It took more than three decades of championing the principles of environmental design for dementia and developing the research evidence base on how the physical environment can support the independence and wellbeing of people with dementia to reach a point where cognitively supportive design should be the default requirement for new and existing long term residential care facilities. It has taken a fraction of that time for an emerging coronavirus to displace concern with residents’ lived experience in favour of strict transmission and infection control measures, forcing a return to more institutionalised and medicalised environments and care practices. We urgently need to consider the impact of COVID-19 on the aspirations of environmental design for long term care and to re-evaluate its future role in this changed context.
As the coronavirus pandemic developed globally, recommended infection control precautions (ICPs) based on the best evidence available were swiftly implemented by long term care providers anxious to protect those that they care for. These ICPs are designed to minimise transmission of COVID-19. In some cases, this was achieved by restricting residents’ opportunities for physical activity and social interaction (e.g. remaining in and receiving meals/care only in their bedroom, no outside visitor policies). Evidence is starting to emerge that these measures have had ongoing detrimental effects on the overall health and wellbeing of residents.
Restrictions imposed to minimise the risk of harm to residents resulting from COVID-19 are suspected to have accelerated physical and cognitive declines and/or indirectly contributed to the deaths of some residents.
Disproportionate numbers of deaths due to COVID-19 have been recorded in long term care facilities in many countries around the world, although there is significant international variation. Comas-Herrera, Zalakaín  report that, as of 26 June 2020, some countries (Hong Kong, Jordan and Malta) had reported no COVID-19 infections or deaths in care homes whereas in others (Canada, Slovenia) more than 80% of the country’s COVID-19 deaths were care home residents. Based on data from 26 countries, excluding those who reported no deaths, Comas-Herrera et al. found that on average 47% of people who died from COVID-19 in those countries were care home residents. They also found that, for 18 countries for which this data were available, the proportion of all care home residents who have died and whose deaths are known to be linked to COVID-19 ranges from 0.04% (New Zealand) to 6.1% (Spain), with these proportions strongly correlated with the severity of the coronavirus pandemic nationally as expressed in COVID-19 deaths per million population.
The indirect impact of COVID-19 in long term care is less clear. Evidence appears to be emerging that responses to COVID-19 which were designed to minimise disease transmission and control infection, such as prohibiting visitors to care facilities in all but life and death situations and encouraging residents to remain in their rooms, may have accelerated the physical and cognitive declines and/or indirectly contributed to the deaths of some residents. In the UK, figures from the Office for National Statistics  suggest that in England and Wales for a three-month period from 15 March 2020, only two-thirds of the nearly 30,000 ‘excess deaths’ over the same period in 2019 could be directly attributed to COVID-19. It has been suggested that COVID-19 may be indirectly responsible for many of the remaining excess deaths, including via adverse consequences resulting from ‘the impact of changes to normal routines for vulnerable care home residents following lockdown’ .
Whilst research is not yet available to substantiate the extent of resident decline following measures taken to improve infection control in long term care during the pandemic, there is significant anecdotal evidence. For example, in oral evidence given on 12 August 2020 to the All-Party Parliamentary Group on Coronavirus, an informal cross-party group of UK Members of Parliament and the House of Lords convened to learn lessons from the UK’s handling of the coronavirus pandemic, Helen Wildbore, Director of the Relatives and Residents Association, commenting on the effects of visitor restrictions and isolation within care homes said (at p7):
‘We hear daily from our helpline callers about how their relatives in care are deteriorating, not just their mental health but also the knock on impact on the physical health of older people losing weight, losing speech, losing their memory, no longer being able to recognise their family members and there’s one relative put it to us that they’re losing the will to live...’ 
The pandemic is not over, we do not know what lies ahead. However we do know that there are serious issues within long term care that need addressed. We urgently need to revise how we manage infection control procedures and maintain the overall health and wellbeing of residents in long term care.
 Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lemmon E, Henderson D, et al. Mortality associated with COVID-19 outbreaks in care homes: early international evidence2020 7 July 2020.
 ONS. Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 12 June 2020 and registered up to 20 June 2020 (provisional): Office for National Statistics; 2020 [updated 3 July 2020. Provisional figures on deaths involving the coronavirus (COVID-19) within the care sector, in England and Wales.]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsinvolvingcovid19inthecaresectorenglandandwales/deathsoccurringupto12june2020andregisteredupto20june2020provisional.
 Stripe N. Twitter THREAD – “Non-COVID” excess deaths [Twitter]. Twitter; 2020 [updated 5 Jun 2020. Thread on Twitter about “Non-COVID” excess deaths. 15 Tweets in original post pluss further tweeted comments]. Available from: https://twitter.com/NickStripe_ONS/status/1268823005305733125.
 APPG-Coronavirus. All-Party Parliamentary Group on Coronavirus: 12th August Oral Evidence Session. Transcript of the hearing . Online: March for Change; 2020 12 August 2020.
Taken from: Dawson et al 2020 ‘Designing for people with dementia and COVID-19’, Alzheimer Disease International, World Alzheimer Report 2020