The Invisible Weight: Dementia, Diaspora, and the Caribbean Women Holding Everything Together

Claudette is 52 years old, and she hasn’t slept properly in six months.

She lives in Toronto, Canada, where she works in a high-profile healthcare administration job. She is raising two teenage boys with her husband, who is from Nevis, in Saint Kitts and Nevis. She is also, quietly and without complaint, managing the care of her 78-year-old mother back in Trinidad and Tobago, who has diabetes and a recently diagnosed form of dementia. Claudette is responsible for coordinating appointments she cannot attend, making decisions about medications she has to research alone at midnight, and fielding calls from relatives who mean well but do little to help.

Three weeks ago, her mother forgot Claudette’s name for the first time.

That morning, she cried in her car before work. Then, she walked in, sat at her desk, smiled, and got on with her day.

Because that is just what Caribbean women do.

Claudette has also been noticing things about herself. Sometimes she cannot find her words or cannot gather her thoughts during phone calls. She is now forgetting appointments that she never would have last year. She is scared, but hasn’t mentioned it to anyone, especially her family. She isn’t even sure she has the language for what she’s feeling. But somewhere beneath her daily exhaustion, there is a question she is afraid to say out loud:

Is this stress, or is this the beginning of my own memory loss?

The Diaspora Caregiving Paradox

Claudette is not my patient, and she is not a case study. However, she is representative of a woman I have met in dozens of forms across my clinical career, and she represents one of the most underacknowledged health crises at the intersection of Caribbean community, life in the diaspora, and modern medicine.

There are hundreds of thousands of Caribbean families navigating what I call the diaspora caregiving paradox. The adult children are abroad, building careers and raising families in Canada, the United Kingdom, or the United States, while their parents are at home in Trinidad and Tobago, Jamaica, Saint Lucia, or another country in the region. They are aging, increasingly dependent, and embedded in communities where formal senior care infrastructure is thin, dementia is still whispered about, and the working assumption is that the family will handle it all.

But “the family” is now spread across four different time zones. Unfortunately, the daughters, nieces, and other women at the center of all the long-distance coordinating, deciding, worrying, and arranging are almost always managing their own biological transitions at the same time.

This is not a niche or generational problem. This is an urgent Caribbean public health story, and it is past time that it finds its voice.

When Your Body and Your Life Peak at the Same Moment

The medical literature is unambiguous: women face a significantly higher lifetime risk of Alzheimer’s dementia than men. Recent estimates say that the lifetime risk for developing Alzheimer’s dementia in women is 1 in 5 at 45 years old, as compared to 1 in 10 for men at that same age.[1] In the United States, roughly two-thirds of people living with Alzheimer’s are women.[1] The reasons are complex and still being studied, but hormonal transition plays a deeply meaningful role.

During perimenopause and menopause, which typically unfold across a woman’s 40s and 50s, declining estrogen levels affect the brain’s energy metabolism, inflammatory regulation, and neuronal resilience.[2] Many women report what they call “brain fog”: difficulty concentrating, word-finding lapses, and short-term memory slips. For most, this is transient. But for women who are simultaneously under chronic stress, sleeping poorly, eating irregularly, and carrying the invisible weight of remote caregiving, combined with a family history of dementia, the neurological burden compounds.

The science of chronic stress and brain health is sobering. Elevated cortisol over sustained periods has been associated with changes in hippocampal volume. Changes to this brain region are most implicated in memory loss.[3] When a woman is navigating grief (because watching a parent’s mind fade is a form of grief), career pressure, financial responsibility, and caregiving across borders, her body is not distinguishing between those stressors. It is simply keeping score and reacting as if she were under overwhelming physical stress.

Caribbean women, in particular, have been socialized to absorb and manage this stress on their own and remain stoic. The societal expectation is that they present wellness even when wellness is nowhere present. The cultural script that calls us strong often functions as a barrier that keeps us from giving ourselves the grace to tend to our own care.

The Capacity Gap We Can Close

The region is not starting from nothing. The University of the West Indies, the Caribbean Public Health Agency (CARPHA), and a regional policy history running back to the 2007 Declaration of Port-of-Spain[8] give us institutional foundations that many regions lack. But across the Caribbean, the demographic picture is shifting faster than our health systems have adapted. Life expectancy has risen substantially over the past two generations. The proportion of adults over 60 is growing in nearly every Caribbean Community (CARICOM) member state: across the Caribbean, the population aged 60 and over is projected to rise from 1.1 million in 2015, 13 per cent of the population, to 2 million by 2035, 22 per cent – a shift driven in part by the emigration of young adults and the return of retirees.[4] And yet, geriatric medicine, the specialty dedicated to the complex health needs of older adults, is sparse in the medical training and clinical infrastructure across the region.[9]

Specialized dementia care is scarcer still. Most families receive a diagnosis, if they receive one at all, without an understanding of what this means for their loved one or their family, without a care plan, without caregiver support, and without any roadmap for what comes next. The diagnosis is given, and then the family is simply expected to absorb and figure it out. In our communities, where dementia is still sometimes attributed to spiritual causes or to psychiatric “madness,” families hide their loved ones away or resign them to being a burden. In cases where cognitive decline is normalized as “just getting old,” families may not seek any evaluation until the disease is already well advanced and their loved ones’ symptoms are uncontrollable for the family.

The cost of this delay in diagnosis and care is measured in years of preventable decline. Why? Because we now know that dementia prevention is real and no longer speculative. The 2024 report of the Lancet standing Commission on dementia prevention, intervention and care estimates that up to 45% of dementia cases globally may be prevented or delayed through modifiable lifestyle factors such as cardiovascular health, sleep, physical activity, nutrition, cognitive engagement, stress regulation, and social connection.[5] None of these require pharmaceutical interventions when done well. They all require cultural, behavioral, and environmental shifts. They also require a healthcare system with the capacity and intentional focus on catching people decades before symptoms appear.

We have not yet built that system across the region.

But we can build it.

What Prevention Actually Looks Like

I am a fellowship-trained geriatrician. I am board-certified in Lifestyle Medicine and a certified Blue Zones physician. My clinical work sits at the intersection of two disciplines that the Caribbean urgently needs to integrate: the science of aging, and the science of how daily life shapes long-term health outcomes as we age.

In my practice, I use a framework I call the MEMORY Method™. It is a clinical framework I developed that addresses the six domains most strongly supported by evidence in cognitive longevity: Metabolic health, Exercise, Mental engagement, Optimal nutrition, Rest and stress regulation, and Your creative practice. That last pillar is one I hold personally. I grew up in the Caribbean playing music, painting, and dancing. I understand in my body, not just my training, that creative practice is not a luxury; it is a neurological necessity. Recent research underscores the invaluable contribution of the creative arts to brain resilience, social connection, and community building – all of which support brain longevity.

The women I see in my clinic are not waiting for disease or memory loss. They are proactively asking: what can I do now, in my 40s and 50s, to protect my mind for the decades ahead? They are the daughters of women with dementia, caregivers who see the trajectory and are terrified of it for themselves and their families. They want science that applies in a practical way to their lives and not just reassurance or a dismissal of their perimenopausal symptoms or worries. They, like Claudette and the women in our Caribbean region, rightly deserve a medical system that provides these to them.

What this requires, at the regional level, is not only clinical capacity, though that is desperately needed. It requires a reframing of our conversations in and out of our families. We must urgently change the conversation that says that dementia and memory loss are an old person’s problem. Neither of them is. Women in their 40s and 50s show measurable changes in brain structure, connectivity and energy metabolism, and in some cases early amyloid deposition, before any signs of memory loss appear.[2][6] We are at a crossroads where we can actively change the conversation to reflect this midlife prevention opportunity. Our stoic Caribbean women, with their heightened biological risk, must be at the center of every single Caribbean brain health strategy.

This shift also requires us to take caregiver health seriously as a clinical priority, and not an afterthought. Caregivers are our patients too. The research is clear that unpaid family caregivers, particularly women, experience accelerated cognitive aging, higher rates of depression, and worsened metabolic health.[7] Claudette’s brain is at risk not only because of her genetics or her hormones, but because of the system that has handed her an impossible job and called it love and caring.

Our Path Forward

The solutions are neither simple nor inexpensive, but they are concrete. Three priorities stand out as immediate and achievable for ministries of health, regional health authorities, and primary care networks across the region:

First, integrate cognitive health screening into primary care for women 30 and older. A single, simple standardized tool, administered routinely, will catch early risk signals that currently go undetected for years. Pairing this with hormonal health assessment during routine gynecological visits, mammograms, and emergency room visits would create an entry point that Caribbean women already use.

Second, we must build caregiver support infrastructure as an urgent public health priority. This means peer networks, psychoeducation, and respite care, not as charity programs, but as recognized healthcare services with funding and accountability behind them. The diaspora dimension of Caribbean caregiving makes this especially urgent; remote caregiving requires a different set of tools and resources than in-person care.

Third, invest in high-quality, specialized geriatric medicine and dementia care training across the region. The University of the West Indies, the region’s principal medical training institution, has the infrastructure to develop a Caribbean-specific geriatrics and dementia care training pathway. Countries across the region also have community colleges and secondary schools that can help educate caregivers and younger family members. Without this, the most complex needs of an ageing population will continue to fall to family members and to physicians who have not been given the specialist training to meet them.

None of these solutions require waiting for perfect conditions or an injection of millions in funding. They require the political will to recognize that the Caribbean’s aging population is not a future problem. It is a present one, and it is growing. All of these can be achieved by integrating dementia risk reduction, screening, and caregiver support into existing healthcare and social systems. We must therefore create a continuum of good brain-health policy that supports our citizens from childhood through their senior years.

Claudette, in my imagination of her, eventually makes an appointment. Not for her mother, but for herself. She sits down with a physician at home in Trinidad and Tobago one morning during a vacation at home to manage her mother’s affairs. Her doctor, who takes her cognitive concerns seriously, understands her cultural context and limitations, assesses her hormonal picture, understands the stress physiology of remote caregiving, and gives her something she hasn’t had in years: a solid, practical, and measurable brain longevity plan with all the social, medical, and legal support she requires.

That physician exists, and this visit is possible.

This outcome, which is close to my heart, is not aspirational for us. It is highly achievable.

But only if we focus, unify as a region, build this continuum, train our clinicians, and change our cultural story across the region that tells our women that their health, especially their brain health, is the last small thing on the list.

It shouldn’t be. And it doesn’t have to be.

We can do this together.

About the Author

Dr. Amy Paul is a fellowship-trained geriatrician, board-certified Lifestyle Medicine physician, Blue Zones certified physician, and the founder of Flourish Cognitive Health, a preventive cognitive medicine clinic specializing in brain health for women. She serves on the board of the Alzheimer’s Association Greater Richmond, Virginia Chapter. She works at the intersection of clinical medicine and health workforce policy, serving as Director of Statewide Graduate Medical Education at the Virginia Health Workforce Development Authority. As a member of the Board of Directors for the Central Virginia Health Executives Group, she has a deep understanding of the foundational needs and challenges of building and sustaining health systems. She is a native of Saint Lucia and maintains her Caribbean roots. Her clinical practice is built around her MEMORY Method™, which has impacted the lives of many midlife women. Dr. Paul is available for speaking engagements, institutional partnerships, and consultancy to health systems and organizations working to advance high-quality, culturally sensitive, aging and dementia care across the Caribbean region. She can be contacted at dramy@flourishcognitivehealth.com.

Disclosure: Dr. Paul is the founder of Flourish Cognitive Health and the developer of the MEMORY Method™, the proprietary clinical framework referenced in this article.

References

1. Alzheimer’s Association. 2026 Alzheimer’s Disease Facts and Figures. Chicago: Alzheimer’s Association; 2026. Lifetime-risk estimates derive from Framingham Heart Study data (Chene C, et al.). United States population.

2. Mosconi L, Berti V, Dyke J, et al. Menopause impacts human brain structure, connectivity, energy metabolism, and amyloid-beta deposition. Scientific Reports. 2021;11:10867. See also Mosconi L, et al. Sex differences in Alzheimer risk: brain imaging of endocrine vs chronologic aging. Neurology. 2017;89(13):1382-1390.

3. Echouffo-Tcheugui JB, Conner SC, Himali JJ, et al. Circulating cortisol and cognitive and structural brain measures: the Framingham Heart Study. Neurology. 2018;91(21):e1961-e1970.

4. Economic Commission for Latin America and the Caribbean (ECLAC). Ageing in the Caribbean and the rights of older persons. Port of Spain: ECLAC Subregional Headquarters for the Caribbean.

5. Livingston G, Huntley J, Liu KY, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. The Lancet. 2024;404(10452):572-628. doi:10.1016/S0140-6736(24)01296-0

6. Mosconi L, Berti V, Quinn C, et al. Increased Alzheimer’s risk during the menopause transition: a 3-year longitudinal brain imaging study. PLOS ONE. 2018;13(12):e0207885.

7. Dassel KB, Carr DC, Vitaliano P. Does caring for a spouse with dementia accelerate cognitive decline? Findings from the Health and Retirement Study. The Gerontologist. 2017;57(2):319-328. See also Allen AP, Curran EA, Duggan A, et al. A systematic review of the psychobiological burden of informal caregiving for patients with dementia. Neuroscience and Biobehavioral Reviews. 2017;73:123-164.

8. Caribbean Community (CARICOM). Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. Adopted 15 September 2007 at the Special Summit of CARICOM Heads of Government, Port of Spain, Trinidad and Tobago.

9. VanDevanter N, Naegle M, Nazia N, Bamodu A, Sullivan Marx E. Health aging and care of the older adult with chronic disease: a qualitative needs assessment in 14 eastern and southern Caribbean islands. Rev Panam Salud Publica. 2023;47:e40. doi:10.26633/RPSP.2023.40.