Ethical Issues in the Management of Patients With Behavioral and Psychological Symptoms of Dementia During COVID-19 Containment: Examples From Institutions in France.

INTRODUCTION

The global pandemic of coronavirus disease 2019 (COVID-19) has prompted many countries to initiate containment measures intended to stem viral transmission. Although these measures are clearly legitimate from an epidemiological point of view, their application leads to significant organizational challenges for institutions caring for the most vulnerable people, such as those with disruptive behavioral and psychological symptoms of dementia (BPSD). Nonpharmacological approaches (the prime means of managing BPSD) often involve close physical contact with caregivers and between patients. The use of walking paths is most effective in patients with certain disruptive behaviors (agitation, wandering, etc.). Thus, containment appears to go against these good clinical practice guidelines and may increase the normally limited use of sedative treatments.

The containment of patients with BPSD raises ethical issues. These issues need to be urgently addressed, in order to protect a population that is particularly at risk of COVID-19.

ETHICAL CONSIDERATIONS AND ORGANIZATIONAL ADJUSTMENTS MADE IN FRENCH INSTITUTIONS

Neurocognitive disorders make it difficult for the patient to understand restrictive health measures, and behavioral disorders (like wandering) increase the risk of contagion. Hence, public health policies aimed at protecting the population as a whole from an infectious threat may therefore increase the risk of physical and mental harm without any counterbalancing benefit for vulnerable individuals. The dangerousness and scope of COVID-19 have accentuated this antagonism.

In France, these ethical issues have been debated locally, with a view to changing the implementation of containment measures. The French National Consultative Committee on Ethics (Comité Consultatif National d'Ethique) advised against the preventive use of containment to promote health measures adherence in nursing home but did suggest that temporary, proportional, appropriate restrictions could be imposed on a case-by-case basis.

Despite entry and exit restrictions in institutions or care units hosting BPSD patients, many organizational adjustments have been implemented to allow continuity of care. Ideas and recommendations have emerged from France's learned societies in the fields of geriatrics, gerontology, and old age psychiatry; the focus is on a balanced risk-benefit assessment of the suggestion actions (ranging from room containment, sedation, and/or physical restraint). The goal was to find the least harmful solution for the patient and his/her social environment, given the current hygiene-related barriers to the implementation of nonpharmacological interventions.

For hospitalized patients with disruptive BSPD and COVID-19, dedicated cognitive-behavioral units have been set up to limit the risk of transmission. Nursing homes (hosting the frailest patients) have reorganized themselves to face these challenges by focusing their activities on acute or intensive medical care, an unofficial change in status for which they were not prepared. They were supported by community healthcare organizations by creating dedicated local platforms, and deploying an organizational strategy to help them in the management of COVID‐19 epidemic. In the most complex situations, out-of-hospital geriatric mobile units (COVID‐19 mobile geriatric medicine team, consisting of a nurse and a geriatrician from the hospital, who visit nursing homes, especially those that are geographically more isolated and have fewer caregiver resources), which help healthcare professionals assess indications for the hospitalization of COVID-19 infected residents, and coordinate local healthcare resources around serious cases. Last, working groups and multidisciplinary board for decision support have suggested solutions for situations whose complexity is further increased by the context of COVID-19.

CONCLUSION

In the unprecedented context of COVID-19 (in which collective interests prevail), containment measures for patients with disruptive BPSD have created organizational difficulties. The challenge is to adapt population-level public health decisions to the inherent specificities of these vulnerable patients. Are drastic containment measures that restrict freedom and remove access to certain therapies justified by the collective interest? Many organizational, ethical and health-related aspects are now being actively discussed. More needs to be done to ensure people's health while maintaining their individual liberties.

Author Contributions

Dr J-A Nkodo wrote the manuscript. Prof. V. Camus and Prof. B Fougère have made substantial contributions to the final manuscript. All authors read and approved the final manuscript, and gave agreement to be accountable for all aspects of the work.