The behavioral and psychological symptoms of dementia (BPSD) are well known in patients
with major cognitive impairment (Bessey and Walaszek, 2019). The COVID-19 pandemic
calls into question the organization of Cognitive and Behavioral Units (CBUs) specialized
in the management of BPSD (Bellelli and Trabucchi, 2011; Koskas et al., 2011) to limit
the risk of contamination for hospitalized patients and staff. Moderate-to-severe
cognitive disorders and BPSDs such as wandering and agitation explain patients’ lack
of understanding of the basic protective measures against COVID-19 and their difficulty
in implementing them (BMJ Best Practice, 2020). It is also difficult to find the right
balance between protective but coercive measures and respect for patients’ dignity.
Another difficulty is how to streamline hospital procedures to reduce workload and
limit the risk of mental and physical exhaustion.
Recently, several expert committees have published guidelines on the treatment and
management of patients with COVID-19 in different clinical situations (BMJ Best Practice,
2020; Wang et al., 2020) but to our knowledge, none of them had focused on elderly
patients with BPSD. Confronted with the urgent medical need of guidelines, a French
geriatric and psychiatric task force developed recommendations based on their clinical
experience in CBU. In France, CBU exists in hospitals for the purpose of managing
very severe BPSD in older adults living with dementia which are systematically assessed
at admission and hospital discharge by using the Neuropsychiatric Inventory. Pathological
wandering is a BPSD and consists in being in constant motion, with no precise or reasonable
goal. It can lead a patient with advanced dementia to involuntarily leave the hospital
without medical authorization with the risk of being harmed. This specific BPSD is
systematically screened prior to admission because it is usually associated with aberrant
motor behavior which implies incapacity to respect barrier measures such as social
distancing, wearing a mask, or sanitizing one’s hands. It is, therefore, associated
with a high risk of cluster outbreak.
Depending on the stage of contamination in the unit, practical proposals are made
to better manage patients with BPSD and reduce the risk of contamination for patients
and hospital staff during the COVID-19 pandemic.
The stages of COVID-19 contamination in a specialized unit and the corresponding recommendations
are shown in Figure 1.
Figure 1.
Decision tree to allow the least restrictive environment for patients who wander.
Stage 0: No patients with COVID-19 infections in the cognitive–behavioral unit
The patients’ COVID-19 status need to be known prior to their admission in the CBU
using protein chain reaction detection methods, or computed tomography scans to avoid
contamination of COVID-19-free patients, bearing in mind the limits of sensitivity
of each approach (BMJ Best Practice, 2020; LaHue et al., 2020). No COVID-19-positive
patients should be admitted to the unit as long as they are considered to be contagious
(LaHue et al., 2020) (minimum 24 days [Zhou, 2020] after the onset of symptoms) due
to the inability of patients with BPSD to comply with protective measures. A newly
admitted patient considered as COVID-19-negative should be closely screened for atypical
signs evocative of COVID-19 infection such as falls, delirium, generalized weakness,
dizziness, headache, rhinorrhea, conjunctivitis, chest pain, digestive symptoms, or
anosmia. Isolated tachypnea or unexplained tachycardia may be warning signs too (D’Adamo
et al., 2020).
However, there is no argument to systematically confine wandering patients in their
rooms (de Santé, 2020). Group activities should be suspended while prioritizing individual
care. Staff will be cautious about the risk of transmitting COVID-19 between patients
by cleaning any items used with a patient and avoiding the use of objects that are
difficult to clean.
Stage 1: Diagnostic or suspicion of a COVID-19 infection in the unit
As a first step, all COVID-19-free patients should be quickly released from the unit
if possible.
Recently diagnosed COVID-19 patients will have to be transferred to a dedicated acute
COVID-19 unit preferably in the same hospital while COVID-19-negative patients in
the CBU should be closely monitored for signs of infection (BMJ Best Practice, 2020).
These are emergency measures that take into account the rapid spread of the virus
(Vanhems, 2020). Moreover, recent studies have highlighted atypical clinical presentations
of COVID-19 infections in elderly patients such as delirium, psychomotor retardation,
and repeated falls (Shahid et al.,
2020; Lin and Han, 2020).
Stage 2: If transferring a COVID-19 patient in an acute COVID-19 unit is impossible
When there are two confirmed cases (BMJ Best Practice, 2020) or more in a unit, this
unit necessarily becomes a COVID-19 unit. Therefore, only COVID-19-positive patients
can be hospitalized and any discharged patient will have to be isolated by droplet
isolation for at least 15 days (BMJ Best Practice, 2020). Personal protective equipment
for the prevention of highly contagious diseases needs to be provided for hospital
staff (Verbeek et al., 2020).
The first step is to group patients together in contiguous rooms on the unit and to
isolate them as much as possible in their rooms. For wandering COVID-19-positive patients,
a special secure and separate section may be created within the unit to respect as
far as possible the principle of freedom of movement. Indeed, grouping COVID-19-positive
patients together in a protected environment can limit spreading the COVID-19 outbreak
while reducing the risks related to confinement such as anxiety and depression. Single
room isolation should be a second-line option and can be considered when the implementation
of such a protected section is impossible for architectural, material, or workforce
limitations. In this case, do not leave healthcare waste bins outside the rooms.
The second step is to reinforce the medical and paramedical staff as recommended by
local health organizations. For example, the ratio of professional caregivers per
patient in France is one auxiliary nurse for six patients with acute COVID-19 infections
(Robert et al., 2018). Moreover, staff needs to be specifically assigned to care units,
either COVID-19-positive or COVID-19-negative units, in order to reduce the spread
of the virus.
Stage 3: Managing COVID-19 patients with BPSD and the hospital staff
The COVID-19 pandemic strains both staff and patients. In France, nursing assistants
in CBU are qualified to manage BPSD (“Assistant de Soins en Gérontologie”) in order
to limit psychotropic drug prescriptions. Nursing workforces are strengthened in COVID-19
units to enable closer monitoring of patients’ vitals and personalized care. Yet,
the healthcare teams confronted with COVID-19 are particularly strained and require
active psychological support from psychologists and unit managers (Bao et al., 2020;
Xiang et al., 2020). The setting up of discussion groups and the provision of a psychological
support telephone platform dedicated to healthcare professionals should be proposed
(Wu et al., 2009).
On the other hand, quarantine can be poorly tolerated by elderly patients, especially
those with BPSD, triggering anxiety, depression, and dehydration and increase BPSD
(Vanhems, 2020; Xiang et al., 2020). To our knowledge, there are no therapeutic guidelines
for the use of psychotropic drugs in this context. Therefore, we needed a daily multidisciplinary
assessment of the benefit/risk ratio to adapt to non-pharmacological and pharmacological
treatments. Non-pharmacological approaches aim to limit the isolation perceived by
patients (Brooks et al., 2020) and staff needs to be particularly aware of depression
symptoms which are often atypical is this population (Bessey and Walaszek, 2019).
This aspect of patient care should not be neglected despite the epidemic situation.
Thus, staff may schedule times during the day to visit patients, help them walk around
the unit or garden, offer individually assisted physical activities, or music programs
in their rooms. In addition, meals are an opportunity for staff to spend time with
their patients.
Since families are not allowed to visit their relatives, effective communication devices
such as regular telephone or video calls could be implemented to reduce psychological
stress and feelings of loneliness (Bao et al., 2020; Brooks et al., 2020). Furthermore,
some patients may feel relief having a “transitional object” with them such as personal
photos, reminders of pleasant memories. Allowing patients to wear their usual clothing
also helps to preserve their sense of identity and dignity. However, due to overworked
teams, families may be called upon to provide laundry services. In that case, any
dirty laundry leaving the unit should be returned to the family caregiver in a water-soluble
bag that is hermetically sealed (BMJ Best Practice, 2020).
Pharmaceutical treatment should be based primarily on the patient’s clinical signs
(delirium, anxiety, depression, and delusion). Although benzodiazepines are often
used as first-line treatments in case of acute agitation, after ruling out any somatic
cause (pain, fever, urinary retention, constipation…), randomized control trials don’t
support their use (McDermott and Gruenewald, 2019). On the other hand, in case of
chronic agitation or anxiety, serotonin reuptake inhibitors may be prescribed, taking
into account side effects such as QTc interval widening with escitalopram and citalopram
(Drye et al., 2012). An alternative medication for chronic agitation is Pregabalin
(Supasitthumrong et al., 2019). If delirium or delusion occurs, standard therapeutic
algorithms can be used (McDermott and Gruenewald, 2019).
Unfortunately, in case of a drug shortage, alternative treatments must be considered.
Midazolam can be used either orally or by subcutaneous injection to treat acute behavioral
symptoms (McDermott and Gruenewald, 2019). When oral administration is not possible,
injectable benzodiazepines are the best option, bearing in mind that diazepam, clorazepate,
and clonazepam all have a long elimination half-life and can accumulate in the body
if used regularly (Wu et al., 2009). Injectable form of lorazepam is available in
some countries and should be preferred for its shorter elimination half-life.
Good clinical practice for the prescription of psychotropic drugs (Livingston et al.,
2017) recommends daily assessment of the risk/benefit ratio and reducing the dosage
to limit iatrogenic side effects. Fever increases the risk of side effects due to
psychotropic drugs particularly antipsychotics, such as falls and dysphagia (LaHue
et al., 2020). Moreover, COVID-19 infections are associated with thrombogenic and
arrhythmogenic risks (Guo, 2020). As with any infected frail patient, medical staff
should implement nutritional supplementation (high-calorie and high-protein foods)
and hydration monitoring (Lin and Han, 2020). Comprehensive geriatric assessment remains
a key component to avoid usual complications such as constipation, and pain.
If chemical restraint is not possible, physical restraint may exceptionally be prescribed
preferably with abdominal and pelvic straps (Livingston et al., 2017). The prescription
needs to specify the kind of equipment needed and the duration of validity. Patients
with nighttime pathological wandering should only be confined in their rooms overnight.
The medical prescription and tolerance of such restraint should be reassessed hourly.
Prescriptions can, however, be anticipated through a staggered procedure. Physical
restraint should be discontinued as soon as possible once the chemical restraint is
effective. As always, it is important to document reasons, consent, and review procedures
if physical restraint is prescribed. In some countries, physical restraint is forbidden
by law, and in others, it is mandatory to obtain consent from the families or main
support person.
The COVID-19 outbreak is overwhelming all healthcare systems and we need to provide
new guidelines for better medical management of elderly BPSD patients and their families
and preserve hospital staff by streamlining their procedures.