Health impact of the first and second wave of COVID-19 and related restrictive measures among nursing home residents: a scoping review

The following research questions were identified:

Five scientific databases were systematically searched including PsychInfo, PubMed, CINAHL, Science Direct and Google Scholar using a search string of three categories of key words related to ‘COVID-19’, ‘nursing home’, and ‘older adults’ (Appendix 1 and 2). The databases were searched for scientific English language papers published between the start of the COVID-19 pandemic and December 2020. Studies were eligible for inclusion if they met de following criteria:

We excluded studies that collected data among proxies (e.g. health professionals or family members) in order to ensure we captured the health impact from the perspectives of nursing home residents themselves. Also, we excluded studies that focused exclusively on community-dwelling older adults or were not written in English.

Selected articles from the different databases were imported into Endnote. After duplicates were removed, one of the authors (MV, AS1, AS2, LvB or MJ) screened all unique titles and abstracts. In any case of doubt, the other authors were consulted to reach consensus. Next, the remaining full text articles were screened by one of the authors (MV, AS1, AS2, MJ) for inclusion following a comparable approach. During the screening process, several joint meetings took place to ensure that all reviewers used the screening criteria in the same way.

A data-extraction sheet was developed and for each included article, one of the authors (MV, AS1, AS2, MJ) extracted the following data: publication year and month, country, study design, period of data collection or duration of the study, method of data collection, sample size of included nursing homes and residents, and basic demographics of residents (gender and age). Articles were categorized according to the type of impact of COVID-19 the study focused on. Following the biopsychosocial model of health [18], studies were classified into either studying the physical health impact (e.g. infection rates, mortality or symptoms), the psychological health impact (e.g. mood, behavior, quality of life or overall wellbeing) and/or the social impact (e.g. loneliness). Also, included articles were assigned to either studying the direct health impact of the COVID-19 virus (e.g. following an COVID-19 infection) or the health impact of COVID-19-related restrictive measures, such as the lockdown, visitor restrictions or social distancing. Finally, the type of health outcome that was studied was extracted from each article. Examples of such health outcomes are the number of COVID-19 cases or infection rates, mortality rates, loneliness or depression.

Findings are presented using a narrative style. A descriptive summary of basic study characteristics (e.g. country, study design, sample size, data collection method, outcome) is provided and presented using visual representation including a table and bar chart. Results from studies solely focusing on the physical impact of COVID-19 are not reported, as this was not the primary aim of this review and was recently reported by others [2]. In order to get insight into the health impact of COVID-19 from the perspectives of nursing home residents, however, results from studies on the psychological and social health impact more described in-depth.

This scoping review is the first that provides insight into empirical studies on the overall health impact of COVID-19 and related restrictive measures among nursing home residents published during the first and second wave of the pandemic in 2020. A broad search strategy was used to include studies examining both the physical impact as well as the psychological and social impact. However, several limitations of this review have to be mentioned.

First, we searched for literature published in a relatively short timeframe - between the beginning of the pandemic up until December 2020. It may be possible that we have missed studies that examined the impact of the first and second wave because of a delay between acceptance and actual publication dates. Also, because we focused on studies that collected data among residents themselves, which often involves time-consuming ethical approval procedures, such studies may not yet have taken place or were not yet published within this timeframe. This may also explain why the publication date of the included studies drops off as 2020 progresses. Future updates of this review will most likely include more relevant studies that were published after December 2020 and will provide further insight into the impact of later phases of the COVID-19 pandemic on residents’ health.

Second, we only included empirical and peer-reviewed studies to ensure a high-quality standard. Because grey literature was not included, we may have missed relevant reports, papers or other non-academic material published. For example, we excluded a commentary of Mo & Shi from China providing an overview of existing literature on the psychological consequences caused by COVID-19 among residents of nursing homes [13]. To maintain the high-quality standard we, however, recommend future updates to include only empirical and peer-reviewed studies.

Third, we aimed to perform a rapid literature search given the fast developments regarding the COVID-19 pandemic. As such, the search was not performed by a librarian and only search terms were used, i.e. no MeSH/indexed terms. Also, for similar pragmatic reasons, screening and data extraction was performed by only one of the authors, which may be considered as a limitation as independency cannot be guaranteed. However, any doubts regarding inclusion of articles and data extraction were discussed jointly with other authors. Nevertheless, we recommend that future iterations of this review should include more thorough search strategies and ideally involve two authors in the screening and data extraction procedures.

Lastly, the majority of included studies collected data during the first months of the pandemic – March to May 2020. Therefore, the results specifically relate to the impact of the first wave of the COVID-19 pandemic in which whole societies were in lockdown and nursing homes had to deal with frequent outbreaks, shortage in equipment, limited knowledge about consequences and treatment, and strict restrictive measures. It is likely that studies published in later phases of the pandemic provide additional (and potentially other) findings on the health impact among nursing home residents. Future updates of this scoping review are therefore recommended in order to include new studies and to compare the current findings to the health impact of later phases of the COVID-19 pandemic, in which related restrictive measures were eased and to the long-term health impact of COVID-19 and related measures on nursing home residents.

We found that studies into the perspectives of nursing home residents regarding the psychological and social impact of COVID-19 are scarce. Data collection among nursing home residents with a form of cognitive impairment or dementia – which make up for the majority of nursing home residents – can provide important insights into their lived experiences, wishes, needs and possibilities. This aligns with the current paradigm shift in nursing home care, in which care is shifting from a biomedical care model towards a person-centered care model [81, 82]. Person-centered care recognizes each person’s unique identity, preferences and needs and enables older adults to continue their preferred lives whilst living in a nursing home, also during crisis periods such as the COVID-19 pandemic. Being sensitive to individual needs and wishes is an essential prerequisite for person-centered care. Although it can be challenging, both ethically and practically, previous research has shown that data collection among older adults with complex care needs, such as dementia, is possible and provides important insights into their perspectives [83‐86]. Examples of such data collection methods are interviews, observation methods (e.g. dementia care mapping, shadowing, video observations) and diary interviewing. Nevertheless, the perspectives of older adults have been scarcely studied during disasters or crises to date [87]. Although studies using proxies provide important insights, the perspectives of nursing home residents and those of proxies can differ [88]. This difference may affect the resident’s experience of feeling heard, seen, and respected as a unique individual in the care and support he or she receives. Future research into the perspectives of older adults living in nursing homes are therefore needed to fill the knowledge gap and further guide healthcare professionals in providing person-centered care during the remaining COVID-19 pandemic, but also in future crisis periods.

By focusing exclusively on data collected among residents, however, we may have missed important studies that used a proxy to collect data. During the screening process, we indeed excluded a few studies that collected data on the impact of COVID-19 on the psychological and/or social wellbeing of nursing home residents among proxies. For example, Leontjevas et al. examined the impact of COVID-19 on challenging behaviors and psychological wellbeing of Dutch nursing home residents [89]. Data were collected between April and June 2020 using an online survey among nursing home psychologists, elderly care physicians and nurse practitioners. Both increased and decreased challenging behaviors were found, including, amongst others, increased depression and loneliness as well as elevated mood. Although findings of this study are considered relevant, we recommend future studies that involve residents themselves in the data collection to capture their own perspectives.

Because this scoping review focused on literature published during the first and second wave of the COVID-19 pandemic in 2020, we also recommend future research that shed light on the overall long-term impact of the pandemic, as well as on the impact of easing restrictions. For example, Koopmans et al., studied the impact of reopening the doors of Dutch nursing homes during the COVID-19 crisis and allowing visitors again after a 2-month lockdown period. An online survey, regarding changes in resident wellbeing that were observed after the lockdown, was completed by nurses, psychologists and physicians of 26 nursing homes. Although overall visitors and staff noticed that residents seemed to enjoy the visits, became overall more active and returned to their units in good spirit after a visit, some residents experienced sadness because physical contact was prohibited. In some residents with dementia, visits seemed to result in confusion, sadness or restlessness. Consequently, staff advised against visiting these residents anymore under the circumstances of that time [14].