and society. MEDICC Review, 15(4), 54–59.Google Scholar
  35. de Oliveira, A. M., Radanovic, M., De Mello, P. C. H., Buchain, P. C., Vizzotto, A. D. B., Celestino, D. L., … Forlenza, O. V. (2015). Non-pharmacological interventions to reduce behavioral and psychological symptoms of dementia: A systematic review. BioMed Research International, 2015, 1. Scholar
  36. Departamento de Salud de Puerto Rico. (2015a). Datos del registro de Alzheimer en Puerto Rico.Google Scholar
  37. Departamento de Salud de Puerto Rico. (2015b). La Enfermedad del Alzheimer: Detección y Diagnóstico Temprano. San Juan, PR. Retrieved fromódulo de Alzheimer PR 2015.pdf
  38. Departamento de Salud de Puerto Rico. (2015c). Plan de acción para Puerto Rico: Estrategias para mejorar el cuidado y la calidad de vida de las personas con la enfermedad de Alzheimer. San Juan, PR. Retrieved from de Acción.pdf
  39. Departamento de Salud de Puerto Rico. (2016). Informe de la salud en puerto.Google Scholar
  40. Farlow, M. R., & Shamliyan, T. A. (2017). Benefits and harms of atypical antipsychotics for agitation in adults with dementia. European Neuropsychopharmacology, 27(3), 217–231. Scholar
  41. Ferri, C. P., Acosta, D., Guerra, M., Huang, Y., Jacob, K. S. K. S., Krishnamoorthy, E. S. E. S., & Prince, M. (2008). Prevalence of dementia in Latin America, India, and China: A population-based cross-sectional survey. The Lancet, 372(9637), 464–474. Scholar
  42. Ferri, C. P., & Jacob, K. S. (2017). Dementia in low-income and middle-income countries: Different realities mandate tailored solutions. PLoS Medicine, 14(3), 2–5. Scholar
  43. Ferri, C. P., & Prince, M. (2010). 10/66 Dementia Research Group: Recently published survey data for seven Latin America sites. International Psychogeriatrics/IPA, 22(1), 158–159. Scholar
  44. Freidenberg, J., & Jiménez-Velazquez, I. Z. (1992). Assessing impairment among Hispanic elderly. Clinical Gerontologist, 11(3–4), 131–144. Scholar
  45. García-López, R., Romero-González, J., Perea-Milla, E., Ruiz-García, C., Rivas-Ruiz, F., & De Las Mulas Béjar, M. (2008). Estudio piloto sin grupo control del tratamiento con magnesio y vitamina B6 del síndrome de Gilles de la Tourette en niños. Medicina Clinica (Barcelona), 131(18), 689–692.CrossRefGoogle Scholar
  46. Gil-Fournier, I. M. (2014). El Sistema De Salud Pública – Puerto Rico. Oficina Económica y Comercial de la Embajada de España en San Juan. Retrieved from
  47. Gitlin, L. N., Marx, K., Stanley, I. H., & Hodgson, N. (2015). Translating evidence-based dementia caregiving interventions into practice: State-of-the-science and next steps. The Gerontologist, 55(2), 210–226. Scholar
  48. Goldman, J. G., & Holden, S. (2014). Treatment of psychosis and dementia in Parkinson’s disease. Current Treatment Options in Neurology, 16(3), 281.CrossRefGoogle Scholar
  49. Gorry, C. (2013). Community mental health services in Cuba. MEDICC Review, 15(4), 11–14. Scholar
  50. Henderson, J. N., & Gutierrez-Mayka, M. (1992). Ethnocultural themes in caregiving to Alzheimer’s disease patients in Hispanic families. Clinical Gerontologist, 11(3–4), 59–74. Scholar
  51. Hodgson, N., Gitlin, L. N., Winter, L., & Hauck, W. W. (2013). Caregiver’s perceptions of the relationship of pain to behavioral and psychiatric symptoms in older community residing adults with dementia. The Clinical Journal of Pain, 30(5), 1. Scholar
  52. Jack, B. A., O’Brien, M. R., Scrutton, J., Baldry, C. R., & Groves, K. E. (2015). Supporting family carers providing end-of-life home care: A qualitative study on the impact of a hospice at home service. Journal of Clinical Nursing, 24(1–2), 131–140. Scholar
  53. Kales, H. C. (2015). Common sense: Addressed to geriatric psychiatrists on the subject of behavioral and psychological symptoms of dementia. The American Journal of Geriatric Psychiatry, 23(12), 1209–1213. Scholar
  54. Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350, h369–h369. Scholar
  55. Kaneda, T. (2006, October 3). Health care challenges for developing countries with aging populations. Retrieved from
  56. Krogstad, J. (2015). Puerto Ricans leave in record numbers for mainland U.S. [online] Pew Research Center. Retrieved from
  57. Lanctôt, K. L., Amatniek, J., Ancoli-Israel, S., Arnold, S. E., Ballard, C., Cohen-Mansfield, J., … Boot, B. (2017). Neuropsychiatric signs and symptoms of Alzheimer’s disease: New treatment paradigms. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 3, 440–449. Scholar
  58. Lin JS, O’Connor E, Rossom RC, et al. (2013). Screening for Cognitive Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); (Evidence Syntheses, No. 107). Available from:
  59. Livingston, G., Kelly, L., Lewis-Holmes, E., Baio, G., Morris, S., Patel, N., … Cooper, C. (2014). Non-pharmacological interventions for agitation in dementia: Systematic review of randomised controlled trials. The British Journal of Psychiatry, 205(6), 436–442. Scholar
  60. Llibre-Rodríguez, J., Valhuerdi, A., Sanchez, I. I., Reyna, C., Guerra, M. A., Copeland, J. R. M., … Prince, M. J. (2008). The prevalence, correlates and impact of dementia in Cuba: A 10/66 group population-based survey. Neuroepidemiology, 31, 243. Scholar
  61. Llibre-Rodríguez, J. J., Valhuerdi-Cepero, A., López-Medina, A. M., Noriega-Fernández, L., Porto-Álvarez, R., Guerra-Hernández, M. A., … Marcheco-Teruel, B. (2017). Cuba’s aging and Alzheimer longitudinal study. MEDICC Review, 19(1), 31–35. Scholar
  62. Lyketsos, C. G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J., & DeKosky, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: Results from the cardiovascular health study. JAMA, 288(12), 1475–1483. Retrieved from Scholar
  63. Manes, F. (2016). The huge burden of dementia in Latin America. The Lancet Neurology, 15(1), 29. Scholar
  64. Maust, D. T., Kim, H. M., Seyfried, L. S., Chiang, C., Kavanagh, J., Schneider, L. S., & Kales, H. C. (2015). Antipsychotics, other psychotropics, and the risk of death in patients with dementia: Number needed to harm. JAMA Psychiatry, 72(5), 438–445. Scholar
  65. McClam, T. D., Marano, C. M., Rosenberg, P. B., & Lyketsos, C. G. (2015). Interventions for neuropsychiatric symptoms in neurocognitive impairment due to Alzheimer’s disease. Harvard Review of Psychiatry, 23(5), 377–393. Scholar
  66. Miranda-Castillo, C., Woods, B., Galboda, K., Oomman, S., Olojugba, C., & Orrell, M. (2010). Unmet needs, quality of life and support networks of people with dementia living at home. Health and Quality of Life Outcomes, 8, 132. Scholar
  67. Molero, A. E., Pino-Ramírez, G., & Maestre, G. E. (2007). High prevalence of dementia in a Caribbean population. Neuroepidemiology, 29(1–2), 107–112. Scholar
  68. Neary, S. R., & Mahoney, D. F. (2005). Dementia caregiving: The experiences of Hispanic/Latino caregivers. Journal of Transcultural Nursing, 16(2), 163–170.CrossRefGoogle Scholar
  69. OECD. (2011). The impact of caring on family Carers. In Help wanted? Providing and paying for long-term care (pp. 85–98). Paris, France: OECD Publishing. Retrieved from
  70. Olazarán, J., Reisberg, B., Clare, L., Cruz, I., Peña-Casanova, J., del Ser, T., … Muñiz, R. (2010). Nonpharmacological therapies in Alzheimer’s disease: A systematic review of efficacy. Dementia and Geriatric Cognitive Disorders, 30(2), 161–178. Scholar
  71. Pan American Health Organization [PAHO]. (2017). Dominican republic. Health in the Americas (Vol. I). Retrieved from
  72. Panza, F., Solfrizzi, V., Seripa, D., Imbimbo, B. P., Santamato, A., Lozupone, M., … Logroscino, G. (2015). Progresses in treating agitation: A major clinical challenge in Alzheimer’s disease. Expert Opinion on Pharmacotherapy, 16(17), 2581–2588. Scholar
  73. Porsteinsson, A. P., Drye, L. T., Pollock, B. G., Devanand, D. P., Frangakis, C., Ismail, Z., … Lyketsos, C. G. (2014). Effect of citalopram on agitation in Alzheimer disease. JAMA, 311(7), 682. Retrieved from Scholar
  74. Prince, M., Acosta, D., Castro-Costa, E., Jackson, J., & Shaji, K. S. (2009). Packages of care for dementia low- and middle-income countries. PLoS Medicine, 6(11), 1–9. Scholar
  75. Prince, M., Acosta, D., Chiu, H., Scazufca, M., & Varghese, M. (2003). Dementia diagnosis in developing countries: A cross-cultural validation study. Lancet, 361(9361), 909–917. Scholar
  76. Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: A systematic review and metaanalysis. Alzheimer’s & Dementia, 9(1), 63–75.e2. Retrieved from Scholar
  77. Prince, M. J. (2009). The 10/66 dementia research group – 10 years on. Indian Journal of Psychiatry, 51(Suppl 1), S8–S15.PubMedPubMedCentralGoogle Scholar
  78. Rabins, P. V., Blacker, D., Rovner, B. W., Rummans, T., Schneider, L. S., Tariot, P. N., Blass, D. M. (2010). Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. Retrieved from
  79. Reinhard, S. C., Given, B., Petlick, N. H., & Bemis, A. (2008). Supporting family caregivers in providing care. Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US). [book accession]
  80. Seitz, D. P., Adunuri, N., Gill, S. S., Gruneir, A., Herrmann, N., & Rochon, P. (2011). Antidepressants for agitation and psychosis in dementia. Cochrane Database of Systematic Reviews (Online), 2(2), 8191. Scholar
  81. Shiota, S., & Sugimoto, Y. (2016). Classification of the behavioral and psychological symptoms of dementia and associated factors in inpatients in psychiatric hospitals – With special reference to rehabilitation. Journal of Alzheimer’s Disease & Parkinsonism, 6(4), 258. Scholar
  82. Tible, O. P., Riese, F., Savaskan, E., & von Gunten, A. (2017). Best practice in the management of behavioural and psychological symptoms of dementia. Therapeutic Advances in Neurological Disorders, 10(8), 297–309. Scholar
  83. Torres Rivera, E. (2005). Espiritismo: The flywheel of the Puerto Rican spiritual traditions. Interamerican Journal of Psychology, 39(2), 295–300.Google Scholar
  84. Torres, W. (2016). Alzheimer’s disease registry. XXVI Jornadas Neurológicas – Academia Puertorriqueña de Neurología (Vol. 362, p. 329). San Juan, PR: Academia Puertorriqueña de Neurología. Scholar
  85. Trujillo-Pagan, N. E. (2014). Modern colonization by medical intervention: U.S. medicine in Puerto Rico (Studies in Critical Social Sciences). Leiden: BRILL.Google Scholar
  86. Tsolaki, M. N., Kounti, F., Agogiatou, C., Poptsi, E., Bakoglidou, E., Zafeiropoulou, M., … Vasiloglou, M. (2011). Effectiveness of nonpharmacological approaches in patients with mild cognitive impairment. Neurodegenerative Diseases, 8(3), 138–145. Retrieved from Scholar
  87. U.S. Department of Health & Human Services. (2015). Puerto Rico. [online] Retrieved from
  88. Watchman, K., & Kerr, D. (2014). Non-pharmacological interventions. In Intellectual disability and dementia: Research into practice (1st ed., p. 334). London, UK: Jessica Kingsley Publishers.Google Scholar
  89. World Bank. (2017). Population ages 65 and above (% of total). Retrieved from
  90. World Health Organization and Pan American Health Organization. (2008). WHO-AIMS report on mental health systems in Central America and Dominican Republic. Retrieved from
  91. Zec, R. F., & Burkett, N. R. (2008). Non-pharmacological and pharmacological treatment of the cognitive and behavioral symptoms of Alzheimer disease. NeuroRehabilitation, 23(5), 425–438. Retrieved from Scholar
  92. Zeisel, J., Reisberg, B., Whitehouse, P., Woods, R., & Verheul, A. (2016). Ecopsychosocial interventions in cognitive decline and dementia. American Journal of Alzheimer’s Disease & Other Dementiasr, 31(6), 502–507. Scholar

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Authors and Affiliations

  • Ivonne Z. Jiménez-Velázquez
    • 1
    Email author
  • Juan Llibre-Rodríguez
    • 2
  • Daisy Acosta
    • 3
  • Christian E. Schenk-Aldahondo
    • 1
  • Mackenzie T. Goertz
    • 4
  1. 1.Universidad de Puerto Rico, School of MedicineSan JuanPuerto Rico
  2. 2.Universidad de Ciencias MedicasLa HabanaCuba
  3. 3.Universidad Nacional Pedro Henriquez UreñaSanto DomingoDominican Republic
  4. 4.Marquette UniversityMilwaukeeUSA

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