Aide médicale urgente — établissement d'hébergement des personnes âgées dépendantes : retour d'expérience d'une organisation innovante pendant la crise Covid-19

La crise sanitaire Covid-19 a obligé les Samu–Smur à adapter leurs organisations au jour le jour. La régulation a dû trouver des réponses spécifiques aux types d'appels, au plan quantitatif et qualitatif. En lien avec la médecine générale et les recommandations ministérielles, le Samu devait être le garant d'une juste orientation des patients vers les services hospitaliers. Le Samu 94 et la faculté de santé de Créteil ont créé une cellule dédiée aux établissements d'hébergement des personnes âgées dépendantes, accessible via une ligne spécialisée du Samu–centre 15, offrant 24 heures/24 l'accès à des compétences gériatriques et conseils divers, véritable lien ville–hôpital. Le retour d'expérience montre que cette cellule est une des facettes, dans le domaine de la gériatrie, de ce qu'est le concept de service d'accès aux soins (SAS) et qu'il ne faut pas attendre un rebond de crise pour en consolider les fondements.Alternate : The COVID-19 health crisis forced the French emergency call centers (SAMU), and related prehospital medical mobile teams, to quickly adapt and reorganize on a daily basis. Call centers had to come up with specific responses to all types of calls, as well as to manage quantitative increases in call intakes, and to maintain high qualitative standards. In collaboration with general practices, and aligned on ministerial recommendations, the SAMU was to be the gatekeeper of the surge in referrals of elderly patients to in-hospital emergency departments. SAMU 94 and the health faculty of the University of Créteil, France, jointly set up an online unit dedicated to nursing homes, accessible via a specific SAMU telephone line. It offered 24/7 access to geriatric expertise and advice, and aimed to strengthen the chain of care between general practices and hospitals. Feedback shows that this geriatric unit is one of the facets of the healthcare access system that the innovative French SAS relies on, and that we should not wait for a second-wave crisis to consolidate its foundations.

[Excess mortality in nursing homes during the first wave of the Covid-19 pandemic]. / Surmortalité dans les Ehpad pendant la première vague de la pandémie de la Covid-19.

Overall mortality in France is 147 568 deaths since the first wave. Although accounting for nearly 20% of deaths in France, the excess mortality in long-term care facilities compared to previous years has not been fully studied. The Covid-19 pandemic has highlighted the vulnerability of residents in long-term care facilities, with highly dependent elderly patients being the most exposed to the risk of death, with deleterious effects linked to the effects of confinement, which in Ehpad has resulted in major isolation of residents and the appearance by care teams of cognitive disorders appearing or deteriorating in residents, as well as a significant loss of autonomy.

[Ethical and professional issues in the pandemic crisis]. / Enjeux éthiques et professionnels dans la crise pandémique.

Changes have accompanied the profession of psychologist in residential institutions for dependent elderly people after the Covid-19 crisis. Clinical interviews, assistance in changing life perspectives, support in painful moments and in letting go are concerned. Concrete actions can give meaning to daily life, as well as the contribution of a relaxation tool for the residents and the professionals of the establishment. Testimonial.

La réalité virtuelle personnalisée sur les troubles de l’humeur en établissement d’hébergement pour personnes âgées dépendantes et unité de soin de longue durée : étude de cas chez un résident présentant des troubles cognitifs modérés

Résumé Introduction La maladie d’Alzheimer et les maladies apparentées entraînent des troubles de l’humeur et des troubles anxieux chez les résidents institutionnalisés. La thérapie par réminiscence a démontré un intérêt dans le traitement de ces symptômes. Objectif L’étude pilote randomisée « Réminiscences et Émotions » utilise la réalité virtuelle personnalisée pour diminuer les troubles de l’humeur des résidents. Les objectifs secondaires visent à évaluer l’acceptabilité du dispositif et la qualité de vie des résidents. Méthode Monsieur G. présente des troubles cognitifs modérés ainsi que des troubles de l’humeur. Il participe à dix séances de réalité virtuelle personnalisée pendant une période de six semaines. Les variables sont mesurées en amont et à la fin du protocole. Résultats Une analyse visuelle des scores illustre les résultats. Le dispositif de réalité virtuelle est accepté et toléré par le participant. Les scores aux échelles de l’humeur (dépression, apathie) et de l’anxiété diminuent. Aucune différence n’apparaît sur l’échelle de qualité de vie. Les interventions génèrent du plaisir et de la vivacité en lien avec l’émergence de souvenirs positifs. Conclusion Il existe un intérêt de la thérapie par réminiscence en réalité virtuelle pour améliorer l’humeur du participant. Les futurs résultats permettront de conclure sur la méthode et son indication thérapeutique en institution gériatrique. Introduction The World Health Organization defined dementia as a syndrome in which there is deterioration in cognitive function beyond what might be expected from the usual consequences of biological aging. Currently, 55 million people live with Alzheimer's in the world. Unfortunately, there isn’t any drug treatment to cure the degenerative disease although clinical trials are promising regarding the use of monoclonal antibodies. But, Alzheimer's disease and associated diseases lead to behavioral and psychological symptoms (anxiety, apathy, depression) which can be frequent in nursing homes. In the context of pandemic, these conditions are amplified because of the sanitary restrictions. Since the beginning of the sars-cov2 pandemic, residents have felt alone, sad and more anxious. Nowadays, non-drug interventions are recommended by health organizations for the treatment of behavioral and mood disorders in the elderly with cognitive disorders. Reminiscence therapy is a non drug intervention which has been shown to be effective in the treatment of mood disorders on elderly. Many nursing homes use this non pharmacological treatment for their residents. Some studies take interest in reminiscence and virtual reality. The use of new technologies is innovative in geriatric care and it can be used as a personalized support for reminiscence therapy. The “Bien Vieillir Nice 2030” Project of Nice's University Hospital supports this research on virtual reality and mood disorders in nursing homes/long term care unit. Objective The objective of this study (University Hospital of Nice, CoBTeK France) is to evaluate the effects of personalized virtual reality on reduction of mood disorders in nursing homes residents with minors and moderates neurocognitive disorders. The secondary objectives are to assess the acceptability of the device, the emotional valence and the resident's quality of life. Method A single case study is presented to illustrate reminiscences and emotions protocol. Participants are randomized into two groups: neutral versus personalized. The neutral videos consist of unknown places like random streets or public gardens while the personalized videos are known places that mattered to the residents. Places are filmed with a camera GoPro Fusion 360°. The healthcare team and families are actively involved in the research protocol. Their help is invaluable in targeting memories related to the resident's life history. A clinical psychologist specializing in gerontology is in charge of the virtual reality sessions. The t erapeutic alliance is central to our study. A humanistic method of person-centered approach allows communication with the resident to offer him to participate in the sessions. The sessions always start and end in the same way in order not to cause stress in the resident. The hardware is tested before the protocol starts, for familiarization purpose. Potential side effects related to virtual reality are identified using a cybermalaise questionnaire. The sessions are held in a sitting position for the participant's safety. In this paper, Mr. G, 92 years old benefits from personalized video according to his life story. He has moderate cognitive impairment as well as mood disorders. He received ten virtual reality sessions over a period of six weeks. The exposure time varies between five to ten minutes. We use an Oculus Rift S headset and a computer in partnership with C2Care. Variables were measured before and at the end of the protocol. We performed a visual analysis of the scores. Results The results indicated a decrease on mood rating scales scores (Geriatric Depression Scale, Apathy Inventory, Neuropsychiatric Inventory and Hamilton Depression Rating scale). The interventions produced pleasure and alertness in connection along with the emergence of positive memories. The headset was well tolerated by the participant, but we did not observe any effect on quality of life. Conclusion There is an interest in the use of reminiscence therapy using virtual reality to improve participants’ mood. Future results will allow us to conclude on the method and on its indication in nursing homes after the inclusion of 30 participants.

The “elderly” during the covid-19 crisis: a convenient scapegoat or a revelation of social dysfunction?

With the arrival of the coronavirus disease 2019 (covid-19) pandemic, the French society has been deeply shaken in its overall functioning. The proliferation of patients and the increased demand for care, particularly in hospitals and intensive care units, have particularly disrupted the health and social functioning of French society. In this particular context of crisis, the latter played the role of “social analyzer” in the sense given to it by sociologists, that is to say, it shed new light on the social practices instituted normally. We have chosen for this article to examine the way in which a particular category of people “the elderly” had been treated on three registers which appeared to us to be emblematic of the social treatment of these “elderly people” during the covid-19 crisis. First there was the reactivation of what some have called “the struggle of ages” or even the war of generations. Then, this crisis has particularly highlighted the situation of elderly people residing in nursing homes: their increased mortality, their problematic confinement and their priority vaccination. Finally, this crisis raised the question of the relevance of setting up specific confinement according to age. Our conclusion is that crises are conducive to simplistic explanations and the search for scapegoats, but that they are also a formidable indicator of social dysfunctions that predate the crisis. In this sense, the crisis has brought to light an obvious fact in French society of the primacy of “life course inequalities” as a major vector of social exclusion. © 2022 Elsevier Masson SAS Avec l'arrivée de la pandémie de coronavirus disease 2019 (covid-19), la société française a été profondément ébranlée dans son fonctionnement global. La multiplication des malades et l'augmentation de la demandes de soins notamment hospitaliers et en services de réanimation ont particulièrement perturbé le fonctionnement sanitaire et social de la société française. Dans ce contexte particulier de crise, cette dernière a joué le rôle d’ « analyseur social » au sens que lui donnent les sociologues, c'est-à-dire qu'elle a été porteuse d'un éclairage nouveau sur les pratiques sociales instituées en temps normal. Nous avons choisi pour cet article d'examiner la façon dont avait été traitée une catégorie particulière de personnes « les personnes âgées » et ce sur trois registres qui nous sont apparus emblématiques du traitement social de ces « personnes âgées » pendant la crise covid-19. D'abord il y a eu la réactivation de ce que d'aucuns ont appelé « la lutte des âges » ou encore la guerre des générations. Ensuite cette crise a particulièrement mis en lumière la situation des personnes âgées résidant en EHPAD : leur mortalité accrue, leur confinement problématique et leur vaccination prioritaire. Enfin cette crise a posé la question de la pertinence d'une mise en place d'un confinement spécifique en fonction de l’âge. Notre conclusion est que les crises sont propices aux explications simplistes et à la recherche de boucs émissaires, mais qu'elles sont aussi un formidable révélateur des dysfonctionnements sociaux antérieurs à la crise. En ce sens la crise a remis en lumière une évidence, dans la société française, la primauté des « inégalités de parcours de vie » comme vecteur majeur de l'exclusion sociale. © 2022 Elsevier Masson SAS

[In old people's homes, carers face Covid-19]. / En Ehpad, les soignants face à la Covid-19.

Many ethical issues were raised by the pandemic crisis. Caregivers were under great pressure and stress in their work in residential care facilities for the dependent elderly (Ehpad), both with residents and their families. The implementation of ethical support tools was only gradual, particularly for the management of residents' deaths. Anxiety has set in among all the people working or living in the Ehpad, blurring interpersonal relations and increasing tensions and professional exhaustion.

Les « personnes âgées » pendant la crise du Covid-19: un bouc émissaire commode ou un révélateur des dysfonctionnement sociaux?

Résumé Avec l’arrivée de la pandémie Covid-19, la société française a été profondément ébranlée dans son fonctionnement global. La multiplication des malades et l’augmentation de la demandes de soins notamment hospitaliers et en services de réanimation ont particulièrement perturbé le fonctionnement sanitaire et social de la société française. Dans ce contexte particulier de crise, cette dernière a joué le rôle d’ « analyseur social » au sens que lui donnent les sociologues, c’est-à-dire qu’elle a été porteuse d’un éclairage nouveau sur les pratiques sociales instituées en temps normal. Nous avons choisi pour cet article d’examiner la façon dont avait été traitée une catégorie particulière de personnes « les personnes âgées » et ce sur trois registres qui nous sont apparus emblématiques du traitement social de ces « personnes âgées » pendant la crise Covid-19. D’abord il y a eu la réactivation de ce que d’aucuns ont appelé « la lutte des âges » ou encore la guerre des générations. Ensuite cette crise a particulièrement mis en lumière la situation des personnes âgées résidant en EHPAD : leur mortalité accrue, leur confinement problématique et leur vaccination prioritaire. Enfin cette crise a posé la question de la pertinence d’une mise en place d’un confinement spécifique en fonction de l’âge. Notre conclusion est que les crises sont propices aux explications simplistes et à la recherche de boucs émissaires, mais qu’elles sont aussi un formidable révélateur des dysfonctionnements sociaux antérieurs à la crise. En ce sens la crise a remis en lumière une évidence, dans la société française, la primauté des «  inégalités de parcours de vie » comme vecteur majeur de l’exclusion sociale. Summary With the arrival of the Covid-19 pandemic, French society has been deeply shaken in its overall functioning. The proliferation of patients and the increased demand for care, particularly in hospitals and intensive care units, have particularly disrupted the health and social functioning of French society. In this particular context of crisis, the latter played the role of "social analyzer" in the sense given to it by sociologists, that is to say, it shed new light on the social practices instituted normally. We have chosen for this article to examine the way in which a particular category of people "the elderly" had been treated on three registers which appeared to us to be emblematic of the social treatment of these "elderly people" during the Covid-19 crisis. First there was the reactivation of what some have called “the struggle of ages‿ or even the war of generations. Then, this crisis has particularly highlighted the situation of elderly people residing in nursing homes: their increased mortality, their problematic confinement and their priority vaccination. Finally, this crisis raised the question of the relevance of setting up specific confinement according to age. Our conclusion is that crises are conducive to simplistic explanations and the search for scapegoats, but that they are also a formidable indicator of social dysfunctions that predate the crisis. In this sense, the crisis has brought to light an obvious fact in French society of the primacy of “life course inequalities‿ as a major vector of social exclusion.

The practice of psychologist in nursing home during the health crisis: How to maintain psychic care?

Nursing homes were particularly impacted by the COVID-19 pandemic during the two waves of contamination in 2020. Caregivers had no previous support and knowledge to think this crisis. The confinement, the sanitary rules came to reinforce the split between the external world and the interior of these establishments. Everyone was active, in an almost maniacal movement, to reject the death's anxiety. It is in a transitional space between inside and outside that the role and the practice of the psychologist have found their full meaning, by trying to maintain a fragile link with the familiar. From a clinical situation illustrating the evolution of the link between an elderly resident in nursing home, Mrs. O. and her daughter, this article attempts to show how the psychologist needs to reorient his intervention framework, by flirting with limits of it. Not only did this crisis provide irrefutable proof of our vulnerability, but it also allowed us to exploit new resources in our practices. © 2022 Les établissements d'hébergement pour personnes âgées dépendantes (Ehpad) ont été particulièrement touchés par la pandémie de COVID-19 lors des deux vagues de contamination de 2020. L'ensemble du personnel n'avait aucun appui antérieur et connu pour penser cet état de crise. Le confinement, les règles sanitaires sont venus renforcer la scission entre le monde extérieur et l'intérieur de ces établissements où tous s'activaient, dans un mouvement quasi maniaque, à rejeter les angoisses de mort. C'est dans un espace transitionnel à créer entre dedans et dehors que la pratique du psychologue a trouvé tout son sens en tentant de maintenir un lien fragile avec le familier. À partir d'une situation clinique illustrant l’évolution du lien entre une résidente âgée en Ehpad, madame O. et sa fille, cet article s'emploie à montrer que cette épreuve inédite a forcé le psychologue, non seulement à réorienter son cadre d'intervention, mais à flirter un peu plus avec les contours et les limites de celui-ci. Cette crise nous a apporté non seulement la preuve irréfutable de notre vulnérabilité, mais elle nous a aussi permis d'exploiter un panel de ressources nouvelles dans nos pratiques. © 2022

La pratique du psychologue en Ehpad en période de crise sanitaire : comment maintenir le soin psychique ?

Résumé Les établissements d’hébergement pour personnes âgées dépendantes (Ehpad) ont été particulièrement touchés par la pandémie de COVID-19 lors des deux vagues de contamination de 2020. L’ensemble du personnel n’avait aucun appui antérieur et connu pour penser cet état de crise. Le confinement, les règles sanitaires sont venus renforcer la scission entre le monde extérieur et l’intérieur de ces établissements où tous s’activaient, dans un mouvement quasi maniaque, à rejeter les angoisses de mort. C’est dans un espace transitionnel à créer entre dedans et dehors que la pratique du psychologue a trouvé tout son sens en tentant de maintenir un lien fragile avec le familier. À partir d’une situation clinique illustrant l’évolution du lien entre une résidente âgée en Ehpad, madame O. et sa fille, cet article s’emploie à montrer que cette épreuve inédite a forcé le psychologue, non seulement à réorienter son cadre d’intervention, mais à flirter un peu plus avec les contours et les limites de celui-ci. Cette crise nous a apporté non seulement la preuve irréfutable de notre vulnérabilité, mais elle nous a aussi permis d’exploiter un panel de ressources nouvelles dans nos pratiques. Nursing homes were particularly impacted by the COVID-19 pandemic during the two waves of contamination in 2020. Caregivers had no previous support and knowledge to think this crisis. The confinement, the sanitary rules came to reinforce the split between the external world and the interior of these establishments. Everyone was active, in an almost maniacal movement, to reject the death's anxiety. It is in a transitional space between inside and outside that the role and the practice of the psychologist have found their full meaning, by trying to maintain a fragile link with the familiar. From a clinical situation illustrating the evolution of the link between an elderly resident in nursing home, Mrs. O. and her daughter, this article attempts to show how the psychologist needs to reorient his intervention framework, by flirting with limits of it. Not only did this crisis provide irrefutable proof of our vulnerability, but it also allowed us to exploit new resources in our practices.

Psychological impact of COVID-19 lockdown on staff and residents of nursing and care homes in Belgium and EHPADs France.

More than a third of the world's population is currently living under lockdown due to the coronavirus pandemic. Lockdown measures have been in place in many countries for several weeks. The health authorities are waging war against COVID-19 and have to provide information to the public on it while facing many unknowns about the virus. What impact does this have on mental health? What impact can lockdown have upon a population? What psychological impact will this lockdown have on elderly people living in nursing and care homes in Belgium and EHPADs France? We are not aware of any French-language research which has been published on the psychological aspects of the coronavirus among the population. We will try, through this article, to approach the psychological impact upon nursing staff and residents within nursing homes.

[Medico-psychological aspect relating to the coronavirus epidemic: implementation of a support strategy for nursing staff by coordinating doctors in rest and care homes in Belgium and in France and psychological impact for the residents of these private and public nursing and care homes]. / Aspect médico-psychologique relatif à l'épidémie du coronavirus : mise en place d'une stratégie de soutien pour le personnel soignant par les médecins coordinateurs dans les maisons de repos et de soins en Belgique ou Ehpad en France et impact psychologique pour les résidents de ces maisons de repos et de soins privées et publiques.

More than a third of humanity is currently under containment due to the coronavirus pandemic. Containment has been in place in many countries for several weeks. Health authorities are on the warpath against a still mysterious virus and for which they are brought to inform the population while being confronted with many unknowns concerning the Covid-19. So what about mental health? What can generate a situation of containment with the population in quarantine? What psychological impact will this confinement have on our elderly people who are accommodated in rest and care homes in Belgium or in Ehpad in France? Currently, we are not yet aware of French-language articles already published in the medical-psychological aspects related to the coronavirus among the population. We will try, through this article, to approach the medico-psychological question of the nursing staff within the nursing homes and the psychological impact of the residents.

[Seroprevalence, risk factors and clinical presentation after the first wave of COVID-19 in nursing homes of the UNIVI group: The SEROCOVID study]. / Séroprévalence, facteurs de risque et présentation clinique après la première vague COVID-19 dans les EHPAD du groupe UNIVI : étude SEROCOVID.

INTRODUCTION: The pandemic caused by SARS-COV-2 infection spread rapidly during the "first wave" through France between March and May 2020. It was responsible for high mortality in subjects with comorbidities and the elderly who lived in nursing homes. In May 2020, 75% of the deaths occurred in people over 75 years old in nursing homes. It is difficult to estimate accurately the prevalence of COVID-19 infection during this period because only 50% of the diagnoses in nursing homes were made by RT-PCR. During this period, the diagnosis was mainly based on the clinical symptoms. POPULATION AND METHODS: We carried out a prospective study among residents of the 27 EHPADs in the UNIVI group (SEROCOVID study) between August 31 and October 16, 2020 using rapid ELISA serotests carried out by pricking the fingertip. We looked for the seroprevalence by the use of rapid serotests as well as the overall prevalence by cumulating the positive results of the RT-PCR when done and of the rapid serotest. The secondary objectives were the study of risk factors for infection by multivariate analysis as well as the description of the symptoms that led to the diagnosis. RESULTS: In total, 1145 residents were included aged on average 89±7.5 years old (female 78.7%). The time between the COVID-19 disease and the rapid inclusion serotest was on average 5±1.7 months. The prevalence estimated by the three diagnostic evaluation methods (medical diagnosis, RT-PCR or by rapid serotest ELISA) is about 14%, underestimated compared to the overall prevalence at 22.7%. The study of risk factors in multivariate analysis shows that the most dependent residents, living in a protected unit due to behavioral disorders or whose close contact with a person with COVID-19 had significantly higher rates of infection. Finally, the symptoms most frequently observed in residents differed from those in younger subjects with geriatric characteristics, such as the higher frequency of digestive symptoms and geriatric syndromes. Fever has only been observed in one third of cases in the elderly. Smell and taste disorders were seldom described. CONCLUSION: Our study provides an estimate of the overall prevalence as well as the mean seroprevalence of COVID-19 in EHPAD residents five months after the diagnosis of COVID-19 disease. The difference between the two estimates is probably explained by the frailty and decreased immunity of the nursing home residents. Therefore, it would need to be reactivated by vaccination of all residents, even those already infected with SARS-COV-2. These elements corroborate the governmental strategy of vaccination deployed in all residents of EHPAD regardless of their previous contact with the virus.

[COVID-19 in care homes, a new organisation required]. / Covid-19 en Ehpad, une réorganisation nécessaire.

The unprecedented covid-19 health crisis required emergency measures to be put in place. The main aim was to prevent the pandemic from spreading within care homeof Côte Fleurie (14), while limiting the negative effects of the lockdown. It was also necessary to anticipate the support needed by residents receiving palliative care in a new and unique context.

[Ambivalence, control, support. Caring for the elderly patient at a "good enough" distance]. / Ambivalence, emprise, soutien. De la difficulté d'entourer le patient âgé à « suffisamment bonne ¼ distance.

OBJECTIVES: In the wake of the Covid-19 pandemic, visits by relatives to Nursing Homes for the Elderly (EHPAD) and Long-Term Care Units (USLD) have been severely restricted or even prohibited in order to protect the residents and patients, especially the most vulnerable among them. This situation has revived the debate around the place and role of the relational entourage in caring for the elderly. The relevance of family ties in supporting the narcissistic and objectal cathexis of the elderly has thus gained recognition. There is, however, the risk of an emerging form of uniformization and idealization, which the present article seeks to address by highlighting some aspects of the intrapsychic and inter-relational dynamics that drive the inherent complexity of those bonds. METHOD: The authors seek to identify the psychic processes involved in varying forms of presence and of motivation of "natural caregivers" and "professional caregivers." Their approach is based on a psychodynamic analysis of the consequences of the Covid-19 pandemic and the changes induced in the links between the patient or elderly resident and his or her entourage. Complex movements fueling the dynamics involved in these links are revealed. A clinical vignette based on research in clinical psychology and psychopathology is provided. RESULTS: The pandemic context showed the creative strategies devised by relatives and carers to maintain forms of presence and links "at a distance" with isolated and confined elderly people. However, the various configurations of these arrangements also highlighted the tensions, sometimes tinged with rivalry, in the negotiations that inform the respective places and roles of family members and professionals around the subjects concerned. The caregiver's position is not self-evident and presupposes an involvement that cannot be construed on a merely functional and behavioral level. Rather, it requires a need for psychic work drawing on the identificatory and projective movements inevitably mobilized in closeness with the subject, without alienating oneself. Ambivalence, empathy, and support can then be deployed, where excessive control, covert hostility, and over-excitement are constant threats to such a necessarily close relationship. This disposition in the caregiver also encounters a singular psychic disposition on the part of the person being helped, informed by a lively conflictuality. This sometimes takes on surprising undertones, as in the case of Georges, an 86-year-old patient, where the caregiver as a "close-human-being" was fully recognized only on the condition that the relationship of help and care supported, sustained, and nourished unconscious masochistic needs. DISCUSSION: These perspectives are an invitation to ponder the plurality of figures of the "close-human-being" and to find one's place in a psychic and relational economy where the self-preserving and psychosexual registers are in constant interplay. They also underline the need to focus on working, individually and collectively, on the quality of the entourage's presence. This is all mediated by a complex organizational pattern anchored in the potential for reciprocal support between the family group, the caregiving group, and the institutional setting. CONCLUSION: These various propositions help clarifythe components of the psychic conflictuality implied, on the one hand, in the horizontal tensions existing between the various members of the familial and professional circle and, on the other hand, in the vertical tensions inherent in intergenerational dynamics. The elderly are far from being passive objects in this and their contribution is essential. The concern to ensure the close involvement of the elderly person's relatives and foster the quality of the ensuing exchanges is laudable, indeed vital. This should not, however, lead us to downplay the crucial and singular place the elderly subjects themselves occupy in individual, family, and societal dynamics, as full citizens, members of their relatives' entourage, and essential figures in the establishment of the great psychic organizing functions that structure the difference in generations and the psychic processes of identification.

[Sustainable and efficient cooperation to protect residents from the COVID-19 epidemic]. / Coopérer pour protéger les résidents de la Covid-19.

The health crisis has had a major impact on residential institutions for dependent elderly people. Professionals practising in the Nouvelle-Aquitaine region are reviewing the measures adopted to protect residents, their families and staff. Resulting from a collective work between four public establishments in common direction, the fight against the epidemic of COVID-19 was organized by combining management of the immediacy of ministerial directives and anticipation in order to be sustainable.

[Ethics and Covid-19 in nursing homes, a return of experience]. / Éthique et Covid-19 en Ehpad, retour d'expérience.

Covid epidemic and containment have generated numerous ethical dilemmas. Autonomy is the most frequently jeopardized ethical principle. Continued commitment has run into specific funerary rules of deceased residents. Professional proficiency has been eroded by omnipresent feelings of fear and powerlessness, and by medicalized daily activity. Decontainment and after-crisis raise specific ethical questionnings.