Interim guidance for health-care professionals and administrators providing hospital care to adult patients with cognitive impairment, in the context of COVID-19 pandemic.

OBJECTIVE: We developed interim guidance for the care of patients with cognitive impairment in hospital during the COVID-19 pandemic.
METHODS: A Guidance Committee and Readers Group were recruited. The content was identified by the Committee and content-specific subgroups, resulting in a draft document, which was sent to the Readers for review. People with dementia and care partners were involved in all aspects of the process.
RESULTS: Infection control measures can lead to an escalation of distress. In an environment where visiting bans are applied to care partners/advocates, hospitals need to ensure care partners can continue to provide decision-making support. Health-care professionals can proactively engage care partners using videoconferencing technologies. Developing models of care that proactively support best practice can minimise the risk of delirium, mitigate escalating symptoms and guide the use of non-pharmacological, pharmacological (start low, go slow) or physical restraint in managing behavioural and psychological symptoms.

PATIENTS WITH COGNITIVE IMPAIRMENT IN HOSPITAL DURING COVID‐19 PANDEMIC

Interim guidance for health‐care professionals and administrators providing hospital care to adult patients with cognitive impairment, in the context of COVID‐19 pandemic. More information at https://chsr.centre.uq.edu.au/interim-guidance-care-adult-patients-cognitive-impairment-requiring-hospital-care-during-covid-19-pandemic-australia

COGNITIVE IMPAIRMENT MAY INCREASE DURING COVID‐19

COVID‐19 can cause delirium

Admissions may increase for patients with dementia or intellectual disability due to COVID‐19 spatial isolation and reduced community resources

Patients with any kind of cognitive impairment are at higher risk of complications and distress, for example adverse events, long length of stay, behavioural and psychological symptoms and death

Higher risk warrants increased preventative strategies to reduce the risk of harm

PEOPLE WITH COGNITIVE IMPAIRMENT MAY REQUIRE INNOVATIVE APPROACHES TO CARE BECAUSE OF:

Inconsistent historians, comprehension of care requirements and remembering/following instructions

Challenges in maintaining infection control principles (eg keeping mask on) due to the person experiencing anxiety, restlessness, breathlessness, exit‐seeking behaviours/wandering, fear, agitation or aggression

Limited access to their usual care partner/advocate (eg due to COVID‐19 control measures or illness)

Fear of people wearing PPE, which can be frightening and unfamiliar

CLINICAL STRATEGIES TO MAINTAIN EFFICIENT, EFFECTIVE AND ETHICAL CARE

Assess patients to identify contributing factors to delirium and factors that are treatable

Manage hypoxia, pain, infection, dehydration, constipation, hunger and strange environments

Reduce polypharmacy and tethers where possible (IVC, IDC and bed rails)

Normalise infection control practices

Use regular calm reorienting conversations, maintain calm demeanour, prioritise dignity and respect

Provide sample packs of personal protective equipment (PPE) to enable patients’ familiarisation

Consider humanisation of staff by placing large print name labels and photographs on staff wearing PPE

Consider the best environment for individual patients based on their acceptance of PPE

Provide education on PPE and infection control to care partner/advocate who will be present in hospital

Orient people with cognitive impairment using biopsychosocial reinforcement

Welcome care partner/advocates to stay with people with cognitive impairment

Document the ‘Top 5’ strategies that were requested by the person (or care partner/advocate) for help with their care in their medical record

Place items in view (family photographs, music, phone and personal items)

Encourage activity (life storybook/app, puzzles, fidget boards, towel folding and toolbox)

Use human solutions (hearing and visual aids, music, pictures, TV and video)

Support time orientation: day/night lighting; bedside clock/calendar; and assist with meals

Promote the use of staff familiar to the patient; social and mobilising time

Write down information and instructions for patients, use visible whiteboard

Discuss and document goals of care

Identify the lawful decision‐maker if substitute decision‐making is occurring

Support shared decision‐making, informed consent and advance care planning

Plan comprehensive care based on the patient’s goals of care, and in line with their values and preferences, ensure regular communication

Focus on reablement, palliative care or end‐of‐life care as relevant

Respond to any behavioural crisis (breach of infection control and aggressive behaviour) (Figure 1)

Figure 1

Flow chart of COVID‐19–related care decisions for people with cognitive impairment. The full 2‐page version of this poster can be viewed in the article’s Online Supporting Information.

Implement non‐pharmacological strategies (as above)

Medications should be avoided and used only in extreme circumstances in a timely manner with consent policies and procedures implemented, and cessation plan written

GOVERNANCE STRATEGIES TO MAINTAIN EFFICIENT, EFFECTIVE AND ETHICAL CARE

Review whole‐of‐hospital policy, procedures and guidelines, risk management systems, clinical and support staff training (Figure 1)

Separate wards and staff with health‐care workers skilled in managing cognitive impairment challenges

Enable hospital avoidance strategies if safe to do so

Enable hospital stay to include recovery, restorative care and rehabilitation

Conflicts of interest

No conflicts of interest declared.

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