Journal of Dementia
Open Access

The COVID-19 pandemic has significantly altered the framework of society in general, but it has been even harder on specialized organizations like dementia centers. SARS-CoV-2 infections pose cognitive decline pathways as supported by prevalent neurological symptoms in patients and long-term symptoms in recovered people, indicating that COVID-19 induced cognitive decline has the potential risk of worsening pre-existing dementia. The greatest cognitive risk is immune-mediated from cytokine storms that can target many organ systems including the brain which can impact cognition via cerebral ischemia and can also cause hypoxia, acidosis, and neuroinflammation [1]. As a result, behavioral and psychological symptoms of dementia are worsened due to feelings of loneliness, depression, and boredom [2]. Moreover, COVID-19 has created an opportunity to alter the historical structure of dementia centers to accommodate for patient isolation, social distancing, and staff turnover by highlighting the importance of matching patients’ needs with appropriate care models [3]. Challenges faced by long-term care facilities include infection control, staff resources, resource deficits, increased burden on formal caregivers, Medicaid reimbursement policies, financial constraints, and the decline of cognitive function among residents [2].

The James L. West Center for Dementia Care is the first comprehensive center for Alzheimer’s care in Fort Worth, Texas. The long-term care facility is notable for its unique mission of not only providing compassionate care to individuals with dementia but also supporting and educating their caregivers. As a result, the social distancing measures to curb the pandemic initially posed a challenge for the people-centered facility. In March of 2020, the center had ninety-two residents, nearing its maximum capacity of one hundred. In order to adjust to public health regulations, the center initially closed its day program, stopped in-person visitors, and moved to virtual caregiver education sessions to limit the spread of the virus in this susceptible group. A ten article meta-analysis with over 119,000 participants showed that the mortality rate of those with dementia after being infected with COVID-19 was higher than those without dementia, illustrating the dire need for prevention strategies within long-term care facilities [4].

A majority of family caregivers maintain care provisions for their family members living in dementia long-term care facilities; however, when these facilities closed their doors to visitors, caregivers’ alternative communication methods were not always effective. Family caregivers reported negative outcomes including social isolation, strain, and reduced quality of life. Patients with dementia showed an increase in dementia progression [5]. A cross-sectional study collected data six to ten weeks after the national visitor ban using a semi-open online survey that was administered to family caregivers of long-term care facility residents with dementia. Results showed that family caregivers who visited weekly prior to the visitor ban worried more during the pandemic than caregivers who visited less often before the visitation restrictions. Family caregivers felt that their relatives’ happiness and comfort were dependent on their presence. They felt anger, worry, helpless, grief, guilt, and failure, which were mitigated by telephone and video calls, both when they moved their family member into the facility and throughout the pandemic. Additionally, family caregivers who participated in more diverse activities with their loved ones before the visitor ban showed more resilience and less loneliness during the ban than those who did not. There was a unanimous agreement that national visitor bans should be avoided in the future, but in the case of the implementation of local visitor restrictions, every effort should be taken to help family caregivers maintain on-going contact with the family members [6].

In consideration of the negative consequences that result from isolation and social distancing, the James L. West Center for Dementia Care’s policies has evolved with the course of the pandemic as well. In June of 2022, the center housed ninety-six residents and drastically modified its visitation policy. There are no longer restrictions on the number of visitors for each patient, which is similar to pre-COVID times, and guest entertainers are welcomes for scheduled events. Nonetheless, the center is closely following guidelines and monitoring Tarrant County COVID-19 transmission rates, so all visitors must be masked. Guests fill out COVID-19 screening questionnaires on kiosks, have their temperature checked, and shoes sanitized. Large crowds on the units are also limited not only to curb the spread of the virus but also to avoid disrupting the daily activities of the residents. While the center still offers virtual support groups for caregivers, it also reopened in-person education sessions. The day program has also reopened to serve twelve people at once. Due to the massive increase in health regulations and policies, the additional COVID-19 procedures have become fully integrated into the daily operations, and a Compliance Director has been added to full time staff at the James L. West Center for Dementia Care.

An unexpected disadvantage of the pandemic has been enormous staff turnover. The center has seen at least a fifty percent rate of staff turnover throughout the pandemic, which is unprecedented. Staffs are now faced with additional responsibilities at work including infection control, stringent disinfection protocols, and fear of being infected themselves [2]. These unique challenges are further strained by increasing food and gas prices in the community, the deleterious effects on mental health, and the impact on the family if a staff member was infected by the virus. COVID-19 has been noted as a traumatic event with lifelong implications on mental physical, social, emotional and spiritual health. Three types of fatigue were endured by many: primary, secondary, and tertiary. Primary fatigue describes bio psychosocial feelings such as fatigue, sleep disturbances, chest pain, and shortness of breath, tightness in the throat, heart palpations, anxiousness, isolation, and despair. Secondary fatigue depicts sensory overload. People begin to function on “auto-pilot” and exhaustion. Economic resources are stressed and disproportionately affect vulnerable populations. The bio psychosocial feelings may heighten and lead to anger, irritability, panic, meaninglessness, and apathy. Tertiary fatigue references a diminished sense of one’s sense of control [7]. However, staff turnover has lessened at the facility since June of 2022. As the perception of COVID-19 has changed, fear and panic have been mitigated. The James L. West Center for Dementia Care center is currently completely staffed, which is unparalleled in the last two years since the start of the pandemic. Staff members’ optimism paves the way in finding a balance with managing the disease and in retaining a normal life.

Several lessons can be learned from the James L. West Center for Dementia Care’s approach to adjusting to the COVID-19 pandemic. Dementia care facilities should be designed to consider the resident, staff, caregivers, and the building itself. Large, over-crowded buildings with poor design and layouts, shared bedrooms and bathrooms, lack of colour, and poor lighting do not support an environment of autonomy and greater quality of life, so attention to detail to architecture and interior design is essential to foster a welcoming space for residents [8]. Proposed solutions to the challenges created by COVID-19 management include infection prevention strategies such as early detection, social isolation, source control, screening of visitors, environmental cleaning, and frequent disinfection of high traffic areas.

Virtual communication and care with family members and health care providers can reduce behavioral problems by mitigating anxiety and agitation. Telemedicine allows for remote monitoring, care, and follow-ups. Televisions, smartphones, tablets, and computers have been shown to reduce feelings of isolation by means of connecting residents to family and friends. A survey of one hundred residents of long-term facilities revealed a preference for receiving information via television [2]. Long-term care facilities need increased resources including nonpharmacological tools of technology for residents. Furthermore, training and pandemic preparation solutions include education and training for staff members and caregivers in order to equip personnel with the appropriate skills to manage both infection among residents and their behavioral and psychological symptoms. Proper training among staff can help reduce the burden among staff members, improve workflow, enhance quality of care, and advance safety for all. While the changes brought about by the COVID-19 pandemic to dementia centers has led to increased support of patient needs, government support is also needed. Decisive policy shifts must be implemented to reduce underfunding and discrepancies between public and private sectors, which have unfortunately led to a heavy death toll among nursing home residents in the United States [9]. In conclusion, the COVID-19 pandemic offers a chance for dementia centers to improve their patient care by incorporating adaptable policies, integrating virtual elements, and seeking local and national government support.

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