Effects of Covid 19 and Human Interventions in Care Homes: Part 1

“Confinement Disease” is likely to be more harmful than covid in care homes.

Fleur Anderson MP’s contribution to the Westminster debate on deaths in nursing homes, 27 October 2022. Ms Anderson is asking that any intervention should be based on evidence.

This four-part series is dedicated to those who lost their lives while residing in care homes, their bereaved families and the carers on the frontline. The pain eventually goes away. The sadness and loss are there forever.

The COVID-19 pandemic disproportionately impacted those living in care homes at the highest risk for severe outcomes. However, the pandemic only highlighted and exacerbated a long-running problem: underfunding, poor structural layout, undertraining, under-skilling, under-equipping, and finally, lack of humanity in dealing with the most vulnerable members of our society.

The series provides an up-to-date review of the global effects of the COVID-19 pandemic countermeasures in care homes. We used a mixed methods approach to assess care home mortality by country, how the deaths compared with previous periods, and how excess deaths may be explained. Finally, we look at the long-term effects of what happened.

In this first part, we look at national datasets for 25 countries on mortality. Despite involving vast numbers of care homes around the globe, the quality of the evidence is not good. For example, the majority of the studies infer the cause of extra deaths from the observation window (mainly the spring of 2020) rather than through detailed investigations. To be clear, the reasoning is as follows:

Q: “When did XYZ die?

A: “18 May 2020” 

Conclusion: “Put them down as Covid deaths, then”

This is why we cannot draw any clear conclusions about the specific causes of death, apart from noting their significantly high numbers. In addition, we did not review all policy actions since 2020 but note there has been a scarcity of studies since then - an indicator that interest in care homes has waned and the problems likely not addressed. “Until the next pandemic then, move on please, nothing to see here.”

Because of the dearth of evidence, we analysed national datasets for 25 countries, which shows that care home deaths were, on average, 30% of the total COVID-19 deaths to roughly September 2021. Care home deaths as a proportion of total deaths ranged from 9 per cent in Lithuania to 64 per cent in New Zealand, with an average of 30 per cent. We found no relationship between care home deaths as a proportion of all deaths or cases in the population. (The data is available on Figshare)

In other words, care homes had a high but variable burden of covid deaths compared to other settings. Part of the variability may be due to differences in reporting and definition of care homes. 

This phenomenon is not unique to any particular country for which we have data. Seven countries reported more than 10,000 covid care home deaths: Canada, Belgium, France, Germany, Spain, the UK and the US.

For example, in Ontario, “confinement syndrome” led to roughly 70% of residents with dementia, which may have been treated by nonpharmacologic interventions, being treated with psychotropic medications. These drugs have been the subject of long-time deprescribing initiatives. Many were potentially inappropriate, ‘specifically opioids and anticonvulsants’.

France had 30,395 (43 per cent) of 71,342 total covid-19-attributed deaths occurring in care homes as of 21 January 2021. A study of two hospital-dependent French nursing homes compared with a home with no hospital connection suggested high mortality rates might be associated with a lack of medical care management. Among residents of long-term care in the Southern Ile-de-France region, more than 24 covid deaths among 140 residents occurred in 5 days. None were due to acute respiratory distress syndrome, and death was mainly due to hypovolemic shock as residents were confined to their rooms for several days without assistance with eating and drinking. The authors of this report suggested that “Confinement Disease” is likely to be more harmful than covid. Once a task force deployed providing medical care, including fluids and oxygen therapy, mortality improved.

Regardless, it looks as if a minimum of care quickly made things better.

Heneghan C, Dietrich M, Brassey J, Jefferson T. CG Report 6: Effects of COVID-19 in CarecHomes – A Mixed Methods Review. Collateral Global. Version 1, 3 Dec 2021. https://collateralglobal.org/article/effects-of-covid-19-in-care-homes/.