​Considering novel coronavirus (COVID-19), regulatory bodies like the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention have made very specific recommendations for workers and residents in long term and post-acute care, including no-visitation policies and cessation of communal dining and group activities.

These regulations were put in place to help minimize the risk of exposure to elderly residents in long term care (LTC). However, much of the guidance given requires residents to be able to self-isolate and be cognitively intact enough to follow instructions. 

Residents with dementia, often residing on memory support households, lack the cognitive capacity to report symptoms, remain in their rooms, eat independently, or maintain appropriate six-foot social distance from others. Care staff face challenges in maintaining these recommendations on memory support households, given residents’ tendency to wander and their limited ability to maintain independent activity.

In a review of organizational and online resources, it is difficult to locate COVID-19 guidance specific to individuals with dementia in the LTC setting. Being well-versed in dementia-specific care approaches, the writers pooled their expertise and established the following suggestions for implementation of COVID-19 restrictions in residents with dementia.​

Environmental C​​ontrols

• Stage the household/environment as best as possible. Consider positioning of all seating (chairs, benches, tables in dining room, lounge areas, outside patios, and so on) to ensure that they are spaced at least six feet apart. Place only one chair per table in the dining room.
• Music is the language of dementia. General best practice for dementia suggests utilizing music daily. Consider how staff can incorporate music for a calming environment.

Eng​agement 

• Encourage residents to go outside as much as possible. Fresh air and a little exercise can help provide residents with appropriate activity and stimulation. 
• Develop for each resident a personal kit (or multiple kits) that contains items of interest to them (consider the resident’s career, hobbies, interests). Visit with the resident’s family for input on what the items in the kit might be. It must be personalized to the specific resident. If the resident can engage with the strengths-based station independently, set it up in their room.

Strengths-based stations do best when there are multiple items for sensory stimulation. For example, a cooking strengths-based kit might contain cookbooks, recipes, measuring cups, flour sifters, flour, sugar, spices. Consider utilizing some of the resident’s actual recipes or favorite cookbook from their home. 

• Don’t forget that a strengths-based station must be introduced carefully and with intent. Engage the resident with nonverbal techniques. Slowly and thoughtfully take an item out, gently begin the task. It may require hand-over-hand instruction. Make a simple statement or curious face.
• If the resident needs eyes-on/hands-on assistance with a strengths-based station or activity, set them up, one person per table or at the ends of a table. Be mindful to not make it a group activity. It is not meant to be a group, but rather an individualized engagement that can otherwise not occur due to their diagnosis and potential safety concern.
• Music can also be used as a strengths-based activity. Much like the strengths-based stations, the music must be personalized to the resident. Long into the resident’s disease process, his brain connects music to stored long-term memories and can bring pleasure and happiness. Refer to www.musicandmemory.org for some wonderful resources about developing personalized musical interventions for residents with dementia.
• Incorporate “doorway” restorative therapy, where restorative aides provide direction from the hallway to residents who are seated in the doorways of their rooms. Ensure that social distancing parameters of six to eight feet between residents are maintained. Consider utilizing equipment such as scarves that can be easily laundered between use. Avoid using things that will be passed between residents/staff (balls, balloons) as this may spread any infection/viral particles. If taking residents for a walk, attempt to do so when no other residents are in the hallway. Consider going for a walk outside if possible. ​

Infect​​​​ion prevention

It’s important to note that the following suggestions do not encompass all the recommended guidelines for limiting spread of COVID-19, but are simply some ideas for how to apply them to people with dementia.

• It is ideal that each resident have/use their own materials (such as art supplies). If not, the materials used with residents must be laundered after each use or disinfected. If materials cannot be laundered or disinfected between uses, they should not be reused (such as porous materials, Noodles, and foam balls). Ensure there is a process identified for cleaning items between use. Do not use any shared items such as life-like animals, dolls, puzzles, or art supplies.
• If pets make visits to the residents, make sure that residents wash their hands before and after petting the animal, and do not allow the animal to give “kisses.”
• For successful hand-hygiene, consider providing hand massage during hand-washing to make it a more comforting and accepted task. Staff might also use a hot towel or washcloth. Consider using hand-sanitizer if handwashing is not available, and encourage/assist the resident to use lotion whenever possible if hand sanitizer is used, as dry or cracked skin is more likely to harbor bacteria.
• Given that residents may not be able to report their symptoms, routine screenings should be completed every eight hours. It is important to practice observation as well as interview. Staff may have to phrase the questions in different ways to get accurate and useful responses so that important symptoms are not missed. For example, instead of asking if the resident has a sore throat, one might need to ask, “Does it hurt when you swallow?”
• Containment may be especially difficult for residents who wander on households. Consider installing plastic barriers (wall-to-wall, floor-to-ceiling, zippered in center), sectioning off part of the hallway as a containment area, which will help prevent residents from wandering into other resident rooms. If possible, assist the resident with putting on a mask, and encourage them to wear it whenever they are out of their room.

Dietary Cons​iderations

• The traditional meal service might need to be altered. Instead of tuna casserole, provide a tuna sandwich. Incorporating finger foods may help the resident eat more independently when staffing is limited. Utilize sandwiches, wraps, crepes, crescent rolls, and muffin approaches to add variety.
• Prepare protein bites and other nutritious snacks that can be eaten “on the go.”
• Dining could be modified, and the nutrition can be split up and provided throughout the day—it becomes the activity. For example, start the day with toast, then an egg and bacon casserole muffin—foods that can be provided on the go. This will require conversations with the dietary department to make sure food is available and to coordinate delivery times. 
• Utilize household ovens to create aroma therapy to cue the residents it is time to eat.
• Facilitate independent residents eating in rooms where safe with use of TV trays. Remove the portable items after meals to reduce risk factors, and resume the normal set-up between meals.​

Involve Families Proactively in Discussions ​about Goals for Care

• Have early conversations with the residents’ families about the challenges of infection prevention on memory support. Provide reassurance and explanation of infection prevention in the facility (such as no visitors, no group meals, no group activities, PPE standards, and so forth), but also explain that these precautions can be difficult to implement on memory support households due to wandering tendencies, cognitive impairment, and limited ability to maintain independent activity. Families will be better prepared to cope with these challenges if discussed early on versus at time of crisis. They may also be willing to help with the engagement strategies above. 
• Given that many people are furloughed or unemployed during this pandemic, some families may wish to take their loved one home and care for them in-home, with readmission to the facility when COVID-19 subsides. If the family wishes for more information, the facility should provide appropriate discharge planning and resources for in-home care. 
• Have conversations about life-sustaining treatment and preferences for hospitalization. Discuss with families that hospitalization can present a higher risk for exposure, and the family may prefer more palliative interventions at the facility rather than hospital-based treatment. Discuss wishes for cardiopulmonary resuscitation as well, and ensure families are aware that full-code status will require hospitalization in event of decline. Involve the resident’s physician in conversation if needed. 
  
  

Courtney Schmitz, MS, CTRS, CDP, is a certified therapeutic recreation specialist who has served the mental health population as well in long term care for the past eight-plus years and currently is the life enrichment coordinator for Vetter Senior Living. She also is a certified dementia practitioner with a passion for enhancing the quality of life for the elderly who suffer from dementia. She can be reached at cschmitz@vhs mail.com or 402-895-3932. Corie Sass, LMHP, LCSW, CDP, has worked her entire professional career in the long term care sector, spending the past 11 years with Vetter Senior Living Family in Social Work roles. She now is the social services coordinator at the Vetter home office, providing guidance to Social Services and Admissions Departments, with a focus on individuals with dementia and dementia-specific approaches to care. She can be reached at csass@vhsmail.com or 402-895-3932. Michelle Wallace, RN-BC, CRRN, CDP, has worked as the clinical coordinator at Vetter Senior Living for seven years. She has been in the world of long term care for more than 34 years in various roles. Wallace specializes in the areas of restorative nursing, medical-surgical nursing, dementia care, and gerontology. She can be reached at mwallace@vhsmail.com or 402-895-3932. Mary Ann Thurman, MAM, RDN, LMNT, has worked for Vetter Health Services for the past 25 years as the dining and nutrition services coordinator. When asked, “Do you like what you do?” Thurman responds, “No. I love what I do.” She is a registered dietitian nutritionist and a licensed medical nutrition therapist. With a Master’s degree in management, she recognizes how the proper handling and presentation of good, wholesome food provides the residents with something to talk about and look forward to each day. She can be reached at mthurman@vhsmail.com or 402-895-3932.​

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