Describe circumstances that may trigger potentially catastrophic


Planning for a Pandemic/Epidemic or Disaster: Caring for persons with cognitive impairment

Prepared by:

Alzheimers 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

Alzheimers Associations Campaign for Quality Residential

Care offers practice recommendations for long term care

facilities. The recommendations and information on training

can be found at:

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


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


• 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


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 residents 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 residents


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


• 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 individuals 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 residents 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 residents words, can

be effective.

• Through behavioral observation and attempted interventions,

try to determine what helps reduce exaggerated reactions and

include this information in the residents 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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