Alzheimer Disease and COVID-19

CLINICAL Q&A

During this unprecedented time, many individuals with Alzheimer disease (AD) are homebound with their caregivers. How can clinicians help caregivers deal with common dilemmas under stay-at-home orders? We spoke with Marc Agronin, MD, a geriatric psychiatrist and Senior Vice President for Behavioral Health and the Chief Medical Officer for MIND Institute at Miami Jewish Health.

Psychiatric Times: How can clinicians advise caregivers to help them and their loved ones get through this time?

Marc Agronin, MD: In one word-routine. Remind caregivers it is important to have a set routine each day that is predictable, stimulating, and involves regular exercise, fresh air and sunlight, whether in one’s yard, on a balcony or within a safe perimeter around the home. They should have a set time to wake up, have meals, listen to music, play games, and have social contact with others, either by phone, video chat, or at a safe social distance.

Everyone in the home should get dressed each morning in daily clothes and attend to one’s hygiene as if it is a regular day. They should make certain to get adequate hydration and healthy meals with fruits and vegetables and enforce a regular bedtime. It is also important to avoid excess time watching the news.

Psychiatric Times: How can psychiatrists help caregivers deal with behavioral disturbances at home, without the possibility of having an in-person doctor’s appointment?

Marc Agronin, MD: This is a challenge. When any behavioral disturbances occur, query the caregiver to generate several ideas on what may be the underlying causes: Boredom? Anxiety from watching news about the pandemic on TV? Lack of physical or social stimulation? Underlying pain or discomfort? Discordant interactions with other people in the home? Having some idea of what may be triggering the behaviors can provide immediate solutions.

Caregivers should be counseled to provide a set daily routine as described in the first question. They should be advised to reach out to their internist if they suspect a physical cause, and to you or your office (perhaps with a telehealth option) if they have safety concerns or questions about behavioral changes or psychotropic medications. There are simple de-escalation strategies (eg, deep breathing, distractions) and PRN medication options that can be provided. Finally, help them to feel calm, engaged with the affected person, and hopeful that things will improve.

Psychiatric Times: What approaches can help to relieve anxiety among caregivers and individuals with neurocognitive impairment?

Marc Agronin, MD: Anxiety is a common problem during the pandemic, with people worrying about getting ill, obtaining necessary goods, losing income, or being isolated from other people and activities. Anxiety may present in many ways in someone with cognitive impairment, including mood changes (nervousness, sadness, irritability), sleep and appetite disturbances, physical symptoms (eg, headache, indigestion, muscle aches, or even minor shortness of breath or chest pressure that they misinterpret as coronavirus symptoms) and social isolation. It is important to recognize these symptoms as anxiety and rule out anything more serious. Providing the opportunity for people to describe how they are feeling and vent about their concerns will help, and this can be done over the phone or on a video chat.

Educate caregivers about several simple approaches to relieve anxiety in themselves and the cognitively impaired person, including deep breathing/relaxation techniques, stretching and exercise, fresh air and sunlight, and fun and stimulating activities to distract one’s mind. Some individuals may have more serious symptoms of anxiety or even panic, and will need pharmacologic intervention, especially if there is a history of anxiety or mood disorders or psychosis. Tailor the medication to the symptoms using established regimens, being careful to avoid side effects that can be more difficult to manage over the phone.

Psychiatric Times: What should you say to participants in a research study which has been suspended?

Marc Agronin, MD: Nearly every study for AD in the country has had to be either suspended or delayed because of stay-at-home orders, closed sites, or the inadvisability of conducting in-person visits. It may be months before study procedures can be up and running again. This is unfortunate, but necessary, and will require significant alterations in study procedures.

The FDA is aware of these gaps and have provided guidance to study sponsors. If you are a principal investigator, you will have already been informed by each study sponsor about its status and what to communicate with subjects. If you have a patient who is in a study, encourage them to stay in touch with the study coordinator and/or principal investigator to find out what to do about study medications, and whether any study procedures can be conducted by phone or video.

Psychiatric Times: What should you advise caregivers for individuals with neurocognitive impairment who have difficulty understanding and cooperating with social distancing?

Marc Agronin, MD: First of all, it is important to remind all caregivers to follow stay-at-home orders and not make any trips to stores or anywhere else with someone who does not understand or follow the rules of social distancing, as that will put them and others at an unacceptable risk of exposure to the coronavirus. A cognitively impaired patient who resists wearing a mask properly or approaches others too closely may cause unpleasant social interactions.

This issue will become even more important when rules are relaxed but most people will be out in public wearing masks and still social distancing from one another. If the cognitively impaired person cannot understand or follow the rules, you will need to counsel the caregiver to keep them at home. If the person can understand the rules, you can advise the caregiver to remind them before and during each outing and provide them with a comfortable facemask that will not cause them to unnecessarily touch their face to adjust it.