Describe circumstances that may trigger potentially catastrophic
Planning for a Pandemic/Epidemic or Disaster: Caring for persons with cognitive impairment
Prepared by:
Alzheimer’s Association
American Association of Homes and Services for the Aging
American Health Care Association
American Health Quality Association
American Medical Directors Association
National Association of Directors of Nursing Administration
National Center for Assisted Living
Emergency situations such as a pandemic, epidemic or disaster present special circumstances for staff in long term care facilities. Residents in long term care facilities are particularly vulnerable to complications of influenza (the “flu”)
due to their age and other concurrent medical conditions.
Employees would also be affected by a serious flu outbreak.
Maintaining operations in a long term care setting with the
expected staffing shortages during a pandemic, epidemic or
disaster would be very challenging. During this time, non-
clinical staff may be needed to assist with patient care. This
document is designed as a guide for non-licensed staff and lay
people who may become involved in direct patient care during
a major disease outbreak or disaster. Note: these are suggestions
for care. It may be unrealistic to expect all items in this
document to be carried out in a pandemic or disaster situation.
This document is not a substitute for facility training. The
Alzheimer’s Association’s Campaign for Quality Residential
Care offers practice recommendations for long term care
facilities. The recommendations and information on training
can be found at: http://www.alz.org/qualitycare.
Approximately 50% of all nursing home residents have some
form of dementia with 26% experiencing mild cognitive
impairment. Among residents in assisted living programs 42% or
more have some form of dementia. Dementia is characterized
by a group of symptoms that include a decline in cognitive
abilities including loss of memory, poor judgment, changes in
personality, disorientation and problems with abstract thinking.
As the disease progresses, residents with dementia will need
additional assistance in conducting activities of daily living.
Due to their decreased cognitive ability, residents with dementia
may require additional assistance and consideration during the
implementation of an emergency plan.
Prevention Issues Residents with dementia may have an impaired ability to
follow or remember instructions regarding:
• Hand washing
• Wearing a mask
• Refraining from placing things in the mouth
• Staying in particular area
• Taking medications appropriately
• Following any other procedures that would require intact
memory and judgment
It is recommended that residents with dementia be placed
on a supervised “hand washing schedule” followed by the use
of moisturizer to avoid skin breakdown. Various approaches
may be needed to ensure that these individuals use masks and
remain in particular areas. This may require additional staff and
volunteer training.
During Plan Implementation Residents with dementia may become more agitated, frustrated,
or even display “catastrophic” reactions during a crisis. They
are often less able to adapt to changes in their environment.
It is recommended to try to minimize any changes in routine,
environment and daily structure for the residents with
dementia.
Below are some areas of concern for residents with dementia
that may require special attention during a major disease
outbreak or disaster along with some potential approaches:
1. Provide person-centered care One of the most important steps in providing quality dementia
care is to get to know the resident. In the event of a major
disease outbreak or disaster, this may be more difficult
for temporary staff members or those working in a new
department. It is recommended that a personal information
form, about each resident be completed and placed in an
easily accessible place, consistent with HIPAA guidelines.
For example, forms can be placed inside a closet door or in
a folder attached behind the door. This will allow temporary
or substitute staff members to quickly identify essential
information about the resident to help maintain a stable and
comforting environment. Information on the form can
include:
• What the resident likes to be called
• Cultural background
• Names of family and friends
• Past hobbies and interests
• Sleep habits
• What upsets them
• What calms them down
• Typical patterns of behavior
• Normal daily structure and routines
• Eating and drinking patterns and abilities
Sharing information learned about a resident with the care
team is very important in terms of providing consistent,
effective care. Given that the care team may change frequently
during a pandemic or disaster, resident briefing meetings at
the start of the shift will allow the staff to share pertinent
information.
2. Communication concerns Residents with dementia may need help to communicate with
their families during a crisis. In fact, it is recommended to
inform residents’ families ahead of time about what to expect
in case of a major disease outbreak or disaster. Facilities should
consider developing a “What You Should Know” fact sheet that
would explain how families can help improve compliance with
facility policies. For example, it might explain that instead of
visiting in person, families can schedule a telephone call to keep
connected and/or leave notes for the resident to read along
with photos. Facilities may also wish to offer to train volunteers
before a crisis hits. It is also important to ensure that adaptive
devices are available to the resident where appropriate, e.g.,
hearing aids and eyeglasses.
3. Nutrition and fluid intake concerns Residents with dementia may need assistance with eating and
drinking, which may include verbal, visual or tactile cues. It
is especially important for residents to maintain their strength
when there is risk of contracting influenza. Staff should
familiarize themselves with the resident’s eating and drinking
patterns and abilities. Residents may need to be reminded or
prompted to drink and eat throughout the day, as they might
not be able to recognize hunger or thirst. Sitting and talking
with the resident during meal times may improve intake.
Any evidence of difficulty in swallowing should be assessed
appropriately by nursing staff with pertinent consultation as
needed. (This may be difficult to address in a situation that has
caused a severe staffing shortage.) Licensed or trained personnel
should assist and monitor all residents who have been identified
as having a choking risk or a history of swallowing difficulties.
4. Wandering Wandering is aimless or purposeful motor activity that causes a
social problem such as getting lost, leaving a safe environment
or intruding in inappropriate places. The risk for wandering
may increase when residents become upset, agitated, or face
stressful situations. Possible interventions include:
• Provide residents with safe spaces to wander.
• Secure the perimeter of areas with security personnel or
security systems if possible.
• Ensure that residents get regular exercise.
• Provide structured activities throughout the day.
• If non-pharmacological treatment options fail after they
have been applied consistently, then medications may be
appropriate when residents have severe symptoms or have the
potential to harm themselves or others. Continued need for
pharmacological treatment should be reassessed as required
by the medication regimen or upon a change in the resident’s
condition.
5. Catastrophic Reactions A catastrophic reaction occurs when a situation overloads the
mental ability of the person with dementia to act appropriately.
An exaggerated response to the situation may include striking
out, screaming, making unreasonable accusations, or becoming
very agitated or very emotional. One of the first steps in
preventing and responding to a catastrophic reaction is to
identify circumstances that may trigger potentially catastrophic
behavior. It is useful to attempt to identify the root cause
of the behavior. Potential causes of challenging behaviors or
catastrophic reactions are as follows:
• Over-stimulation
• Inadequate attention
• Pain
• Hunger
• Fear
• Depression
• Inability to understand or misinterpretation of the
environment
• Panic reaction to an apparently new situation
• Inability to express thoughts or feelings
Strategies and interventions for responding to catastrophic
reactions and other challenging behaviors include:
• Do not physically force the person to do something.
• Speak in a calm, low-pitched voice.
• Try to reduce excess stimulation.
• Rule out pain as a source of agitation.
• Validate the individual’s emotions, i.e. focus on the feelings,
not necessarily the content of what the person is saying.
Sometimes the emotions being expressed are more important
than what is being said. Look for the feelings behind the
words. Affirming the resident’s feelings may help calm them .
• Understand that the individual may be expressing thoughts
and feelings relative to their own reality, which may differ
from generally acknowledged reality. The resident may be
reacting to an event from their past. Offering reassurance and
understanding, without challenging the resident’s words, can
be effective.
• Through behavioral observation and attempted interventions,
try to determine what helps reduce exaggerated reactions and
include this information in the resident’s individualized plan
of care.
Additional strategies and interventions may include: • Moving the resident to a quiet area; consider having rocking
chairs available.
• Sitting by the nursing station.
• Talking to particular staff or a special person.
• Relaxed breathing.
• Wrapping up in a warm blanket or placing a cool cloth on
their neck or forehead.
• Listening to music or a tape of a familiar person.
• Looking at pictures or a book/magazine.
• Exercising or taking a walk.
Prevention of catastrophic reactions can be difficult in a
changing or chaotic environment, however, applying some of
the following strategies may help:
• Regular verbal and written cueing to the environment can
help, especially for new residents.
• Provide a consistent routine.
• Reduce clutter.
• Encourage the family to provide comforting objects or other
familiar items from home.
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