This issue of International Psychogeriatrics includes a paper reporting the results of in-depth monitoring of reopening the doors of Dutch nursing homes (NHs) during the COVID-19 epidemic (Koopmans etal., Reference Koopmans2022). The study used a mixed methods design and included five of 26 facilities affiliated to an academic network of NHs. Visitors and healthcare professionals participated and the methods included a digital questionnaire and in-depth telephone or in-person interviews with visitors and healthcare professionals, as well as onsite observations. The authors report that: (a) the healthcare professionals agreed that re-opening would increase the well-being of the residents and their loved ones; (b) there were, however, great worries, related to an increased workload, an increased risk of emotional exhaustion, and the risk of COVID infections; and (c) while the compliance with local regulations was generally satisfactory, difficulties were observed in issues such as maintaining social distance and correctly wearing face masks. National and international expert recommendations have been released about the ban in NHs (American Geriatrics Society, 2020), but the difference is that this relevant and timely article produced empirical evidence in a sensitive issue. This is an example of how the data provided to care institutions and health authorities may be used to inform and implement care policy, as it happened with the Dutch government. The opposite of this has occurred in countries such as Spain, where many medical associations have bitterly and publically complained because they were not consulted by the public health administrators (Sociedad Española de Medicina Interna, 2021).

Both governments and care homes across the world decreed blanket bans on visitors to NHs early in the pandemic. There is limited empirical, direct evidence on the effects of confinement, but personal experiences and observational studies suggest that the ban has caused serious difficulties for both patients and families (Stall etal., Reference Stall, Johnstone, McGeer, Dhuper, Dunning and Sinha2020) and that the health systems were largely unprepared for the effects of the pandemic. Lessons now learned should not be forgotten. We focus our commentary on individuals with dementia since they represent a high proportion of residents in NHs in different countries and have been affected disproportionately (Suarez-Gonzalez, Reference Suarez-Gonzalez2020). We sustain in the International Dementia Alliance (IDEAL), a consortium of European specialists (Burns and Robert, Reference Burns and Robert2019), that all the following dimensions of care should be considered for individuals with dementia: physical health, cognitive functioning, activities of daily living, behavioral and psychological symptoms, social support, carer distress, nonprofessional care, and professional care. During the pandemic, people with dementia would probably score very high on the IDEAL scale (Semrau etal., Reference Semrau2015), a staging instrument intended to quantify care needs in the different dimensions. While the article we are commenting on now deals mainly with social support and psychological symptoms, all dimensions should be considered concerning the opening of NHs.

The physical dimension is the first one to approach given the well-documented high increase in physical morbidity and death roll in the initial phase of the epidemic. The lesson to learn is that NHs may need specific preventive plans and protocols to provide personal protective equipment (PPE), to organize and implement safe visiting practices, and to afford medical attention when appropriate, including referrals to acute hospitals (Considine etal., Reference Considine2019). Ample variation has been documented related to the use of PPE (Verbeek etal., Reference Verbeek, Gerritsen, Backhaus, de Boer, Koopmans and Hamers2020). It is now important to know that safe visiting practices are reported to be effective, at least when community transmission levels are not high (Low etal., Reference Low2021).

When planning the reopening of NHs, special attention needs naturally the dimension of behavioral and psychological symptoms. Psychogeriatricians alerted early about the negative effects of the confinement, but mental health needs of NH residents have generally been poorly understood and addressed in cases of dementia. Difficult situations derived from the worsening of cognitive functioning were frequently observed in these persons during the pandemic, even in those living at home (Canevelli etal., Reference Canevelli2020), such as their increased difficulty to understand the complex instructions for preventing infection. Wondering in these circumstances increases the risk of spreading infection or being infected (Burns etal., Reference Burns2021). Other challenging behaviors of different origin, which may need a careful differential diagnosis, as well as symptoms of depression, anxiety, or frustration, which may be severe, all are common in residents with dementia in NHs (Kaelen etal., Reference Kaelen2021). Even for expert health professionals, the management of these problems is not an easy task, and abuse of psychotropic medication has been observed in this context (Suarez-Gonzalez, Reference Suarez-Gonzalez2020). The presence of family carers may alleviate these problems.

It is very much social support the dimension which is approached in the article we are commenting on, in close relationship with the previous dimension. Aside from the negative consequences on psychological reactions and well-being, serious adverse effects of social isolation and restriction of mobility include a negative influence on immunity, muscle mass, and functional performance (Burns etal., Reference Burns2021), as well as increased mortality (Hwang etal., Reference Hwang, Rabheru, Peisah, Reichman and Ikeda2020). These are strong arguments to recommend social support measures when reopening the NHs. Some organizations have vividly reported dramatic consequences of the ban on people with dementia (Alzheimer’s Society, 2020). These individuals were perceived as feeling confused and abandoned by the lack of visits, and emotional scenes of their relatives frustrated because of being unable to be with their loved ones were also described. The fact that many residents have died without contact with the family present to support end-of-life needs requires careful attention (Burns etal., Reference Burns2021). On the contrary, an empirical study of the same group of the authors of this commented article has documented the positive impact on well-being when real and personal contact between residents and their families is facilitated (Verbeek etal., Reference Verbeek, Gerritsen, Backhaus, de Boer, Koopmans and Hamers2020).

An important, partial solution to social isolation has been offered by special measures for interviewing and supporting people on the telephone, or by electronic methods, such as videotelephony (Lester etal., Reference Lester, Holahan, Siskind and Healy2020). However, particularly in cases of dementia, virtual technology is not the best possible solution for family caregivers of individuals who were providing substantial care and support for residents before the epidemic (Stall etal., Reference Stall, Johnstone, McGeer, Dhuper, Dunning and Sinha2020). It is this recognition that isolation of people with dementia from their families can result in a significant toll that supports the crucial decision for the reopening of NHs.

The IDEAL’s purported dimensions of non-professional care and carer’s stress link with the previous comments. The carer’s stress is very well known in the field, and there is abundant literature to support its relevance concerning patients with dementia living at home (Isik etal., Reference Isik, Soysal, Solmi and Veronese2019). A different situation occurs when approaching residents in NHs. There is evidence that the bans have increased feelings of guilt, fear, worry, and isolation in the residents’ families because they could not take care of their loved ones (Bolt etal., Reference Bolt2021). It is widely held now that family caregivers may have a most relevant role in caring for individuals with dementia, particularly in times of pandemic, and this is also a strong argument when considering the reopening of NHs. Related to nonprofessional care, the special psychological needs of the residents may be alleviated by the contact with their loved ones, and this could additionally mitigate the reported increases in staff workload, stress, and burnout due to the visitor bans. However, it seems reasonable to propose that family caregivers who assume important unpaid caregiving tasks should be differentiated from social visitors when programming allowed visits in NHs. They could even be designated as essential partners in a resident’s care during the pandemic (Stall etal., Reference Stall, Johnstone, McGeer, Dhuper, Dunning and Sinha2020).

It is similarly clear that professional care of people with dementia is a crucial dimension to consider related to the closing of NHs. As mentioned in the previous paragraphs, the care in cases of dementia during the pandemic, both from the medical and the psychological perspective need time and very specialized work. Liaison psychiatrists consulted on complex patients in geriatric age admitted to general hospitals during the pandemic have gained an increased recognition from colleagues (Burns etal., Reference Burns2021), and similar interventions might be required from psychogeriatricians consulting in NHs. Indeed, shortness of workforce in NHs and negative consequences in patient outcomes have been reported even previous to the outbreak (Andersson etal., Reference Andersson, Frank, Willman, Sandman and Hansebo2018) and may have been magnified during the pandemic. Furthermore, some reports suggest that staff such as the nurses do not have necessarily the skills, resources, training, and scope of practice in dealing with the challenges of individuals requiring complex care (Davidson and Szanton, Reference Davidson and Szanton2020).

The experience of geriatric psychiatrists is that carers in NHs have often been overburdened during the epidemic, and higher than usual levels of stress and exhaustion have been reported among caregivers (Canevelli etal., Reference Canevelli2020). The professionals have been confronted with professional and ethical dilemmas. Their concerns about the residents’ condition were commonly accompanied by their inability to deliver sufficient personal care and support, and by fear of contagion, sometimes without sufficient personal protection. Strategies have been tried to confront these problems, but solutions, particularly those related to staff shortness were not easy (Davidson and Szanton, Reference Davidson and Szanton2020). The article we are commenting on adequately documents the challenge of the professional teams and the ethical dilemmas. This lesson has also to be learned.

In summary, personal experience and the available evidence suggests that the unprecedented lockdown of NHs, an invasive decision that might even have legal implications (Stall etal., Reference Stall, Johnstone, McGeer, Dhuper, Dunning and Sinha2020) had important negative consequences, which were particularly harsh in individuals with dementia. However, not all the negative effects of the pandemic in the NH interns could be ascribed to the effects of the residential lockdown, since similar problems have been observed in people with dementia living in the community (Canevelli etal., Reference Canevelli2020; Suarez-Gonzalez, Reference Suarez-Gonzalez2020), and the general impact was observed in the general population of the elderly (Burns etal., Reference Burns2021). Furthermore, although the administrators of NHs were largely unprepared to confront the consequences of the COVID infection, it is remarkable that the available studies suggest that the staff in NHs often looked at innovative ways of maintaining activity, and many services continued working even in the early phases of the epidemic. New ways of working identified during the pandemic could serve as a positive legacy from the crisis. The resilience factors in our elders, who have overcome previous, infinite vicissitudes in life have also been highlighted by NHs administrators.

In line with other studies and authorized opinions (Bergman etal., Reference Bergman, Cohen-Fridel, Shrira, Bodner and Palgi2020), the relevant, empirical study we are commenting on suggests that in a similar circumstance in the future, limits should be set on the initial blanket bans and complete lockdown on visitors of NHs. Moreover, given the similarities of dementia care in European countries (Burns etal., Reference Burns2021), we believe the conclusions might be generalized to other counties. The recognition that isolation of NH residents and their families can result in a significant toll is a crucial support for the re-opening of NHs. However, the expected improvement in the quality of life of NH residents, particularly in their psychological well-being, has to be balanced with the potential risks we have discussed, certainly the risk of contagion; we similarly alert about the risks associated with short staffing, not well trained, which needs to be addressed; and the added workload for the staff, with an increased risk of emotional exhaustion and burnout. All dimensions of dementia care have to be considered and, because of between-NH differences, a more tailored approach for individual facilities would be warranted.