key: cord-0705391-rtgopiug
authors: Rolland, Yves; Baziard, Marion; De Mauleon, Adelaide; Dubus, Estelle; Saidlitz, Pascal; Soto, Maria Eugenia
title: COVID-19 in older people with cognitive impairment
date: 2022-03-21
journal: Clin Geriatr Med
DOI: 10.1016/j.cger.2022.03.002
sha: 7984b9437bc5b5c3aa6df188a5069e421cbf50bb
doc_id: 705391
cord_uid: rtgopiug

Patients with cognitive impairment have paid a heavy price for the COVID-19 pandemic. Their clinical characteristics and their place of life made them particularly exposed to being contaminated and suffering from severe forms. The repercussions of the isolation measures also had significant repercussions on the expression of their neuropsychiatric symptoms and the burden on families and health care professionals.

Dementia affects approximately 50 million people worldwide and this number is predicted to triple by 2050. Dementia is a disease with significant and prolonged repercussions on the patient and their family and a huge cost for the community. 1 The combined impact of dementia and the COVID-19 pandemic have raised serious concerns about people living with dementia. Faced with the COVID-19 pandemic, the population of patients suffering from dementia has been shown to be particularly vulnerable to contamination, and to the severity of the disease. The application of health measures has proved particularly difficult to apply in the community as in hospital units or in nursing homes (NH). Caregivers were challenged to ensure quality care in difficult conditions combining the application of appropriate health measures for the safety of all and individual respect for human dignity and ethical rules of care.

This narrative review aims to report current data on the pandemic in the population affected by dementia. After having summarized the epidemiological data on the increased risk of contamination and death in this population, this review will successively discussed (i) the behavior consequences of the social isolation and distancing measures (lockdown) such as anxiety, delirium, depression as well as the challenges of dealing with the wandering/pacing behavior, (ii) the current strategies including vaccination to face the epidemy in the dementia population, (iii) COVID-19 as a risk factor for cognitive decline and dementia, (iv) the burden of dementia for caregivers, social support during the pandemic, (v) the ethical issues including the advance directives and decision making for hospitalization or resuscitation of dementia patient with COVID, (vi) palliative care and the critical need for advance care planning and finally (vii) care for dementia patients living in nursing homes (NH).

From the first wave of COVID-19, the dangerousness of the COVID-19 pandemic in patients with dementia worried the medical community. 2, 3 Epidemiological data quickly highlighted the increased risk in patients suffering from dementia, not only of contamination but also of severe forms, with a frequent need for hospitalization and a high risk of death [3] [4] [5] [6] and specific complications related to their behavior disturbances.

The most recent meta-analysis on the risks associated with COVID-19 contamination 3 and grouping together nearly 46,391 dementia patients suggests that suffering from dementia increases by 2 to 3 the risk of contracting COVID-19 compared to subjects of comparable age (RR = 2.7; 95% CI [1.4-5.3] ). Some researchers even report in studies carried out at the start of the epidemic, a significantly higher increase in risk among dementia subjects (RR = 8.5; 95% CI [5.0-14.5]) 7 . This increased risk of contamination can be explained by the difficulty in applying protective measures and in particular in wearing the mask while living in an environment where many healthcare professionals circulate as well as other potentially sick patients who do not observe the protective measures. 5 A meta-analysis was published in May 2021 6 to evaluate factors associated with mortality in older adults with COVID-19. After adjustment, dementia was an independent risk factor for death (RR = 3.6; 95% CI [2.4-5.5] ) significantly higher than other classically recognized pathologies as a risk factor for death ( [1.5-3.1 ] ). This excess mortality of dementia patients has been observed in particular in patients living in NH. 5 Another meta-analysis published in 2021 3 , grouping 24 studies, also confirms that dementia is a risk factor for severe COVID-19 (RR 2.6; 95% CI [1.4 -4.9] ), and excess mortality by COVID-19 infection (RR 2.6; 95% CI [2.04 -3.36] ). In the United Kingdom, data from a large community cohort show that the risk of hospitalization for COVID-19 is around 3 times greater in dementia subjects than in nondementia subjects. 7 There are many reasons for the severity of the disease in dementia patients. 8 Patients with dementia are often very old, multi-morbid and their functional reserves are low, which translates their frailty that limits their ability to cope with a potentially serious infection. 9 However, even after adjusting for these confounding factors, dementia remains a risk factor for severe COVID-19. The atypical clinical expression of patients infected with COVID-19, such as confusion can also lead to diagnostic and therapeutic delay. 10, 11 Bianchetti et al. reported in a cohort of dementia patients infected with COVID-19, that delirium was the most frequent presenting symptom on arrival at the hospital. 12 Delirium is an independent well-known risk factor for mortality and adverse outcomes in older adults. Various authors have reported that dementia was associated with more unspecific symptoms and less clinically detected dyspnea. 12, 13 More specifically linked to Alzheimer's-type disease, carrying the ApoE4 genotype, a genetic factor associated with an increased risk of the disease, has been reported as a risk factor for more severe COVID-19 infection. 14 The modulatory function of AoE4 on the cells of the inflammatory response, especially in the lungs, could be the explanation. 15 ApoE4 contributes to the production of pro-inflammatory cytokines by macrophage and may potentiate the cytokine storm seen in severe forms of COVID-19. 16 Finally, during the epidemic, the health of dementia patients depended more than ever on caregivers who were sometimes left out of care to limit the spread of the virus or affected by COVID-19 themselves. The impact of the reorganization of patient support, and social isolation measures (lockdown) that are often difficult for patients to understand, has potentially affected their health status 17 and help decompensate pre-existing chronic diseases of patients with dementia more than others. 18 The negative effects of the measures taken around the world to control the spread of the virus have certainly been more derogatory in dementia patients. 9 Various studies point out that people with dementia have increased their psychiatric symptoms and behavioral manifestations caused by social isolation. 19 Loneliness at home or in NH has facilitated the onset of confusion and may have resulted in agitation. Many healthcare providers intervene with dementia patients living at home. The epidemic has often constrained or reduced the fragile balance of the organization of essential human care for maintaining patients at home. [17] [18] [19] [20] Neuropsychiatric symptoms of dementia patients during the outbreak Since the beginning of 2020, social isolation and distancing measures have been imposed on several occasions. These periods of confinement have led to a significant increase in psychological distress such as anxiety or depression in the general elderly population. 19 In the NH, residents had a higher risk of infection by COVID-19 than the population living at home and were also confronted with the absence of their relatives, the limitations of activities and social interaction. 19 Recent literature undeniably shows that the outbreak has increased neuropsychiatric symptoms (NPS) in people with and without major neurocognitive impairments. 8 This increase would be more important in subjects with dementia. 19 Moreover, outbreak measures have been responsible for an increase in NPS in more than a quarter of subjects with dementia and a worsening of symptoms in more than half of them. 21 Whiting et al. highlighted that the severity of NPS measured by the Neuro-Psychiatric Inventory (NPI) increased significantly since the beginning of the outbreak and especially during periods of lockdown. 22 In subjects with major neurocognitive impairment, apathy appears to be the most frequently found NPS. Anxiety and agitation would be the second most frequent NPS. 23 In contrast, irritability, apathy, agitation, and anxiety would be the most frequently worsened NPS in this population. 21 Finally, anxiety and sleep disturbances were reported to be higher in subjects with dementia living alone at home. 24 In several studies, agitation and aggression were more severe than other NPS with a high impact on professional and family caregivers 8, 19, 21 . An Argentinean study suggests that NPS: anxiety, depression, and sleep disorders occur more frequently in subjects living in the community with mild Alzheimer's disease compared to more advanced stages of the disease. 25 An Italian study focused on subjects with vascular dementia living at home. It would seem that these subjects have more severe NPS overall and that the most frequently found NPS were anxiety, delusions, hallucinations and apathy. 26 Patients with Lewy Body Disease seemed to have a preference for anxiety, sleep disorders and, to a slightly lesser extent, hallucinations. 21 In frontotemporal lobar dementia, the most frequently increased NPS would be wandering and eating disorders. 21 In NH, eating disorders have also been more frequent during the outbreak and notably during periods of lockdown. 23 On the other hand, the increase in mood disorders was found inconsistently, mainly in association with social isolation and the loss of family contacts at home or in the long-term care facilities. 27, 28 Finally, psychotic disorders appeared to be the least impacted by the outbreak. 12, 19, 21 The main hypotheses trying to explain the increase and worsening of NPS would be social isolation and distancing measures resulting from successive lockdowns 23 , the abrupt absence of professional interventions and the outpatient care (respite day care, rehabilitation services) and, to a lesser extent, the COVID 19 infection itself. 19, 25, 26 A small number of studies seem to suggest that delusions would be the NPS most frequently found in hospitalized dementia subjects infected with COVID-19. 12, 19 In the long-term care facilities, social isolation, limitations of activities, in particular the sharing of meal times, and the absence of family members, explains, to a large degree, the increase in NPS. 23 Longer periods of lockdown appear to be the major cause of more severe NPS, particularly in the apathy of individuals with Alzheimer's disease living at home. 27 Some experts have suggested that NPS secondary to periods of lockdown may become chronic. 19 On the other hand, during these same lockdown periods, family caregivers of patients with major neurocognitive impairment also presented more NPS such as anxiety, mood or sleep disorders, and eating disorders 29 . One study suggests that some NPS such as depression in informal caregivers may cause NPS to emerge in subjects with dementia, and symptoms such as anxiety and depression in informal caregivers may exacerbate pre-existing NPS. 30 

Finally, several studies have highlighted that the most common response to increased NPS during lockdown and outbreak periods has been increased prescribing of psychotropic medications. 21, [25] [26] [27] 

Patients with dementia, particularly the elderly, are one of the most vulnerable population facing COVID-19 infection. This population often suffer from sensorial deficits and perceptions troubles, including visual and hearing difficulties and the inability to recognize or understand their environment and so, to adapt to them. This is even more important with the mask wearing measures. In addition, COVID-19 social isolation measures led both to a greater psychological distress and at the same time, to a minor cognitive and functional stimulation in the dementia patients. As consequence, cognitive decline has been shown to be exacerbated by the pandemic. [31] [32] [33] More specifically, memory, orientation, motor abilities and language skills seem to be the most affected cognitive domains in these patients. 34 On the other hand, it is known that COVID-19 infection may have an impact in neurological functioning resulting in worsening cognitive decline even in patients free of dementia and so, in patients with dementia. The potential mechanisms underlying these symptoms are not fully understood but are probably multifactorial, involving indirect "pro inflammatory general state" and direct neurotrophic effect of SARS-CoV. 35 Neurotropism is associated with various mechanisms including retrograde neuronal transmission via olfactory pathway, a general hematogenous spread, and the virus using immune cells as vectors. 35 Lessons learnt from this pandemic show that further crisis and emergency phases should not neglect the multiple needs of patients with neurocognitive disorders and that a special support will be urgently necessary to be addressed to these patients in order to avoid decline in cognitive functions hallmark symptoms of Alzheimer's disease and related disorders.

People with dementia suffering from COVID-19 infection are a higher risk of severe forms, longer hospitalizations and high mortality rates. 36 On the other hand, social isolation and distancing, face mask, proper hands and other anti-COVID-19 measures, often become extremely difficult to be respected due to patients' cognitive and behavioral disturbances. Therefore, given these negative health outcomes and difficulties, these patients should greatly benefit from the COVID-19 vaccine, and they should be considered as a health priority in vaccination campaigns in both living settings: community-dwelling and in NH. However, they might need the encouragement of health professionals and families to become vaccinated. Proxy and professionals' preferences regarding vaccination for this group are, therefore, extremely important to increase the use of this preventive measure. 37 Nevertheless, concerns still arise from safety of these news vaccines in this population with neurocognitive disorders. 38

"Stay at home measures", mainly lockdown periods and social isolation during COVID-19 crisis have had an important negative impact in patients with dementia. In fact, health J o u r n a l P r e -p r o o f outcomes such as functional, cognitive and behavioral ones and, finally quality of life, have significantly worsened in this vulnerable population over this pandemic. 8 The main reason is that patients with dementia have suffered all the "collateral sides effects" of COVID-19 measures; firstly, by cancelling many ambulatory and outpatient activities and/or planned hospitalizations, these patients lacked of their regular disease follow-up and care at his family doctor or at the memory specialist. In addition, decompensation of other chronic conditions or emerging acute diseases were not be able to be correctly managed 39 . Secondly, all care activities provided to patients with dementia such as daily home care, respite day care, home professionals like physiotherapist, logo therapist or mobiles teams diminished their interventions or event were disrupted because of COVID-19 measures. As consequence, patients' disease has worsened in terms of cognitive and physical decline but also in behavioral and psychological disturbances. This negative impact has been also observed in caregivers who were facing the disease alone. However, the challenges posed by COVID-19, have led to develop and bring innovation in terms of providing care -whether that be telemedicine, the development of new online tools, and getting treatment within one's home. 40 In fact, COVID-19 pandemic has been an accelerator of implementation of new technologies applied into care management of patients with dementia and their caregivers. This has been notorious in the implementation of teleconsultation; being a tremendous advance. 41 Patients and caregivers were extremely grateful and relieved that health professionals "were still there". Although there are several limitations to teleconsultation, patients and caregivers have well accepted this new way of interaction and follow up. Nowadays, health professionals, mainly physicians, still use this way of care in complementation to the traditional follow-up consultation, especially in cases such severe dementia and behavioral disorders. Concerning the future, this experience has opened many doors and provide new possibilities to enhance follow up based on telehealth and being complementary to the classical inperson consultations for patients with dementia. For example, monitoring alerts first signs of cognitive decline, or risk for falls, or risk for behavioral disturbances is an important challenge for future tele monitoring tools in order to implement preventing interventions, or to monitor pharmacological treatment both tolerance and efficacy. Concerning caregivers, in the same manner, new tools addressed to them could be used to enhance their training or support. Indeed, monitoring alerts first signs of high burden, depression or health problems could allow to implement preventing interventions in caregivers. Finally, COVID-19 and these new technologies have allowed novel ways of providing care much closer to patients and caregivers, towards a home care centered model for dementia, far away from the hospital centered model.

Major neurocognitive disorders 42 , led by Alzheimer's disease 43 , are the cause, according to their definition, of a loss of independence on instrumental and fundamental activities 42 of daily living. These disorders can also be associated with behavioral disorders 44,45 as discussed above. Thus, these symptoms can cause a burden on caregivers. This burden causes psychological [46] [47] [48] and physical 47 stress for caregivers, which can lead to institutionalization for patients. 49 The COVID-19 pandemic has caused many disturbances. First, due to the high mortality rate of COVID-19, especially in the elderly 50 , and the lack of an effective specific molecule or vaccine, most countries in the world implemented social distancing and home confinement measures to avoid gatherings and thus the spread of the virus. 51 Second, the health situation has caused indirect effects on formal and informal caregivers and the health system they rely on. Indeed, several care procedures considered non-urgent were temporarily suspended 52 , centers closed 53-55 , health professionals sick or having to modify their schedules to cope with their own difficulties and telemedicine was promoted. 40, 56 In the general population, these measures contributed to mental health problems 57 , a decrease in physical activity and thus an increase in sedentary behaviour. 58 For people with major neurocognitive disorders, it may have been difficult to understand the health situation and, more specifically, to implement social distancing measures 59 , which may have led to an increase in behavioral problems and a loss of functional independence in the activities of daily living. 33, 60 The caregivers, sometimes still working, have had to adapt their workstation, for example by teleworking. Most of the time, they have had to cope with increased financial stress while continuing to manage their family and their sick loved one. Indeed, several studies show that the health situation related to COVID-19 caused an increase in caregiver burden and a decrease in their well-being 33 , an increase in caregiver exhaustion 32 , an increase in stress levels 61, 62 with an increase in anxiety 63 , particularly about transmitting the infection to their relative 53 and finally an increase in depressive symptoms. 64 In addition, older caregivers appear to have been the most vulnerable to this increase in stress. 53 Finally, the burden was greater the more advanced the stage of neurocognitive impairment was. 65 In order to reduce the burden of the caregiver, several researchers have worked on proposing concrete solutions. For example, the work of Ercoli's team has put forward 3 approaches to limit the stress and burden related to COVID-19: first, education about COVID-19. The second approach is stress prevention by maintaining daily routines, especially sleep, daily physical activity and communication with the ill family member, as also shown by the Goodman-Casanova team. Finally, the last axis is based on the self-care of caregivers, notably through monitoring their mental health, participation in discussion groups or mindfulness meditation. 24, 66 Other studies emphasize the use of telemedicine for patients and their caregivers. Indeed, studies have shown the effect of teleconsultation on the well-being of patients suffering from dementia and their caregivers. 56

The COVID-19 pandemic, both through health and psychological effects, and through the impact of control measures, raises many ethical questions in the care of patients with cognitive impairment. Some bibliographic sources have been interested in ethical questions and their main pillars: beneficence, non-maleficence, justice, autonomy and dignity. 67 Impact for care of elderly with cognitive disorders.

The presence of cognitive impairment represents a risk factor for a serious form of infection with SARS COV 2 68 for many reasons: associated comorbidities, drug iatrogenia, delayed -or sometimes inappropriate -treatments, behavioral disorders making care complex. However, some less obvious factors may be associated, as socio-economic conditions and more frequents inequalities. 69 In this sense, the ethical discussion concerning sometimes heavy care (high flow oxygen therapy, transfer to hospital or intensive care unit) must consider the presence of cognitive impairment, and sometimes associated neuropsychiatric symptoms. It is the prognosis for the person, and not their age only, that must be taken into account in this discussion. 70 The difficulties in obtaining the consent of people with cognitive impairment, in the discussion concerning the continuation of heavy care, highlighted the importance of seeking upstream the designation of person of confidence and the realization of advance directives 71 . Some recommendations have been made to facilitate the management of patients with cognitive impairment in the context of the COVID-19 pandemic 72 , particularly for palliative support, stressing the need for collegiality and inter-professionalism.

Social isolation, reduction in outside workers for people living at home, may have contributed to greater psychological weakness, more frequent mood disorders, or even to the increase in certain neuropsychiatric symptoms linked to neurological disease. 23 Likewise, social distancing measures, starting with wearing a mask, can make it difficult to communicate with people with cognitive impairment. Non-verbal communication and use of suitable face masks can be of great help in promoting understanding despite cognitive disorders. 5 In long-term care units, residents regularly experience periods of isolation and less outside interventions or activities. All of the caregivers in these facilities observed changes in the mental health of residents with cognitive impairment. The health measures in these structures, in particular the isolation of residents who sometimes cannot give informed consent to these measures, require them to be adapted to the well-being and safety of people. 73 Reflection on the appropriate isolation measures for the epidemic situation, as well as the adaptation of existing legislative texts, remains necessary in this context. 74 

With the pandemic and the health containment measures, we have seen the development of new activities and the acceleration of others less developed until then. This is particularly the case with telemedicine, which has made it possible to continue medical support for isolated people or with cognitive disorders, living at home or in institutions. 71, 75, 76 We have also seen, for elderly people with COVID-19 requiring complex medical care (oxygen therapy), for whom hospitalization had not been made, the development of home hospitalization significantly increased during this period.

Patients with dementia have an increased risk of developing COVID-19 infection. Moreover, all-cause dementia is considered a comorbidity associated with an increased risk of mortality. 77, 78 In this context, there has been a significant use of palliative care in the management of dementia patients with COVID-19. This palliative care is a comprehensive and individualized care that should be early. 79 During the pandemic, there was a lack of hospital beds, and palliative care had to be developed in long term care units. 80 This led to ethical discussions in the institutions and caused distress J o u r n a l P r e -p r o o f among the staff and relatives. 72 Care choices, if they were not anticipated, had to be taken in a tense context. The overload caregivers' work during this period, the shortage of health care professional, the absence of families and their doctor (prohibited from entering the NH), the low availability of beds at the hospital and hospital professionals forced the health care professional in the NH to endorse complicated ethical choices, for which they were sometimes not prepared. This situation has revealed the importance of palliative care networks and the need for NH to work on advance directives and procedure on end-of-life and palliative care management. The therapeutic means used in the management of respiratory symptoms are preferably opioids and oxygen therapy in case of hypoxemia. For behavioral disorders such as agitation and anxiety, the recommended treatment is benzodiazepines. 81 These behavioral disorders can be increased by isolation or restrictions of visits. 82 This also required care and support for the families, especially since isolation measures had to be respected. 83 This management of the COVID-19 pandemic highlighted a lack of early discussion about the life plans of NH patients. Kaasalainen et al. established recommendations on end-of-life and palliative care management for dementia patients during the COVID-19 crisis and for beyond. 83 In this manuscript the Alzheimer Society of Canada proposes a coordinated multistep approach to improve palliative and end-of-life care for people with dementia in NHs during the COVID-19 pandemic.

The COVID-19 infection is a disease mainly affecting elderly people and among them, the most vulnerable living in NH. Some data demonstrate the severity of the epidemic in NH: Across the US, around 1.4 million people live in NH, that is to say about 0.4% of the 330 million inhabitants. This nursing home population accounted for more than 180,000 COVID-19 deaths, or about 30% of all COVID-19-related deaths in the United States. In France, around 1% of the general population live in NH. This small group has also accumulated, as in other European and industrialized countries, around 30% of all COVID-19 deaths. 84, 85 The drama experienced by the NH can be explained by the physical regrouping of people; their very old age, their great vulnerability due to their immunosuppression and their polymorbidity and in particular a prevalence in NH of more than 50% of dementia residents. Dementia has been repeatedly reported as an important risk factor for deaths related to COVID-19. This has led to the completion of numerous studies on the COVID-19 epidemic in NH. [86] [87] [88] The scientific literature quickly highlighted the challenge of providing care for dementia residents, both to limit the risk of the virus spreading in the NH and also to ensure quality care for this group of residents. 89 Various authors highlighted the difficulty of taking care of residents treated with psychotropic drugs during the epidemic 72 , as well as those with cognitive impairment. 67 The increased risk of COVID-19 in dementia patients living in NH and their roommate or environment, who are often also suffering of dementia, is explained in particular by their great difficulty in applying barrier measures. All the unfavorable components of a severe and difficult to control epidemic are present in dementia subjects living in NH. 90, 91 J o u r n a l P r e -p r o o f

The use of masks, room isolation, and reduced mobility in the NH quickly proved to be complicated to understand by the residents and unrealistic to apply by the NH staff among the most impaired residents, especially those exhibiting wandering behavior. 92, 93 Distancing (quarantine, isolation, cohorting) are effective strategies for fighting against epidemics 94 but it has been difficult to implement effectively in NH, especially for residents with dementia. 73 Moreover, the side effects of recommendations against the spread of COVID-19 in NH were particularly significant among residents with dementia. Indeed, recommendations based on barrier measures (social distancing, limiting visits, especially from families) reduced the possibilities for social interactions, physical activity and other non-pharmacological measures reducing psycho-behavioral disorders. These measures were associated with an increase in anxiety, loneliness, depressive symptoms of the residents with cognitive impairment for whom the explanations given were not understood. 39, 93 Likewise, the strict application of social isolation and distancing measures have sometimes increased the use of physical restraints or the use of psychotropic drugs. 39, 73, 93 For the family, restricting visits has generated concern about the consequences of loneliness on their loved ones. 95 The involvement of families in providing palliative care support to their loved ones suffering from dementia during the epidemic has been hampered due to the constraints of NH visits. 96 Articles on the subject highlight the difficulties encountered by nursing home staff in discussing advance directives for hospitalization or resuscitation with dementia patients who do not understand the situation and with referring families who were prohibited from visiting their loved ones because of the epidemic. 72 Despite these constraints, the epidemic period seems to have favored team discussions and discussions with residents' representatives on advance directives in NH. 97 Despite the frequency of this situation, a recent review of the literature shows that work on the specific challenges of supporting the end of life of dementia residents duly infected with COVID-19 is lacking. The ethical dimensions, and the cultural and spiritual aspects of the accompaniment of residents, their relatives and care teams have so far been little studied. 72 Recommendations for nursing staff on providing palliative care for people with dementia in long-term care facilities have been proposed. 72

The epidemic was indicative of the limits of organizations caring for the elderly with dementia, but also of the capacity for innovation and resilience of caregivers and families.

The architecture of NH often accommodating large number of residents on a single site, most of them with dementia and unable to understand and apply social isolation and distancing measures, has contributed to the contamination problem. The difficulties caused by the double rooms of large and sometime poorly ventilated institutions should lead to reflection on the NH of tomorrow. 98 The cohorting has often been difficult to organize in NH clusters due to architectural constraints. Research should question the applicability of barriers measures, particularly in specialized Alzheimer's units and in the particular situation of wandering patients. 99, 100 The challenge is considerable because all the previous data argues for an increase in social interactions in NH. 101 A major problem in the community and in NH has been the isolation of dementia patients and their disconnection from their families. The multiple innovations initiated by caregivers or families must be sustained, improved and be evaluated through research. 102 The epidemic will have had the merit of showing everyone, as obvious, the interest of telemedicine, so far in its infancy in many health care structures, in the prevention of avoidable hospitalizations and the improvement of care. 103 Once the epidemic has passed, it will be up to us to perpetuate these practices for the good of dementia patients.

Data from the literature shows that the consequences of the pandemic in dementia patients go far beyond the risks of COVID-19 pneumonia. It appears that the quality of care given to NH residents has been particularly complex to maintain. 67, 91 The long-term consequences of the decline in physical activity in dementia patients most often at high risk of motor functional decline and falls will be assessed in future work. Current data is already showing the impact on the well-being, cognitive decline and loss of functional abilities of the most fragile patients. 104 The experience acquired on the evaluation of the benefit / risk balance of barriers measures and their ethical dimensions will be taken into consideration for future years and in the event of a new epidemic. Longitudinal studies will also be needed to assess the neuro-cognitive consequences associated with COVID-19 in the long term. 105 Although no study has specifically looked at the efficacy of vaccination in dementia patients, or in the most fragile patients 106, 107 , observational data, particularly in NHs, have confirmed the benefits of vaccination in this population without a greater number of adverse effects than in the rest of the population. This is reassuring but testifies to our difficulty in carrying out research and providing solid scientific data on the subjects most affected by the epidemic.

Healthcare teams, such as in Singapore (no doubt more accustomed to using new technologies) report innovative initiatives 108 for dementia patients such as physical exercise programs but also dementia patient care programs offered by the ADA such as "Stay Home Fun" which contains fun activities such as karaoke, bingo, cooking or singing. 109 These multiple spontaneous initiatives should be made known to everyone.

In conclusion, we cannot ignore the impact of the epidemic on the progress of therapeutic clinical research on Alzheimer's disease, which has most often been stopped for sanitary reasons. The delay and loss of opportunity for innovative drugs for participants and future patients as well as the loss of research money for the disease is also a tragedy. This should inspire us to have a procedure allowing the pursuit of remote research in such a situation. In the field of research, this epidemic should lead us to be innovative by using new methods and virtual remote evaluation devices that are efficient and validated. 39 

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The Psychological Impact of COVID-19 Pandemic and Lockdown on Caregivers of People With Dementia

Impact of Social Isolation on People with Dementia and Their Family Caregivers

Coping with Dementia Caregiving Stress and Burden during COVID-19

Ethical care during COVID-19 for care home residents with dementia

Prognostic factors for severity and mortality in patients infected with COVID-19: A systematic review. Lazzeri C

Older Adults and Covid 19: Social Justice, Disparities, and Social Work Practice

Dementia in the era of COVID -19. Some considerations and ethical issues

Medical home visit programs during COVID-19 state of emergency

Practical nursing recommendations for palliative care for people with dementia living in long-term care facilities during the COVID-19 pandemic: A rapid scoping review

Achieving Safe, Effective, and Compassionate Quarantine or Isolation of Older Adults With Dementia in Nursing Homes

Isolating residents including wandering residents in care and group homes: Medical ethics and English law in the context of Covid-19

Telehealth for the cognitively impaired older adult and their caregivers: lessons from a coordinated approach

Remote cognitive and behavioral assessment: Report of the Alzheimer Society of Canada Task Force on dementia care best practices for COVID-19

Dementia is an age-independent risk factor for severity and death in COVID-19 inpatients

Comorbidities associated with mortality in 31,461 adults with COVID-19 in the United States: A federated electronic medical record analysis

Care for Older People with Dementia During COVID-19 Pandemic

Invited letter: Integrated palliative care in a geriatric mental health setting during the COVID-19 pandemic

Palliative care for patients with severe covid-19

Symptom Management, and Outcomes of 101 Patients With COVID-19 Referred for Hospital Palliative Care

Improving End-of-Life Care for People with Dementia in LTC Homes During the COVID-19 Pandemic and Beyond

Updated rapid risk assessment from ECDC on the novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK. Eurosurveillance 25

Understanding the impact of COVID-19 on residents of Canada's long-term care homes -ongoing challenges and policy responses

Evolution and effects of COVID-19 outbreaks in care homes: a population analysis in 189 care homes in one geographical region of the UK

Epidemiology of Covid-19 in a Long-Term Care Facility

Nursing homes or besieged castles: COVID-19 in northern Italy

Living at Home with Dementia Now More Complicated with COVID-19

Death Rate Due to COVID-19 in Alzheimer's Disease and Frontotemporal Dementia

Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands

Providing quality endof-life care to older people in the era of COVID-19: perspectives from five countries

Mental health of people living with dementia in care homes during COVID-19 pandemic

Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review

Evaluating Perspectives of Relatives of Nursing Home Residents on the Nursing Home Visiting Restrictions During the COVID-19 Crisis: A Dutch Cross-Sectional Survey Study

Commentary: COVID in care homeschallenges and dilemmas in healthcare delivery

Advance Care Planning in Dutch Nursing Homes During the First Wave of the COVID-19 Pandemic

Design": Impact on COVID-19 Death Rates in Long-Term Care Facilities Around the World

Nursing Homes and Long Term Care After COVID-19: A New ERA?

Long-Term Care Policy after Covid-19 -Solving the Nursing Home Crisis

Assuring Quality in Nursing Home Care

Videoconferencing for Health Care Provision for Older Adults in Care Homes: A Review of the Research Evidence

Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation

The Adverse Effects of the COVID-19 Pandemic on Nursing Home Resident Well-Being

Coping with Dementia in the Middle of the COVID-19 Pandemic

An mRNA Vaccine against SARS-CoV-2 -Preliminary Report

Safety and Immunogenicity of Two RNA-Based Covid-19 Vaccine Candidates

Coronavirus: Activity kits, exercise videos rolled out for adults with special needs. The Straits Times (Online)

Alzheimer's Disease Association. ADA Memo (Online)