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New Ways of Working with People in Dementia Care Settings

During the 2020 COVID-19 Pandemic

It is recognised that staff working in dementia wards/ care homes will be working with people who may have COVID-19. It is possible that we may be asked to care for them in their current setting rather than transfer them to a general hospital.

The aim of this guidance is to help staff to see how they can continue to provide positive and proactive care in the context of infection prevention and control advice. It is of upmost importance that an ethical balance is maintained of safeguarding the patient and others in relation to infection control whilst also maintaining patient wellbeing. We will need to deliver non-pharmalogical and pharmalogical care and treatment very differently.

Preventative Interventions

Talk with the person and/or those important to them to write a person-centred care plan based on the person's history, choices and their current needs. Include strategies and activities to aid the development of an individual isolation pack.

Understand any possible triggers for psychological or behavioural distress and identify what the person finds helpful and unhelpful.

Share accessible information about COVID-19 and how to keep safe e.g. talking about COVID-19 in simple clear language and using pictorial posters.

See easy-read / pictorial information about COVID-19 here:

Physical health observations need to be taken at least twice a day, escalating any concerns in line with the NEWS protocol. It is known that patients with dementia and COVID -19 are more at risk of developing delirium. Staff should aim to reduce the risk of delirium by ensuring that the patient maintains good hydration, is not constipated, that any pain is well managed and that any superadded infections are identified and treated early.

Staying connected with loved ones using telephone or IT resources can reduce distress both for the patient and their loved ones.

Continuing tailored individual and group activity programmes whilst observing infection control guidelines, such as social distancing, will help to reduce distress and boredom.

Social distancing

Patients will be encouraged to spend more time in their own rooms in order to protect themselves and each other from infection. Where this is not possible or may be detrimental to the patients' wellbeing, staff need to think of alternative ways to enable social distancing. Physical restraint should not be used (British Geriatric Society 2020)[endnoteRef:1]. [1: https://www.bgs.org.uk/resources/covid-19-managing-the-covid-19-pandemic-in-care-homes]

Patients'/ Residents' rooms

Staff teams will need to find ways to improve the environment of patients' rooms to make them a more appealing place to spend time and support patients' wellbeing. These are some of the ways that they can do this:

· Use the persons social profile, talk to families, use pictures and photos to decorate walls (laminated for infection control), wipeable memory books and rummage boxes with items which can be easily cleaned.

· The therapeutic benefits of music is well documented, therefore music will be a priority for each room. Ask patient/family what music they like? Ask family to drop off preferred music player to the ward; ward staff to order CD players (or other) for each room; collate a library of music, podcasts, audio books that are deemed appropriate for each patient; avoid radio with news broadcasts due to the current climate of fear and anxiety in the media.

· Where a risk assessment deems it appropriate TVs and DVD players may be made available for patient's use in their bedroom. For infection prevention and control reasons, TVs and DVDs must not be moved from room to room.

· Use individual isolation packs developed by Occupational Therapy (OT)/ activities co-ordinators.

Further useful ideas for maintaining activities for people during the COVID-19 pandemic can be found here in the Health Innovation Network Document on maintaining activities for older adults during the pandemic[endnoteRef:2]. [2: https://healthinnovationnetwork.com/wp-content/uploads/2020/04/Maintaining-Activities-for-Older-Adults-during-COVID19.pdf

]

The nurse in charge of the shift will need to consider allocating specific staff to specific patients, in order to reduce opportunities for transmission and to support good infection prevention and control procedures. Staff should also be enabled to support patient wellbeing through engaging in conversation and activities whilst following infection prevention and control guidance. It is important to consider proactive contact for those who have a greater need for social interaction and this should be specified in their care plan.

Mealtime support

Mealtimes offer an additional and potentially higher risk for the spread of infection. The following suggestions should be considered to mitigate the risks:

· Consider whether it would be safe for some patients to eat in their own rooms

· Make space in the dining room to allow for social distancing

· If social distancing is not possible in the dining room, consider using different rooms

· Consider whether to extend mealtimes so less people are eating at the same time.

Supporting People Who Walk with Purpose (Thwaites and Marshall 2020)

If staff are instructed to isolate a patient and stop them ‘walking with purpose’, this intervention itself may trigger an escalation in behaviours that challenge (e.g. physical/verbal aggression). We 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. People are most likely to ‘walk with purpose’ when they have moderate/severe dementia. At this stage, the person may have little understanding of what is said to them, so are unlikely to benefit from verbal explanations about the risks to themselves or others of leaving their room.

If the person cannot be encouraged to remain in their room staff must consider how to keep others safe e.g. ask other patients if their bedroom door can be closed for a short time, unless this poses a risk. Consider how to provide a safe space for the patient to move around.

If you are trying to get the person to stop doing something (i.e. walking), you may have to walk with them and match their speed, then gradually change the rhythm or pattern rather than opposing them (Snow, 2012). Further information can be found in this really helpful document:

Personal Protective Equipment

It is important to acknowledge that it is impossible to avoid close contact with some patients and other members of staff when delivering care. For example personal care activities, 'seeking' behaviours and the risk of falls, will involve staff getting close to patients and each other. Staff and patients are at high risk of spreading COVID-19, especially during the incubation period, before symptoms show, therefore it is extremely important that staff follow PPE guidance. Some patients may find face masks frightening, but there has been some anecdotal evidence that patients have also found them funny. We cannot know how each patient will respond until we try it therefore staff should be sensitive to this.

The introduction of face masks as routine could be helpful in desensitising patients. A poster has been designed to support the use of masks. Wards should laminate them and display them wherever it would be useful to do so.

Decisions about escalation of care and treatment to acute hospital

In the context of the COVID-19 pandemic the MDT/ care team must consider revisiting Advanced Care Plans and DNAR decisions with patients and their loved ones. Escalating a patient's treatment to an acute hospital should be considered when it is agreed that the patient requires treatment that cannot be provided on the dementia ward.

Staff Support

The ebb and flow of each care environment is unique and ever-changing; what may be a settled ward/ home one day could become a very different place the next. Being around people who have COVID-19 is anxiety provoking for staff. Lack of PPE also raises anxieties. Wearing PPE all day is physically draining and dehydrating. It is extremely important to really think about staff wellbeing.

Nurses in charge should consider a check in at the start of each shift, extra breaks, where staff are working long day shifts, consider having a huddle in the middle of the shift and a check out at the end of the shift. Sharing concerns, sharing the load and sharing feelings can support problem solving and provide reassurance to stressed staff.

Supervision is also important to provide individual support and guidance to staff.

1

Conversation Topic: Corona Virus/ Covid -19

Images © KCann free for reproduction under creative commons license

Cut up and use these images to support e�ective communication skills.

Support understanding by using short sentences and illustrating key words with these images.

Support expression by supporting the user to manipulate the images to illustrate their thoughts/ questions.

Virus Symptoms

Pneumonia

Breathing

Temperature weak

coughheadache Hospital






wash hands

don’ttouchface

cough/sneezeinto elbow

cough/sneezeinto tissue

one weektwo weeks

avoid crowds20 seconds-wash hands






sharp pain

swab Eyesswab Mouth

dull pain O.K

angrysadworried






family older person

nurse doctorhealth care

professional

paramedic ambulance care






YES No






medicine

No

news research water

timebed

air travelphone

R.I.P

PPE easy read

covid-19 story.pptx

Coronavirus (Covid-19)

How to keep Safe

BHSCT Covid-19/easy read/13/3/20

Staff often wear a uniform when they are at work.


How to keep Safe


Staff might need to put on gloves, aprons and masks to keep you safe and keep them safe.


How to keep Safe


They might look different. It is still the same person.


How to keep Safe


This is to help stop germs spreading to help make sure you are safe and they are safe.


How to keep Safe


Staff helping you might look different. They might wear, gloves, aprons and masks.

This is to help stop germs spreading to help make sure you are safe and they are safe.

Supporting people

who ‘walk with purpose’ during the COVID-19 pandemic - version 1.0.docx

Supporting people living with dementia who ‘walk with purpose’ during the COVID-19 pandemic

Susannah Thwaites (Occupational Therapist) and Dr Joanna Marshall (Clinical Psychologist)

The COVID-19 pandemic raises particular challenges for care home residents, their families and the staff that look after them. Recent guidance from the British Geriatrics Society (BGS; Gordon et al., 2020) states:

· “Once care home staff have a suspected case they should isolate that resident to their room and commence use of the personal protective equipment (PPE)”

· “This will pose particular challenges for residents who ‘walk with purpose’ (often called ‘wandering’) as a consequence of cognitive impairment but require isolation”

· “Community mental health and dementia teams should be prepared to prioritise support to care homes who need to isolate a resident ‘walking with purpose’”

· “An antecedent, behaviours, consequences approach should be used to understand the behaviour and try to modify it where possible”

· “Physical restraint should not be used

There are normally many positive aspects to people living with dementia ‘walking with purpose’ (e.g. exercise, stress reduction), so it is often appropriate to provide safe walking areas, rather than deny people the opportunity to engage in this behaviour (James, 2011). Under normal circumstances, we would not attempt to treat /intervene with ‘walking with purpose’ unless: there is a risk to the person’s nutritional intake; it is causing extreme fatigue; risk of falls; or distress to the person or others. However, if the person has a suspected or confirmed case of COVID-19, the care home may receive clear medical guidance to isolate the resident to their bedroom (Gordon et al., 2020).

We know that most behaviours that challenge happen around interactions with carers when they are trying to get people to do what they do not want to do, either to stop some problematic behaviour (e.g. stop going into someone else’s room) or to start a behaviour aimed at enhancing person’s wellbeing (e.g. start taking medication or start getting washed/dressed) (Stop Start Scenarios; James and Hope, 2013). If care home staff are instructed to isolate a resident and stop them ‘walking with purpose’, this intervention itself may trigger an escalation in behaviours that challenge (e.g. physical/verbal aggression). We need to support mental health staff to assess the needs that may be driving the ‘walking with purpose’ behaviour and to develop individualised Behaviour Support Plans to attempt to meet these needs in other ways while they are isolated, minimising the risk of residents walking out of their bedrooms. We need to support care home staff to use effective communication strategies to reduce the risk of escalation in behaviour that challenges when staff intervene (James, Marshall and Thwaites, 2017). We 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. If a person living with dementia has or is suspected of having COVID-19, they are a high risk of having a delirium, which could contribute to their presentation and ‘behaviour’; however we still need to support the care home to implement individualised non-pharmacological interventions to minimise the risks.

Use the Behaviours that Challenge Clinical Link Pathway (CLiP)

· As part of the Assessment:

· Gather information about the person (personal history document)

· What did they do for a job, what were their hobbies, routines?

· Ask questions to establish their level of dementia

· Communication skills, GEM level, visual field

· Prior to developing symptoms of COVID-19 what was their level of activity? Have they always been a person who walks a lot or is this something new?

· What do they do when they walk – Do they gather things, rub surfaces, move furniture, push trolleys or go into other’s rooms?

· Are they usually safe walking or is there a falls risk?

· Is there a time of day when they are more likely to need to be active and walking?

· What sort of things (or time of day) are they more likely to sit down for?

· PINCHME – Could the person be in pain or discomfort and what is their current pain relief regime, compliance etc.?

Develop an individualised Behaviour Support Plan:

· There are many common biopsychosocial causes of walking with purpose (see Table 2.5 in James, 2011).

· What is the need that the ‘walking with purpose’ is meeting / trying to meet for the person?

· Exercise – they may have been a life-long active person.

· Occupation – are they fulfilling a previous work or home-life role?

· Seeking – are they looking for a particular person or place or seeking reassurance, company, food?

· Pain – we know some people who have back or joint pain are more likely to walk excessively.

Primary preventative strategies - (Things we do to improve the person’s quality of life and reduce the likelihood of Behaviour that Challenges)

· Interventions need to be chosen according to what we think the unmet need may be. The following is not exhaustive list but ideas could be:

Exercise seekers:

· Playing ‘football’ with large exercise ball up and down the corridor, when others are not around, or in their room if it is large enough.

· Dancing to lively music that they like.

· More use of garden areas if on the ground floor. Allow them time in the garden when others are not using it and encourage them to be active – carrying a heavy watering can, sweeping etc.

Being busy seekers:

· Can they have an individualised rummage box in their room that has objects that are more easily sanitised?

· Encourage them to sort their drawers and wardrobe, even if this means messing things up first so that they need to sort, fold and put the things away.

Reassurance / company seekers:

· The BGS guidance recommends that care homes should take advantage of videoconferencing software on smartphones, tablets and portable computers as much as possible to maintain human contact for residents (Gordon et al., 2020).

· Consider Simulated Presence Therapy (SPT) if the sight or sound, on audio or video, of a loved one may provide comfort and reassurance. Having a video/audio recording may enable care home staff to play this repeatedly if videoconferencing contact is forgotten by residents with dementia.

· If the person is calm and does not walk if they have another person with them this may build a case for a period of one to one staff support.

Environmental adaptation:

· Try to make the person’s room as recognisable as their space and homely as possible. Family cannot come in to visit but may be willing to drop off some extra items to help with this. If the room is not enriched, they will seek elsewhere.

· Do they have access to individualised music (such as Playlist for Life)?

· Do they have access to a TV and programmes on that do not need too much understanding of language? Be careful of having the news on or programmes with distressing content that they may interpret as real.

· Do they have access to a DVD player and DVDs of familiar and favourite films, sports they like?

Secondary (reactive) strategies - Things to do when we notice a behaviour occurring or getting worse (i.e. if a resident tries to leave their room):

· People are most likely to ‘walk with purpose’ when they have moderate/severe dementia (Amber or Ruby on GEMS). At this cognitive level, the person will have little understanding of what is said to them, so are unlikely to benefit from verbal explanations about the risks to themselves or others of leaving their room.

If the person cannot be encouraged to remain in their room:

· Close other’s bedroom doors, unless this poses a risk, as they are less likely to open a closed door.

· Can a portion of the unit be given over to them so they have the space to move around?

· If you are trying to get the person to stop doing something (i.e. walking), you may have to walk with them and match their speed, then gradually change the rhythm or pattern rather than opposing them (Snow, 2012).

References

Gordon, A., Burns, E., Astle, A., Barker, R., Kalsi, T., Williams, C., and Clegg, A. (2020). Managing the COVID-19 pandemic in care homes. GOOD PRACTICE GUIDE. www.bgs.org.uk/COVID-19.

James, I.A. (2011). Understanding Behaviour in Dementia that Challenges: A Guide to Assessment and Treatment. Jessica Kingsley Publishers.

James, I.A., and Hope, A. (2013). ‘Relevance of emotions and beliefs in the treatment of behaviours that challenge in dementia patients’. Future Medicine, 3, 6, 575-588.

James, I.A., Marshall, J. and Thwaites, S. (2017). Improving communication skills in dementia care: utilising the BPS’s stepped-care model for treatment of behaviour that challenges. FPOP Bulletin, 137, 36-41.

Snow, T. (2012). Dementia Caregiver Guide; Teepa Snow’s Positive Approach techniques for caregiving, Alzheimer’s and other forms of dementia. Cedar Retirement Community.

Starting shift-going

home checklist v2.docx

Self-care

· When and how can you take care of yourself this shift?

· Breaks are important, make sure you are allocated one and if not then ask the nurse in charge for one - get off the ward, go for a walk, watch a YouTube videos, find something to distract yourself

· Remember we won't be able to do everything for our patients, so don't expect yourself to.

· We need to remember that both the patients and ourselves are tolerating different ways of working

· Safety huddles within the shift - take time to check in when the ward is acute

Team support

· Think about things you can do to check in and offer support to your colleagues both during the shift and after.

· Help each other to keep perspective - these are unprecedented times and we need to remind each other of the reality of our ability in this context.

· Remember to be kind to each other!

Check -in

· How are people feeling? Do you have any worries from the last shift you worked?

· It's OK to be feeling anxious/worried and to talk about it.

· Please tell someone if you're not OK. Your colleagues, senior team and MDT are here to support you.

· Find a 'shift friend' who you feel safe to check in with during the shift.

· Any hopes or things you want to achieve for the shift?

· Has everyone seen and read the current guidance - things are changing daily

STARTING SHIFT CHECKLIST

· Now switch your attention to home.

· Think about how are you going to rest and recharge?

· If you notice thoughts about your day creeping in, try to just notice them and leave them there.

· Use distraction techniques that work for you.

Try downloading a new app - headspace, calm or the mindfulness app

· Are you ok? If not, have you told someone? Your colleagues, senior team and MDT are here to support you.

· Check in with your 'shift friend' and colleagues ask if are they're ok and share with them if you're not ok.

· If you're struggling that's ok, it means you are human! Talk to someone about it.

· Acknowledge your colleagues contribution – Say Thank you!

· Before you leave take a moment to think about today, reflect on the shift the things that were difficult and the things that went well.

· Think about one thing that was difficult – try and let it go.

· Consider 3 things that went well.

· Do you or the team need a defuse/ decompress at the end of the shift, if so ask for one.

· Remember you did your best today.

GOING HOME CHECKLIST

Covid-19-visual-aids.

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