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H. Tan1, A.X. How2, X.X. Wang2, J.E. Lee3, W.S. Lim4,5


1. Woodland Health Campus, Pre-Operations, Nursing, Singapore; 2. Tan Tock Seng Hosptial, Nursing, Singapore; 3. Woodland Health Campus, Pre-Operations, Medicine, Singapore; 4. Tan Tock Seng Hospital, Department of Geriatric Medicine, Singapore; 5. Tan Tock Seng Hospital, Institute of Geriatrics and Active Ageing, Singapore

Corresponding Author: Hongyun Tan, Woodland Health Campus, Nursing Service, Level 5, Tower E, 2 Yishun Central 2, Singapore 768024, Phone: +65-97688748 , Email: hongyun_tan@whc.sg


Dear Editor,
The double whammy of dementia and coronavirus disease 2019 (COVID-19) has raised huge concerns for healthcare systems which are already struggling to cope with care demands of persons with dementia (PWD) in non-pandemic times (1). PWD who are admitted to acute care services are particularly vulnerable to behavioural changes and adverse outcomes from delirium (2, 3). During the COVID-19 period, ward relocation is frequently encountered due to COVID-19 screening and segregation; this constant changing of environment and care teams puts PWD at risk of behavioural exacerbations. This is aggravated by restrictive visitor policies in hospitals, depriving PWD of the reassuring presence of family members. Not surprisingly, caring for persons with dementia (PWD) with behavioral issues in acute care settings has become extremely challenging.
Traditionally, behavior management was taught in face-to-face settings with multiple pedagogies, including didactic talks, group discussions, and role play. The advent of COVID-19 has spurred innovations in teaching methods to circumvent challenges in continuous professional education due to a lack of face-to-face interaction. User-friendly acronyms which can be easily shared via a group chat, is one way to share tips about caring for PWD with challenging behaviors. In this letter, we share the E-VADE acronym (Table 1) to help frontline nurses manage challenging behavior issues in PWD during the COVID-19 pandemic.


Evaluate unmet needs: The 5Ps

Behaviors in PWD are often the expression of unmet needs with decreased ability to communicate these needs or to provide for oneself (4). For instance, discomfort from difficulty in micturition and defecation from prolonged immobilization may lead to new-onset agitation, which can be erroneously attributed to ‘adjustment’ to the hospital environment. Thus, the evaluation of unmet needs constitutes the cornerstone of behavioral management. We, therefore, propose the 5Ps mnemonics to help frontline nurses remember the areas of unmet needs, namely pee (passing urine), poo (opening bowels), pain, pruritus, and physical restraint. The use of physical restraints violates the basic human needs of dignity and comfort, and can paradoxically lead to increased levels of agitation (5). When confronted with unprovoked behaviors in PWD, the nurse should evaluate using the 5Ps and administer specific measures to address identified needs.

Table 1
EVADE mnemonic for managing with challenging behaviours


The sequence of managing behavior: VADE

In behavior management, it may be tempting to immediately offer activities in an attempt to calm the PWD. However, it is unlikely that the PWD will cooperate if others do not validate their inner feelings, or if they do not feel safe. We therefore propose VADE (Validation, Accommodation, Distraction, and Engagement), a theory-guided and logical sequence to guide nurses in managing challenging behaviors. Case discussion via group chat in relation to EVADE is helpful for the consolidation of learning and clinical application.
Validation therapy has been developed by Naomi Feil for older persons with cognitive impairment. Validation encourages the caregiver to listen to the PWD, connecting with them through empathy; and it de-emphasizes the importance of orientating facts to the confused PWD (6). In the mal-orientation stage, validation therapy helps explore the introspective meaning and motivation for confused expressions from the PWD (7). Simply put, validation encourages the caregiver to step into the PWD’s shoes to understand the world from their perspective.
For instance, a wandering PWD will not sit down for dinner if the caregiver does not understand that “she is anxious as she is in a hurry to go and pick up her young child from school.” Adopting their perspective, we can understand the anxiety and worry of a mother for her young child. Empathetic words like “You must be worried for your child” will convey empathy and help connect with the confused PWD.
Accommodation means to provide measures to allay the PWD’s anxiety and fear, such as informing her that “I received a call that your daughter had already gone home” or “I will help you hail a cab.”
Distraction from the current topic will help de-escalate the situation. Distraction can be carried out via conversation or activities, such as “What is your daughter’s favorite food?” or “Do you mind sharing with me your recipe?”
Engagement involves the use of individualized therapeutic activities when the PWD is calmer. It is important to keep in mind that the VADE sequence is iterative instead of linear, such that it may be necessary to revisit validation and accommodation steps before the PWD is ready to be engaged. Therapeutic recreation activities such as music, art, and handcrafts are beneficial for PWDs as they improve self-esteem, increase mental stimulation, enhance positive sleep habits, and minimise behavior changes (8). It is important to understand the hobbies, occupation and recreational activities of the person in order to match the appropriate activity. A therapeutic box is made available in the ward for nurses to use, and it contains useful activity items such as puzzles, cards, and threading beads.



The COVID-19 pandemic has disrupted many of our lives, but it has opened a new channel for innovative ways of teaching. The E-VADE acronym provides a quick and easy approach for frontline nurses to systematically evaluate and manage challenging behaviors in PWD patients, and thus evade the harmful impact of inadequate or inappropriate management of such behaviors.


Acknowledgement: The authors would like to thank nurses from Woodland Health Campus, pre-operation wards and Tan Tock Seng Hospital for their team effort and support, particularly to: Sister Kala, Chee Lien, June Kue, Fauziah, Esther Tan, and D88 nurses from Woodland Health Campus, and Siah Cai Yun from Tan Tock Seng (in no specific order).
Conflict of interest: No conflict of interest.



1. Lim WS, Liang CK, Assantachai P et al. COVID-19 and older people in Asia: Asian Working Group for Sarcopenia calls to actions. Geriatr Gerontol Int 2020;20: 547-558.
2. Wang H, Li T, Barbarino P et al. Dementia care during COVID-19. Lancet 2020;395:1190–1191.
3. Aprahamian I, Cesari, M. Geriatri syndrome and SARS-COV-2: More than just being old. J Frailty Aging 2020;9: 127-129.
4. Cohen-Mansfield J, Dakheel-Ali M, Marx MS, Thein K, Regier NG. Which unmet needs contribute to behavior problems in person with advanced dementia? Psychiatry Res 2015;228: 59-64.
5. Werner P, Cohen-Mansfield J, Braun J, Marx MS. Physical restraints and agitation in nursing home residents. J Am Geriatr Soc 1989;37:1122-1126.
6. Feil N. The Validation breakthrough: Simple techniques for communicating with people with “Alzheimer’s-type dementia.” Baltimore, MD, US: Health Professions Press, 1993.
7. Feil N. V/F validation: The Feil method. Cleveland, OH: Author, 1982
8. Cohen-Mansfield J, Marx MS et al. Can agitated behaviour of nursing home residents with dementia be prevented with use of standardized stimuli? J Am Geriatr Soc 2010;58:1459-64.