Editorial: Research in nursing homes in the time of COVID

Abstract

effort in human history. The drama experienced in longterm care facilities (LTCFs) during the epidemic period must however raise questions about the ability of the scientific community to find specific solutions for the oldest and most vulnerable people living in LTCFs in a timely manner. Many epidemiological works carried out in developed countries such as France, the United States, Spain, Italy, Canada alarmed the medical community on a major number of deaths due to SARS-CoV-2 in LTCFs (1). Schematically, about 30% of all deaths due to SARS-CoV-2 concern residents of LTCFs (2,3). This high percentage of deaths within a very minority subgroup of the population (1% of the French population) contrasts with the low number of scientific studies involving residents of LTCFs. A quick search on the PudMed. gov website proves it. By filtering on the research carried out on “humans”, only 694 references emerge by associating the keywords “nursing home” and “COVID-19” (less with “longterm care facility”). This number is derisory (around 0.49%) compared to the 141,237 results obtained with the keyword “COVID-19” alone. To put it another way, 1 in approximately 200 COVID-related manuscripts to date relate to residents of LTCFs. Of course, this observation can be balanced by the research which, without focusing specially on the population living in LTCFs, has led to advances in the care of people living in LTCFs. Research on vaccination is one example among others. However, should we not again be surprised that before the massive and priority vaccination of the residents of LTCFs, none were included in the original work that led to the implementation of the vaccination against SARS-Cov-19 in all institution worldwide? To date, only 5 Randomized Controlled Trial (RCT) have been published on COVID-19 in “nursing home”. In the initial phase, the preventive measures implemented in the LTCFs relied on common sense and were mainly empirical (4). Yet, the severity of the epidemic in the LTCFs due to (i) the specificities of the population but also (ii) the organizational characteristics of the institutions justify a strong commitment for research work to bring improved geriatric medicine and quality of care in LTC during the pandemic. The very high age of the residents, their multiple morbidities, their undernutrition explain their immunosuppression and the high rate of deaths. The very high prevalence of neuro-degenerative diseases in LTCFs, often at severe stage and complicated with psychobehavioral disorders such as wandering compromise the feasibility in applying protective measures and in particular in wearing the mask. Finally, community life, in closed spaces, sometimes old and poorly ventilated, is conducive to the spread of the virus. The conjunction of these three factors (patients at very high risk of severe COVID-19/impossibility of applying health rules/promiscuity of many individuals in a closed place), made it possible, from the start of the pandemic in spring 2020, to announce a disaster in LTCFs. To this observation must be added the insufficient number of health care professional, their low level of training and equipment and sometimes the insufficient support provided by hospital staff overwhelmed by the workload in the emergency room. Despite the need for research data in LTCF, many challenges must be overcome to conduct high-quality research in LTCF. More than ever, evidence-based medicine should guide the practices of caregivers in LTCFs and improve the care of residents. However, the pandemic has added challenges to an already difficult research to conduct in LTCF. In a systematic review, Lam et al. (5) report the multiples challenges, constraints and specificities of research in LTCFs. Among the challenges to be met, it is worth mentioning the increased costs of research in LTCFs compared to the community and few funding opportunities for research projects, the high turnover of health care professionals and residents, the heterogeneity of residents, the difficulty of recruitment to participate in research and in particular the obstacles to obtaining consent and assent of residents (in cognitively impaired residents with or without legal guard, among other ethical challenges), barriers related to relatives who are afraid of research and who do not want their relatives to be involved in clinical research, poor or complicated access to imaging or lab exams, low number and overloaded health care professional. Moreover, the directors and administrative officers of the LTCFs do not know the world of research and show little interest. Research in LTCF also generates concern that the data collected from residents and health care professional may lead to criticism or even controls of regulatory guardianship (6). In randomized placeboEDITORIAL