Worsening behavioural and psychological symptoms of dementia during the coronavirus disease 2019 pandemic

Abstract

During the coronavirus disease 2019 (COVID-19) pandemic, social distancing and home isolation have been practised to limit the spread of infection.1, 2 Unfortunately, changes in daily routines have had a tremendous impact on dementia patients and may worsen their behavioural and psychological symptoms of dementia (BPSD). We would like to share our clinical experience in managing three patients with BPSD. A 67-year-old man with early-onset Alzheimer's disease was admitted to hospital because of violent behaviour after he was unable to attend his day-care centre (DCC) during the COVID-19 pandemic. The patient had initially presented with episodic memory impairment 6 years earlier. 18F-fluorodeoxyglucose-positron emission tomography revealed hypometabolism over the bilateral temporoparietal lobes, and brain magnetic resonance imaging showed bilateral hippocampal atrophy. The score on the patient's most recent Montreal Cognitive Assessment, Hong Kong version, had been 2/30 (<second percentile). Before COVID-19 restrictions were implemented, the patient had been prescribed with memantine and rivastigmine and had visited a DCC five times per week.3 He was noted to be agitated, yelling, throwing objects, and being physically violent towards his wife and maid. Quetiapine was prescribed at 25 mg BD p.o. without effect. At the emergency department, the patient was uncooperative during the physical assessment. CXR showed no evidence of consolidation. Brain computed tomography was unremarkable. Blood tests showed no leucocytosis or electrolyte disturbances. The patient was given an intramuscular injection of haloperidol 5 mg before psychiatric admission. Unfortunately, he developed neuroleptic malignant syndrome with confusion, limbs rigidity, elevated creatine kinase (3635 U/L), and positive urine myoglobin. All antipsychotics were stopped, and bromocriptine was prescribed. Confusion and rigidity gradually resolved. Clonazepam 0.5 mg nightly and sertraline 25 mg nightly were prescribed for the management of his BPSD. Our patient has remained calm and no longer displays physical violence to caregivers. An 84-year-old woman with Alzheimer's disease was noted to have nocturnal wandering and increased prosopagnosia after isolation at home during the COVID-19 pandemic. She had initially presented with episodic memory impairment with temporal and spatial disorientation 2 years earlier. Vitamin B12, folate, and thyroid function were unremarkable. Brain computed tomography showed medial temporal lobe atrophy. The patient was intolerant to memantine and donepezil. The score on her most recent Montreal Cognitive Assessment, Hong Kong version, was 4/30 (<second percentile). Before the pandemic, she visited her DCC six times per week. After the closure of her DCC, the patient developed nocturnal wandering and searched for things repeatedly by opening and closing wardrobes, disrupting her daughter's sleep. Additionally, she became unable to recognize her grandchildren and mixed up her children. Physical examination was unremarkable with no evidence of delirium. Zopiclone 7.5 mg nocte and quetiapine 12.5 mg nocte were prescribed on a need basis. DCC has been reopened on 22nd May 2020 and after resuming usual DCC routines, nocturnal wandering has improved and sedating drugs were no longer needed at night time. A 99-year-old woman with Alzheimer's disease was noted to have dysphoria and agitation during isolation at home during the COVID-19 pandemic. The patient had initially presented with episodic memory impairment and anxiety symptoms, as well as with difficulties managing her medications 8years earlier. Vitamin B12, folate, thyroid function, and brain computed tomography were unremarkable. The patient was intolerant to memantine and donepezil. The score on her most recent Mini-Mental State Examination was 12/30. Before the COVID-19 pandemic, the patient's daughter used to take her on a walk in the garden every day. Because of home isolation, she was noted to have low mood and decreased appetite. She would become agitated and repeatedly hit the table or chair or stomp on the floor in anger. At hospital, quetiapine was increased to 25 mg nightly p.o. The patient's daughter was encouraged to practise reminiscence therapy with her mother using old photos. With these measures, agitation has become less frequent and more manageable. Because of the COVID-19 pandemic, DCC services in Hong Kong were closed on 27 January 2020, but they are now gradually resuming. From our experience, social distancing and home isolation disrupt the normal routines of patients with dementia, potentially causing agitation, wandering, prosopagnosia, dysphoria, and even violent behaviour. The unprecedented closure of the DCCs has greatly limited the opportunity for patients with dementia and their caregivers to engage in meaningful activities, get out of the house, and strengthen social connections, possibly worsening BPSD.4 In addition, informal caregivers may be under the dual stress of working from home and caring for a relative with worsening BPSD. With reduced access to non-pharmacological options via community services, patients, including our own, have had to resort to potentially harmful medications to manage their BPSD. Moreover, concerns have been raised about elder abuse during COVID-19 due to increased carer stress, but luckily this was not observed in our three patients.5 It remains unknown whether telecommunications or virtual reality technology may prevent the worsening of BPSD.1, 6, 7 In summary, the COVID-19 pandemic can worsen the BPSD of patients with dementia who require support in their daily lives. As such, we call for the community to provide continued support for patients with dementia and their caregivers during COVID-19 pandemic. The authors have no conflicts of interest to declare and received no funding for this report.