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COVID-19 (Coronavirus info)

Information and guidance for public, NHSGGC staff, and community-based services.  Hospital visiting restrictions now in place.

Dementia

Dementia and COVID-19 

Care facilities like other settings have to implement social distancing and social isolating measures to reduce the risk of infecting residents and carers with COVID-19 with the aim of reducing the number of deaths in care homes.  

Implementing social distancing and isolating measures is challenging for staff and care home residents.  It is particularly challenging when considering how to best implement these measures with residents living with dementia. Residents may become distressed at being required to isolate in their bedrooms and may move outwith their immediate bedroom areas, risking contamination and cross-infection to other residents and staff.  

This section will provide information and guidance on how to support residents living with dementia to adhere to the new restrictions. It will also offer details of where to access further support. The content of this section was developed using a number of sources including resources from the NHS Lothian Edinburgh Support Services.  

Here is a useful short animation on how to help continue to meet the needs of people living with dementia during COVID-19, as well as a poster (pdf) to download for display in your care home about how to help you support someone living with dementia during this time. 

  

Studies have shown that PPE can create barriers to effective communication, particularly for people who live with dem...

Studies have shown that PPE can create barriers to effective communication, particularly for people who live with dementia and those with hearing problems. Given this, you might want to consider: 

  • Introducing yourself to the resident from a distance before you put on your PPE and explaining what you are going to be wearing and why.
  • Laminating a photograph of yourself with your first name or a smiley face and wearing it on your uniform to help residents recognise, feel more reassured and safer. Ensure this is cleaned regularly using a 70% isopropyl alcohol wipe, a Clorox disinfecting wipe or just soap and water.
  • Acknowledging the mask or equipment you are wearing saying “sorry I look a bit funny today, I’m wearing this to protect us both from any bugs or germs we might have.”
  • Try smiling with your eyes as this can offer a lot of reassurance to residents who appear frightened by a staff member approaching them with a mask.
  • Using laminated signs with basic information if the person finds it difficult to understand you with the mask on. These can be wiped down after the care task.

NHS Lothian have produced a useful document on the impact of PPE on people with dementia.

Hand washing is crucial in reducing the risk of contracting COVID-19 but it can be difficult to explain to a person w...

Hand washing is crucial in reducing the risk of contracting COVID-19 but it can be difficult to explain to a person with dementia why they should wash their hands more frequently. 

Staff should adopt a person centered approach to support people to maintain good hand hygiene which should be clearly documents within their plan of care. 

Many people with dementia can experience distress or struggle with hand washing. Some measures for encouraging and improving hand washing you may want to consider include: 

  • Prompt hand washing, either verbally, by actions or by putting visual prompts near the sink such as a towel and a bar of soap/liquid soap. If needed, you may need to physically help the individual to wash their hands. Remember to promptly give praise and acknowledgement each time.
  • Tackling sensory issues with soap by finding out if an individual prefers liquid soap, bars of solid soap or a particular scent. Some people find it easier to manage soap when it is inside a fabric pouch or to use an automatic soap dispenser.
  • If soap and water are really not an option, then use antibacterial hand gel. You may need to help an individual to use this and to find out if they prefer scented or unscented, gel or spray ones.
  • Some people with dementia are distracted by the feeling after they have washed their hands: using a hand lotion immediately after washing may help.
  • Further information on handwashing can be found in NES Learning Bytes Unit 2: supporting the physical health needs of people with dementia and their families during the COVID-19 pandemic

Normally, you wouldn’t try to stop a person who has dementia ‘walking with purpose’. However, if the person has suspe...

Normally, you wouldn’t try to stop a person who has dementia ‘walking with purpose’. However, if the person has suspected or confirmed COVID-19, you may need to isolate the resident to their bedroom. You may not be able to eliminate the risk or stop the person ‘walking with purpose’ completely, but every effort needs to be made to minimise this risk.

Understanding why someone “walks with purpose” will help you to decide what interventions try, for example: 

Those in need of physical activity: Play ‘football’ with large exercise ball in the corridor, when others are not around, or in their room if it is large enough; dance to music that they like or make more use of outdoor space if safe to do so. 

Those in need of occupation: put together anindividualised rummage box” in their room and support them to access this if needed (prompts to access the rummage box may be needed); encourage them to sort out their drawers and wardrobe, even if this means messing things up first so that they need to sort, fold and put the things away. 

Those in need of reassurance or company: use videoconferencing software on smartphones, tablets and portable computers as much as possible to maintain human contact for residents; consider Simulated Presence Therapy (SPT) if you think the sight or sound on audio or video of a loved one may provide comfort and reassurance. Or of the resident would prefer telephone contact as they might find seeing a loved one on a screen confusing, then support them to use the phone.

 

If space allows you may want to consider “zoning” communal spaces within your care home into “Covid” and “non-Covid” ...

If space allows you may want to consider “zoning” communal spaces within your care home into “Covid” and “non-Covid” areas.  This allows you to provide space for those residents who need to walk, whilst reducing the possibility of residents who are negative for the virus, contracting it from those who are positive. Individuals who are shielding should not be placed in cohorts

In zoning, you colour codes areas in your care home as red, yellow and green zones, using visible signs:

  • Red – areas with suspected or confirmed resident (pdf)
  • Yellow – areas with residents without COVID-19 symptoms (pdf)
  • Green – staff only areas (pdf)

You should identify potential areas that can be kept separate from the rest of the facility behind a locked door i.e. a locked unit or locking of fire doors to section off an area.  This would provide a red zone area. 

Where possible, empty rooms should be reconfigured into the red zone prior to any cases so residents can be transferred quickly as and when required. 

If you are working in red zones you need to wear fluid resistant mask, gloves, and apron.  Eye protection should also be worn during direct resident contact if there is a risk of coughing etc (see infection control guidance). 

Staff working in yellow areas should wear fluid resistant mask at all times. 

There should be limited changing of staff between red and yellow areas. 

Non-essential footfall into red zones should cease and residents in red zones should be asked to remain in bedrooms if possible. 

Residents can be moved back into yellow area on day 15 after first symptom if they have a temperature of 37.7 or less for 48 hours.

Residents may be concerned as to why things appear so different at the moment, why they aren’t able to go outside, wh...

Residents may be concerned as to why things appear so different at the moment, why they aren’t able to go outside, why family can’t visit, or why they have to keep their distance from other people in the care home. This section will help you to explain to residents the changes in the care home caused by Covid-19.

Help residents to feel safe and reassured - People with dementia can be very tuned into emotions and may pick up if you feel anxious or worried. If you feel anxious, which is understandable during this time you could try talking to colleagues as it is likely they will feel the same too or raise your worries with management. If your anxiety persists then you could contact the Health & Social Care Helpline on 0141 303 8968 (Monday-Friday 8am-6pm). If you feel relaxed, then residents are likely to feel more relaxed as this will communicate safety and reassurance.( editor note: Is this just for Glasgow – other HSCP helplines?)

Maximise communication strategies:

Every time you approach the resident, introduce yourself, say hello and tell them your name and what you role is, for example Hello Sadie, I’m Mary, I’m the nurse. Is it OK if I help you with…”   

Ensure the person has their glasses or their hearing aids on if they need them. 

When talking to residents with dementia use short simple sentences and questions. 

Allow the person additional time to understand what you are saying, and give them time to ask questions if they are able to. 

If the person is having difficulties with communicating with you, try using non-verbal communication such as nodding your head and smiling to show you are listening. This can be very reassuring for the person having difficulties 

Validate emotions e.g. “I can see you are upset right now, I would like to try and take your mind off things, shall we listen to your favourite music?” 

Give positive instructions e.g. “shall we go here” rather than “don’t go there”. 

There is an “easy read” information sheet produced by Edinburgh Behavioural Support Centre for residents who want to read information about COVID19 themselves and a sheet with visual prompts to help you explain things to residents who can’t read about it on their own.

 

Aphasia Friendly Resources

Explaining the virus - Part of explaining the virus is to encourage residents to adhere to current hand washing guidelines (See: “Handwashing tips” section).  Use words such as ‘contagious’ and ‘nasty flu’ to explain the virus. Explain that the most common symptoms are a dry cough or a high temperature called a fever. Say that the flu spreads when people are too close, so we need to stay apart to stop it spreading. Aphasia friendly resources  can help you to explain. 

Explaining why the residents have to stay in the care home - Explain the Government is taking this very seriously wants to protect people from becoming ill. Everyone has to stay indoors or in private gardens to keep them safe. 

Explaining why family can’t visit - Explain that just now the care home has to be closed to visitors to keep them safe and to avoid them becoming ill, and that their family are having to stay home to keep themselves safe too. Explore alternative ways for residents to keep in touch with family and friends. ( See: “Maintaining contact with family and friends” section).

For people with dementia, like most of us, regular contact with family and friends is a key part of their lives and c...

For people with dementia, like most of us, regular contact with family and friends is a key part of their lives and contributes to wellbeing. Sudden changes in a person’s routines such as not seeing family can increase anxiety, and cause distress and confusion. Whilst is important that everybody follows the current guidelines to keep residents and staff as safe as possible, it is important to acknowledge and respect people’s needs for social contact and mental health, as well as their human rights. 

You should advise residents and families of alternative ways to stay in touch. The opportunities will differ depending on the individual resources and circumstances in each care home. People’s care and support plans should explain how they will be enabled to stay connected. 

Options include:

  • Using Simulated Presence Therapy (SPT): using the sight or sound of a loved one via audio or video to provide comfort and reassurance. Having a video/audio recording means you can play this repeatedly to the individual. This can also reduce the burden on relatives to ring/video call several times a day.
  • Asking family members to send cards/letters with reassuring messages.
  • Using mobile phones or laptops for live communication or to share pictures, voice messages and videos using applications such as Facetime, Whatsapp, Zoom, Microsoft Teams, Skype.
  • Providing residents with access to a phone so they can speak with their family members (although this would be dependent on the person’s stage of dementia). Make sure you clean the device using a 70% isopropyl alcohol wipe, a Clorox disinfecting wipe or just soap and water before and after use.
  • Using communication cards to help explain why family/ friends cannot visit: aphasiafriendly.co/covid-19-accesible-information.html
  • Looking at photographs of family and friends and engaging residents in conversation to help them focus on happy memories and good times.
  • Some providers have now also set up social media feeds to give families an inside into current life and activities in the care home.
  • Further information is available on NES Learning Bytes Unit 3: using activities, connections and communication to prevent distress which considers how to prevent distress by using proactive approaches to communication, social networks and community connections.

Some things to consider when thinking about which communication to use: 

  • How will the person with dementia react? - Have they used Skype or smartphones before? Seeing a loved one on a small screen might be stressful and confusing if it is the first time they’ve used this technology. Can staff support the resident with this each time they want to make contact?
  • Preparation - Some methods of communication need a bit of preparation. For example, downloading the application and having a calm, quiet and private environment to use for live or pre-recorded communication to maximise the impact of this.

If a resident is confined to the same room for a long time with limited activity, they are very likely to become bore...

If a resident is confined to the same room for a long time with limited activity, they are very likely to become bored and try to leave their room. Try to provide routine and predictability as far as possible to give a sense of safety and security. You may want to try:

  • Relaxation techniques such as hand massages if safe to do so, playing music from Playlist for Life playlistforlife.org.uk or gentle relaxation exercises to promote rest and recovery.
  • Try meaningful activities related to previous jobs, roles or routines and things that the residents used to enjoy for example, if the resident used to be a cleaner, provide them with a rummage box with a tea towel, a cloth and an apron to either fold or to use in their room
  • Be mindful of which TV channels residents are watching. A news channel left on for long periods with extensive coverage of Covid-19 could increase someone’s distress. Instead try playing a resident’s favourite DVD or box set instead.
  • Try Memory Radio musicmemories.bbcrewind.co.uk - an online radio station playing BBC radio segments from past decades with downloadable activity worksheets.
  • Create individual “rummage boxes” for residents with favourite or meaningful objects to look through.
  • Involve residents in activities such as drawing, colouring in, crochet, folding clothes or listening to music which can be done in resident’s bedroom. 
  • There are lots of options for virtual entertainment- giving residents the chance to get involved in the outside world without leaving the care home! Here is a list of links (Editor note: insert link to doc below) that can be streamed through a laptop and connected to a TV. Smart TVs have access to certain entertainment apps and internet browser where events can be streamed directly from the TV. 

  People who are living with dementia are much more likely to develop delirium (a confused state) if they become inf...

 

People who are living with dementia are much more likely to develop delirium (a confused state) if they become infected with Covid-19. The British Geriatrics Society has recently produced guidance on “Managing delirium in suspected and confirmed cases of COVID-19”. 

If possible you should try to reduce the risk of delirium by avoiding or reducing the causes. This includes regular orientation, avoiding constipation and urinary retention, treating pain, identifying and treating infection, promoting a good sleep/wake cycle, providing regular fluids and positioning individuals to support breathing. See SIGN delirium guidelines for more information.

Maintaining isolation and the use of PPE may worsen agitation and/or delirium. As a result you may need to use medication sooner than you normally would to reduce the risk of transmission of COVID-19. 

If a resident tests positive for Covid-19, they should be quarantined and isolated as far as possible from other resi...

If a resident tests positive for Covid-19, they should be quarantined and isolated as far as possible from other residents. Supporting and encouraging someone to spend time in their room may pose an ethical and practical challenge for care services, particularly where the person lives with dementia and they may not understand the reasons for the request. The Mental Welfare Commission www.mwcscot.org.uk/ has produced comprehensive guidance for services to use, underpinned by a human rights approach. 

All decisions to limit the free movement of a person must be reasonable, proportionate and justifiable. It is important to remember that any limitations put in place must be the least restrictive for the person and used for the shortest period necessary. 

Try and communicate in a clear, simple way the reasons for quarantine e.g. to manage infection control procedures and try and encourage other residents not to enter that person’s bedroom.  The isolation is likely to make the person feel lonely contributing towards a deterioration of their mood and may result in the person becoming more withdrawn. 

Here are some strategies that may help reduce distress experienced by someone having to self-isolate in their room due to COVID-19. 

Further information can be found by accessing the NES Unit 4 on proactive approaches to prevent distress and promote psychological wellbeing during COVID-19 pandemic

Reduce social isolation 

  • Maximising contact: You will already have to use PPE and stricter infection guidelines to enter the person’s bedroom, so making use of the time spent in the bedroom will reduce the number of times you have to go back in. Try having a 5 minute chat, holding the individuals hand before or after personal care or sitting with the person while they are eating as this will help to reduce the feelings of loneliness.
  • Activity: Try and have at least 1 planned activity with the person each day, even if that activity is short or only a brief conversation about something of interest to the resident (See:  “Supporting meaningful activity” section).
  • Visibility: If possible, try and face the person’s bed/chair towards the door so they can see people walking by. If the risk of leaving their bedroom is low, could you leave the door to the room open? Try and wave or say hello every time you walk past the person’s room, so they feel that people know they are there.
  • Family contact: Encourage family members to phone/video chat/send letters to keep in contact with the person (See;  “Maintaining contact with family and friends” section).
  • Further information can be found by access NES Learning Bytes Unit 2: supporting the physical health needs of people with dementia and their families during the COVID-19 pandemic

Reducing the distress associated with self-isolation   

Having to stay in a room can cause distress; this can be worse for a person with dementia who has difficulty understanding or remembering the reason why they need to stay there. The person may not recognise their surroundings, due to their dementia. However, it may also be due to delirium (See; “Delirium” section). If a person continues to come out of their bedroom then you will need another method of infection control. (See: “Walking with purpose” section). Things to consider to reduce the impact of self-isolation: 

  • Conducting a Risk Assessment: You will need to conduct a risk assessment and judge the benefit of keeping a person in their room against their wishes, especially if the person has dementia and is unable to understand why they need to stay in their room. Residents living in care homes retain their full human rights, unless these have been restricted by a legal process and even then, only to the extent by which the law allows (org.uk). Any restrictions need to be considered appropriate, reasonable, of short duration and of the least restrictive method possible. Staff must discuss and agree with the medical team if this is considered to be in the resident’s best interests. All other non-pharmacological interventions should be tried first.
  • Signage: You could put signs up in a person’s room to reminder them to stay there. Keep the wording as kind as possible but clear, e.g. “Jean, for safety, please stay in this room for now. Please call staff if you need anything”. A picture of a stop sign could be incorporated http://www.aphasiafriendly.co/covid-19-accesible-information.html
  • Personalisation: People may already have their own things in their bedrooms such as ornaments, pictures or other important items, but try to maximise this so the person recognises the room as their own and feels more comfortable to stay in there.
  • Planned time outside: If a person is distressed with staying in their room for long periods of time, consider time outside their room in an area with staff only, inside or in the garden.

Dealing with reduced activity 

Being in isolation means a resident can’t engage in their usual routine and this will mean they have significantly less involvement in social activities. Their usual routine and structure of daily life will have changed and this is likely to cause boredom leading to low mood and anxiety. Some further suggestions on activities can be found here in the  “Supporting meaningful activity” section. 

  • Examine their environment: What is in the person’s immediate environment? Do they have access to forms of entertainment (Books, TV, ipad)? Are there photos or pictures on the wall? Do they have access to comfy seating? Is the lighting and temperature suitable?
  • Engage in meaningful activity: Look at the persons care plan or ‘getting to know me’ sheet to find out how you can engage them in more personalised activity, especially activities that they can do in their bedroom. This could include reading magazines, looking at photo albums, doing a craft or watching a movie. They may need to be prompted by staff throughout the day to engage in tasks, e.g. ‘Anne, I see you have some nice new wool, I wonder would you like to do some knitting?

Helping people understand why they have to stay in their room 

It is very difficult for a resident with dementia to understand and retain the reasons as to why they have to stay in their bedroom. This can increase a sense of fear, anger, sadness and anxiety which could result constantly seeking staff, increased repetition, crying or physical/verbal aggression. You could try considering the following strategies. 

  • Explain to residents why they are in their bedroom: Open communication is crucial to provide residents with information about what is happening. Section x on how to talk to someone with dementia about COVID-19 can help (See: “Talking to people with dementia about COVID-19”).
  • Allow the resident a chance to calm down: If a residents is angry, give them space and allow them time to cool down. Go back to their room after a short period of time, acknowledge their frustration and provide them with a short explanation as to why they must stay in their bedroom. Try to distract the resident with a meaningful task or activity that they can do in their room. It can be tempting when busy, to use distraction that has worked previously for that resident or perhaps other residents. However, this can be unhelpful and cause further distress.

General strategies that might be helpful in reducing distress during isolation 

  • Validation: Ask the resident how they are feeling. Validate the emotions and empathise with them e.g. I agree Margaret, it is quite boring here at the moment with all the activities cancelled. It is really tough. Maybe together we can come up with some activities to take your mind off it. ‘
  • Apologising: An apology allows the person to feel listened to, and shows that the staff understand how difficult this must be for them. ‘I’m sorry you have to stay in your room for just now, I would feel the same way if I was in your situation”.
  • Weigh up the options: Does the risk of keeping someone in their bedroom against their will overcome the risk of infection? You might need a different plan of action if the distress associated with quarantine in their room is too high. This may include having a section of the care home dedicated to all residents with Covid-19 which special measures for staff working there.
  • The Mental Welfare Commission for Scotland mwcscot.org.uk has to date information and guidance for care home staff if they are considering using restrictive methods with residents).

 

The ‘Coronavirus (Scotland) Act 2020’ http://www.legislation.gov.uk/asp/2020/7/ contents emergency legislation came i...

The ‘Coronavirus (Scotland) Act 2020’ http://www.legislation.gov.uk/asp/2020/7/ contents emergency legislation came into force in April 2020. It is important for services to understand how this may influence care and support, particularly for individuals living with dementia. 

Schedule 3, Part 2 of the Act describes interim changes to existing legislation related to vulnerable adults, with particular reference to the ‘Adults with Incapacity (Scotland) Act 2000’ http://www.legislation.gov.uk/asp/2000/4/contents 

Most individuals with a diagnosis of dementia who live in care homes will have in place a ‘Section 47 certificate of incapacity’   https://www.gov.scot/publications/section-47-certificate/. The duration of these certificates should not exceed three years in normal circumstances. However, in the current situation, and aligned to the emergency legislation published, any certificate which becomes out-of-date is automatically extended for the duration of the legislation. 

Some individuals who have a Section 47 certificate in place, may also have a legal proxy advocate (welfare guardian/power of attorney). A time limit to decision-making capabilities is sometimes applied for welfare guardians. However, under the emergency legislation, this time limit is removed for the duration of the legislation. When guardianship orders are renewed, again a time limit to these is normally applied (five years). Should the date of expiry for these occur during the emergency legislation, they are automatically extended for the duration of the legislation.

Information on the Human Rights implication of COVID-19 outbreak for people with dementia along with information to support health and social services staff in care homes provide an appropriate response has been produced by NES and can be accessed here, Unit 5 : protecting the human rights of people with dementia during COVID-19

NES have also developed of 5 a set of short learning bytes which you may find useful. The units aims to help staff su...

NES have also developed of 5 a set of short learning bytes which you may find useful. The units aims to help staff supporting people in to develop their understanding about dementia to support people in care homes living with dementia and their families and carers to maintain the best quality of life possible during the COVID-19 pandemic. 

Unit 1: understanding dementia- This unit is for staff who have changed roles, are unfamiliar with working with people with dementia or simply need a refresher in understanding dementia 

Unit 2: supporting the physical health needs of people with dementia and their families during the COVID-19 pandemic- this unit considers the potential impact of COVID-19 on the health and wellbeing of people with dementia, describe appropriate responses to address physical healthcare needs and support the reduction of risk of transmission of COVID-19 

Unit 3: using activities, connections and communication to prevent distress - considers how to prevent distress by using proactive approaches to communication, social networks and community connections. 

Unit 4: proactive approaches to prevent distress and promote psychological wellbeing during COVID-19 pandemic - considers how to use proactive approaches to promote psychological wellbeing for people with dementia during the COVID-19 pandemic 

Unit 5 : protecting the human rights of people with dementia during COVID-19 - aims to support health and social services staff working in care homes to recognise the potential Human Rights implications of the COVID-19 outbreak for people with dementia, their families

Last Updated: 25 November 2020