Coronavirus Disease 2019 and Dementia: Recommendation of the Korean Dementia Association

Coronavirus disease 2019 (COVID-19) has influenced every aspect of our lives. The importance of personal hygiene has been emphasized, and the awareness of the civil society regarding infectious diseases has increased. However, this change has created another dilemma. Quarantine is essentially based on social distancing.¹ The basic principle is to avoid possible contact among individuals. Meanwhile, dementia management is based on interpersonal contact in all aspects.² No patient with dementia can live alone. It was the basic goal and assumption of a national dementia policy to ensure that family support and community safety networks are working properly.³ Patients with neurological diseases, including dementia, may have low awareness of the first symptoms of COVID-19 due to atypical presentations.⁴ In addition, dementia is thought to increase the risk of developing COVID-19.⁵

Since 2008, through the Comprehensive National Dementia Plans, South Korea has been implementing a community-based dementia management policy based on more than 250 dementia centers nationwide.⁶ Since September 2017, the government has maintained the direction of dementia policy, which calls for “the nation to take care of dementia patients,” through the “National Responsibility Policy for Dementia Care.”³ Through these policies, the government intervenes in the entire disease cycle from prevention, early detection, treatment, and terminal care. This intervention presupposes an interindividual relationship. However, the policy is inevitably retreating to the past due to quarantine.

Due to a series of changes related to quarantine, we have recently found a deterioration in the condition of patients with dementia in daily practice. It is a situation where “the person who walks sits and the person who sits is lying down.” Cognitive-enhancing classes in the community dementia center, which have been difficult to build over the years, and various programs to maintain daily activities for patients with dementia have been suspended. Patients with dementia are isolated at home, and information on programs to care for them at home is limited.

In such situations, societies and organizations on Alzheimer's disease in several countries have published various recommendations and reference materials.⁵,⁷ The Korean Dementia Association recently released recommendations for patients with dementia and their caregivers considering the situation of COVID-19 and dementia in Korea.⁸

There are three main points in this recommendation. These include 1) maintenance of daily routine, 2) preparation for sudden situations, and 3) application of quarantine rules for individuals with dementia.

Daily life is important for patients with dementia. Due to limited cognitive function, many patients with dementia cannot easily adapt to sudden lifestyle changes. There is anxiety, agitation, and fear of changes in family members, changes in residence, and unfamiliar environments. Maintaining a regular schedule enables future predictions and can help reduce anxiety in individuals with dementia. If the patient cannot visit usual meetings or day care centers and are isolated within the home, it is difficult to maintain proper interpersonal and physical/cognitive activities, which can lead to aggravation of dementia symptoms. Therefore, it is necessary to conduct methods to cope with such a situation even if it is limited. It may be helpful to create a timetable to maintain a daily routine, avoid oversleeping, and participate in simple cleaning and cooking in the home. It is also necessary to maintain proper physical activity. In addition to walking around the house, indoor exercise methods provided by the National Institute of Dementia can be performed (https://www.nid.or.kr/info/dataroom_view.aspx?bid=121).

It is also important to maintain cognitive activities considering the patient's usual interests. Growing flowers and pets and maintaining interesting activities can be helpful. Some community dementia centers maintain cognitive activities online without face-to-face contact. Although the aforementioned National Institute of Dementia provides cognitive activity programs online, it requires active participation of caregivers in order to be helpful to patients (https://www.nid.or.kr/info/dataroom_view.aspx?bid=161).

Patients who reside in nursing homes are often isolated due to concerns on infection. In this case, it is necessary to maintain regular online contact with a person close to the patient to prevent emotional problems, such as anxiety, irritability, and depression. It can be helpful to see the faces and listen to the voices of acquaintances through a video-call platform and stay in touch. Conversely, COVID-19-related news should be limited to 1–2 times a day so as not to be overly negative.

Many patients with dementia require constant care from caregivers and are often dependent on specific caregivers. Therefore, it is necessary to prepare for sudden isolation of the patient or primary caregiver. When patients are hospitalized, preventive measures against delirium are necessary. It is important to prepare necessary items in advance, such as items the patient is attached to, items related to activities they like doing (books, earphones with iPod, etc.), and shoes that are not slippery to prevent falls. If it is difficult to visit the hospital after admission, it is necessary to set a turn for video calls and ensure that the patient does not feel isolated.

It is also necessary to set the order in which family members may care for the patient in case the primary caregiver is suddenly quarantined or hospitalized. If the patient does not have other family members, it is recommended to consult the local dementia center or call center of the National Institute of Dementia to discuss caring-related measures (+81-1899-9988).

Patients with dementia have difficulty in properly memorizing and performing personal hygiene guidelines due to decreased cognitive ability. Accordingly, it is necessary to simplify the personal hygiene procedure, remind it repeatedly, and adjust the surrounding environment to facilitate execution. Handwashing should be performed for at least 30 seconds before and after going out and during activities, but it is important to prepare conditions so that patients can remember and perform it easily. It can be helpful to put stickers that are clearly visible in front of the bathroom door and mirrors, front doors, etc., describing how to wash the hands and how to wear a mask. It is also necessary to show caregivers washing their hands and encourage patients to follow along. Many patients have difficulty entering the bathroom due to the risk of fall and washing their hands with soap and water. If patients are unable to wash their hands easily, hand sanitizers containing >60% alcohol can be used to facilitate hand hygiene.

When going out, risk of infection should be minimized by securing social distance to avoid crowded places or time zones. It is recommended to wear a mask when going out, but if patients repeatedly take off and touch the mask due to cognitive decline, it is difficult to expect the desired infection prevention effect. It is necessary for a caregiver to assist the patient in wearing the mask so that the mouth can be properly covered. Patients with underlying respiratory and/or cardiovascular disease should consult their physician about wearing a mask and avoid working outside at a long distance while wearing a mask. In the case of these patients, if a distance of >2 m is possible, health authorities suggest that wearing a mask is unnecessary. If there are individuals entering from outside (such as a nursing care provider), symptoms, including fever, should be checked, and a mask should be worn during the visit.

If a patient with dementia suddenly becomes confused, it may be the first symptom of COVID-19. In this case, consultation with a medical staff is necessary.⁹,¹⁰,¹¹

For these recommendations to be effective, specific and detailed content and countermeasures for each situation are needed. To maintain the daily routine, the content of specific exercise and cognitive activities must be continuously and easily accessible. Caregivers should be able to access information without difficulty, and there should be many alternatives that can be selected according to patients’ age, sex, educational level, and physical level. To this end, the academic society and government must be able to continuously supply qualified services with scientific evidence, and a platform that can mediate them is also needed. A good example would be the “Il-Sang-Ye-Chan” (which means an “admiration for everyday life” in Korean), which the Korean Dementia Association and National Museum of Modern and Contemporary Art continue to conduct as a collaborative project. In the United States, the Alzheimer's Association plays a role as a mediator between these program providers and patients and even specifies the appropriate patient population. In preparation for the post-corona era, Korea will also need to establish a platform that connects various nonpharmaceutical treatment methods suitable for the patient's situation.

Crisis can be another opportunity. The era of COVID-19 is clearly a threat to patients with dementia. However, if we reconfirm that the dementia policy to date is appropriate and set the policy according to the changing times, it will be the first step toward becoming a country leading in dementia prevention and care.