The health of vulnerable older people is under threat from both COVID-19 and the infection control measures implemented to protect them from serious illness and death.
Early in the pandemic, it became clear that frail older people with multimorbidity are at greatest risk of serious illness and death and must therefore be shielded from the risk of infection (1, 2). In Norway, most coronavirus-related deaths have occurred in nursing homes, and two out of three deaths associated with COVID-19 have been in the age group 80 years and older (3).
Published research on nursing home residents with COVID-19 is scarce, including internationally. In this issue of the Journal of the Norwegian Medical Association, Kittang et al. present three outbreaks at nursing homes in Bergen (4). The study provides an opportunity to highlight some medical, organisational and ethical aspects.
Older, frail people are less susceptible to the typical respiratory symptoms of COVID-19, but are more likely to experience atypical and non-specific symptoms, such as falls, delirium and reduced general condition. One-third of the 40 nursing home residents with confirmed SARS-CoV-2 in Bergen never developed symptoms of acute respiratory infection, and only one in four had a fever. In contrast, almost all had a marked decrease in general condition, half became confused and one-third either began to experience falls or had an increasing tendency to fall. The mortality rate was over 50 %. Age increases the risk of dying from COVID-19, but degree of frailty is a stronger indicator of the remaining physiological reserves and is an independent prognostic factor (1). It has therefore been suggested that the degree of frailty in all elderly patients with COVID-19 should be mapped (1, 2).
Almost all of the nursing home residents who died had respiratory failure. No patient should have to suffer in their final phase of life, and all are entitled to adequate palliative care (5). Healthcare personnel in the municipality must be prepared for how to alleviate suffering during a dyspnoea crisis and have easy access to real support from the specialist health service, for example in relation to decisions about treatment level and advice on palliative care (6).
A dignified death sometimes requires preparation. Advance care planning discussions with the patient and their family in a calm phase before the patient becomes acutely ill are important for clarifying the level of treatment and facilitating good end-of-life care. Decisions about any treatment limitations should not be based on chronological age alone, but also on the patient's personal preferences and degree of frailty (5).
Proper handling of COVID-19 outbreaks requires both increased staffing and sufficient expertise in dementia
Combining infection control with good dementia care can be challenging. Over 80 % of the COVID-19 patients in the Bergen study had cognitive impairments. Where there is a large number of infected and dying residents and a significant number of employees in quarantine, staff should establish new infection control procedures and safeguard 'good palliative care and measures to protect the dignity of the patient and their family' (7). Delirium and altered behaviour further complicate treatment and infection control measures (8). Infection isolation involves factors we normally try to avoid, such as the use of coercion, unidentifiable personnel in PPE and transfers to an unknown ward. People with cognitive impairments may have difficulty understanding infection control measures, and basic needs of vulnerable patients may need to be set aside. The study by Kittang et al. illustrates how proper handling of COVID-19 outbreaks requires both increased staffing and sufficient expertise in dementia.
The study shows the potential severity of outbreaks of COVID-19 in nursing homes, and reminds us of the balancing act that is now called for. Infection control considerations have been at odds with the patients' need to be with their loved ones at the end of life. Strict visitor restrictions to prevent infection and death have been necessary to protect those who are most vulnerable, but they have also had a major adverse impact on residents and their families. Fortunately, the current infection situation means that visitor restrictions in nursing homes can now be eased in order to prevent social isolation and loneliness (9).
The elderly are well cared for in Norway, but the pandemic has stretched the nursing home service to its limit and illustrated the need for more resources and higher staffing levels, as well as a high standard of medical and ethical competence.