Facetime to reduce behavioral problems in a nursing home resident with Alzheimer's dementia during COVID-19.

To the Editor,

Pandemics increase anxiety, depression, and stress. A variety of negative psychological effects including post-traumatic stress symptoms, confusion and anger have been reported as consequences of COVID-19 related quarantines (Brooks et al., 2020). Confusion, uncertainty about the future, and separation from loved ones lead to despair and feelings that the world is ending. Older adults with pre-existing mental illness or cognitive impairment are particularly susceptible to an increase in anxiety and other behavioral problems (Lima et al., 2020).

Older adults residing in nursing homes have an increased risk of COVID-19 infection, morbidity and mortality. Hence stricter guidelines have been enacted for such high-risk populations. The Centers for Disease Control (CDC) has recommended social distancing and limiting visitors to nursing homes. Nationally, many nursing homes have essentially gone into lockdown. Arkansas has followed the same quarantine protocol as most of the early cases of COVID-19 in the state occurred in nursing homes. Caregivers are prohibited to bring food or person items or visit their loved ones due to concern about the contagion. This necessary and well-meaning quarantine has resulted in an unintentional consequence of increased stress in an already vulnerable population.

The use of phone applications in healthcare is common, but its use has been limited in geriatric care due to concerns about privacy and exploitation. Approved telehealth equipment is sometimes cumbersome and difficult to master/operate by older adults with cognitive impairment and with or without hearing loss. It is important to overcome these barriers as the use of social technology is linked to higher subjective well-being and lower depressive symptoms among older adults (Chopik, 2016). During the COVID-19 pandemic, government agencies have issued an emergency waiver to suspend the requirement of Health Insurance Portability and Accountability Act (HIPAA) compliance and have allowed permission to use popular applications for video chats, such as Apple FaceTime and Facebook Messenger video chat, which are not HIPAA compliant (Wright and Caudill, 2020). This change is welcomed by geriatric healthcare providers. We present a case wherein interaction with family members using FaceTime improved the quarantine-induced behavioral problems in a nursing home patient with Alzheimer's disease.

Mr. A., was an 81-year-old nursing home resident with Alzheimer's dementia, hypertension, hyperlipidemia, and hearing loss. He was generally stable both physically and cognitively before the COVID-19 pandemic. Among other medications, he was on memantine, and there were no recent changes. His-daughters were very engaged in his care and would often visit him and bring home-cooked food. He was noted to have a worsening of behavioral problems after the visitations were stopped due to the pandemic. The daughter reported that her father had increased confusion and anxiety, poor appetite and was “hard to handle”. The daughter reported that she had difficulty communicating with him over the phone. Patient could not understand why his daughters stopped visiting him, which they had been doing daily before the pandemic. The no-contact restriction was distressing for the daughter who wanted to provide comfort to her father, and yet was unable to do so. She took home-cooked food with hope that the nursing home staff could pick it up and was disappointed when they turned her back. A phone assessment was performed by the geriatric psychiatrist for the increasing behavioral problems. The Neuropsychiatric Inventory (Cummings et al., 1994), a global screen for behavioral problems seen in dementia, showed that the patient was experiencing increased depression, anxiety, apathy, irritability, difficulty sleeping, and general restlessness. Several nonpharmacological interventions including increased contact (even if only virtual) with family members was recommended. The staff and his daughter came up with an innovative solution to FaceTime. The nursing home administration was receptive to the idea because of recent loosening of restrictions (Wright and Caudill, 2020). His-daughter was able to make video calls using FaceTime. The patient was reported to communicate well as he could “lip read” during the video session. The daughter reported that her father enjoyed the sessions and seemed to be less anxious and agitated by the end of the video calls. Staff reported that after a series of such video calls, the patient was pacing less and had an improved appetite. The daughter reported that FaceTime had provided a sense of connectedness and had positive impact on his symptoms.

In conclusion, interaction with family members using FaceTime improved behavioral problems in a patient with Alzheimer's dementia during the COVID-19 pandemic. Use of such applications need to be studied both for clinical and research care to be prepared for future pandemics.

CRediT authorship contribution statement

Sanjana P. Padala: Conceptualization, Writing - original draft. Ashlyn M. Jendro: Investigation, Writing - review & editing. Lillian C. Orr: Supervision, Validation, Writing - review & editing.