Coronavirus (COVID-19): living with dementia in care homes

Overview

Throughout the coronavirus pandemic, care homes have implemented protective measures including infection prevention and control (IPC) and self-isolation measures to reduce the risk of the spread of COVID-19.

The following measures continue to be in place to minimise the risk of the spread of COVID-19 to individuals who due to frailty or immune compromise remain at higher risk of poor outcomes. Protective measures are regularly reviewed by Scottish Government Officials, Clinicians, Public Health Scotland and ARHAI Scotland, and a number have been removed in recognition of the progress made with the vaccination programme and treatments for COVID-19.

Self-isolation is a protection that remains in place in care homes under the following scenarios: 

• when an individual has COVID-19 symptoms or a positive COVID-19 test
• in some specific scenarios when being admitted to a care home from hospital or the community. This may include when the isolation period has not been completed in hospital

Details on when and for how long residents should isolate can be found in Public Health Scotland information and guidance for social community and residential care settings.

Where there are recommendations to minimise the risk of COVID-19 transmission in communal settings through restrictions in movement of residents this will result in a change to daily care routines and practices. This is likely to be unsettling for many residents but may be particularly stressful for people living with cognitive impairment who ‘walk with purpose’.

Walking with purpose is likely to be an expression of unmet need and the person’s efforts to communicate, meet or respond to that need. It is important that we continually consider what these needs are, and where possible engage with friends or family members to explore what individualised response may help. People living with cognitive impairment in care homes who walk with purpose may struggle to follow infection prevention and control (IPC) precautions and self-isolation recommendations. They may be distressed by the self-isolation and the change to their routine, and are likely to need specific individualised support to help manage this change. There may also be an increased risk of falls or accidents for residents whose movement is restricted. 

We developed this guidance with partners within the social care sector to assist care home staff when supporting residents self-isolating in their rooms as per Public Health Scotland guidance.

While care for these residents will vary according to the individual, the following summary points should serve as guidance:

• sedation or restraint should not be used, in any circumstances, to enforce compliance with self-isolation or infection prevention and control measures
• care homes should consider any additional support, meaningful activities, and/or one-to-one care which may be advantageous to support the individual’s needs
• Occupational Therapists and Community Mental Health Teams may be able to provide useful advice about using meaningful activity to help support residents who walk with purpose within infection control zones
• if individuals are unable to cope with self-isolation, a person-centred risk assessment should be undertaken. Staff may wish to discuss with local Health Protection Teams any doubts or concerns, and any additional IPC/cleaning measures that may be required

Walking with purpose

People who are living with dementia may find it difficult to understand why they should remain in their room all day and night. Where a person is not able to understand the need for self-isolation measures it is more likely that they will attempt to come out of their room and will want to move freely around their environment.

Common reasons for walking with purpose are:

• looking for someone or something
• attempting to relieve pain or discomfort
• feeling lost and trying to find the way
• fulfilling a previous occupational role or family commitment
• getting hungry, thirsty or needing to go to the toilet
• feeling lonely or stressed
• feeling bored
• walking is part of everyday routine
• they enjoy being physically active

Supporting someone safely

During these situations it is important for the staff team to support the person in a way that is person centred and respects their human rights. Equally it is important to consider the safety of the person, other residents, and staff team.

Where the resident is known to the staff team then it is likely that they will have information about them, such as ‘getting to know me’ or their life story, along with a completed risk assessment and a person-centred plan. Where the person has recently moved into the care home, they will have had an assessment completed prior to moving, and some insight into their life story may well have been supplied from themselves or their family and friends. All this information is important to help with providing safe and effective person-centred care and support.

To support the person to remain safe and respect the safety of all others, it is important the support team have current information about the individual and their habits. This can help to inform their response. Dementia Ambassadors working in care homes and social service Dementia Champions are a particularly good resource for knowledge and understanding about supporting people living with dementia. It is also important that staff engage with family members where they can to build a complete picture about the things that matter to the individual including their interests and preferences.

Risk analysis

Person-centred risk assessment and enablement is a key part to person-centred planning. It is important that the risk assessment undertaken is thorough and detailed to ensure the person can be supported to remain safe and protect others.

While there is a risk of cross infection, should the person move around the care home without completing their self-isolation period, there is also a risk that the person may become stressed or distressed, or be at risk of accidents/falls if they are prevented from leaving their room and moving around freely.

Therefore, risk assessments must consider the prevention of stress and distress in addition to IPC guidance, and  should identify the risks to the person that limitations to walking with purpose may have.

The care environment

It is not possible to eliminate every risk but managing the care environment can help to reduce safety issues associated with walking behaviours by adapting the care environment and considering staffing levels that may be required to safely support the adaptations. Adaptions to consider include:

• the use of Zoning to minimise the risk of cross-infection and to provide safe walking spaces e.g. is there an area of the facility that could be safely sectioned off to give the person/people in isolation space to walk without the increased risk of cross- infection to others?
• closing doors within the vicinity when possible, to minimise the risk of the person entering other residents' bedroom areas
• improving ventilation in any communal areas or corridors where the person may walk
• removing unnecessary clutter, furniture and objects from walkways to minimise the risk of cross-infection
• providing visual and verbal handwashing aids and prompts
• providing structured time in outdoor garden areas whilst adhering to social distancing/isolation requirements

Orientating

Where the person is new to the care home the need for them to explore and familiarise themselves with their environment may be heightened. Taking time to show the person around the home to assist them to get their bearings is also a helpful way to get to know the resident and for them to become more familiar with staff. This can help to alleviate stress and distress. To support this in a safe way the care home should:

• organise and plan a walk round the care home on the day the person moves in and as often as the person needs until they are familiar with the environment and staff
• encourage and support hand washing or use of hand gel by the resident at appropriate times in line with IPC measures
• thereafter, assist the person on a daily walk, around the home and/or outside in the garden (this can be more frequent if required) and can continue to be supported during periods of self-isolation following risk assessment

Develop a plan of activities to support the person in their room

Developing a plan of activities that are in keeping with the persons known social interests, likes and dislikes and which can be undertaken in isolation of others, or using physical distancing (as applicable) can help to alleviate feelings of boredom.

These may include:

• gardening activities such as watering flowers or plants - especially where they have access to their own garden or patio area
• musical activities such as listening to a favourite radio station or Playlist for Life, participation in a music quiz
• watching a favourite television programme or film
• provision of a personalised rummage box
• seated chair exercises, with the aid of verbal and visual prompts
• drawing or painting activities
• reminiscence activities
• sensory stimulation activities
• meaningful occupation
• routine daily tasks

Maintaining connections

To prevent distress in periods where  the individual has to self-isolate, visiting may still be supported. When there is no outbreak in the care home and the individual is self-isolating as they are COVID-19 positive or symptomatic, visiting may be supported following a risk assessment. During an outbreak within the care home, an individual can choose up to three named visitors, and have one visitor each day within their room. 

In addition to the above, essential visits should always be supported, regardless of outbreak status, for those receiving end-of-life care. They can also provide support during periods of distress. For further information on visiting including essential visits please see Public Health Scotland guidance for social, community and residentail care settings.

Other ways of connecting with wider family and friends should be encouraged through the use of telephone, Facetime, WhatsApp.

Additional resources

Care Inspectorate, Policy and Legislation- Dementia

Alzheimer Scotland- Information during coronavirus- helpline and information resources for people with dementia, their carers and families throughout the coronavirus pandemic.

References

Supporting people with dementia who need space to walk. Nicola Wood NHS Forth Valley (based on the work of Susan Holland).