Care Homes and Dementia

François Höpflinger, Prof. Dr. phil., is a renowned social scientist, emeritus titular professor and member of the steering committee of the Centre for Gerontology at the University of Zurich. With his many years of expertise, he is probably the most sought-after expert on ageing in Switzerland and a key voice in the debate on the challenges and opportunities of an ageing society.

The prevalence of dementia in the population is strongly associated with age. While dementias occur only rarely below the age of 65, there is an increase in the prevalence and incidence of dementing disorders from age 65 onward. Advanced age in particular is often accompanied by a dementing illness (16% among people aged 80–89 and more than 40% among those aged 90 and older).

A study conducted in 2010 among care-home residents in 14 cantons of German-speaking Switzerland and Ticino showed that a good 65% of residents either had a medical diagnosis of dementia or exhibited cognitive impairment indicating the presence of dementia (diagnosed dementia plus suspected dementia). Over the past fifteen years, the trend that mainly older people with neurodegeneration-related care needs move to retirement and nursing homes has intensified. In the near future, an increased share of residents with dementing symptoms is also to be expected—on the one hand because a higher age at admission increases the likelihood of neurocognitive problems, and on the other hand because, for the time being, somatic diseases in old age are more readily treatable than dementing illnesses.

However, the use of the care system (hospitals, care homes) by people with dementia varies, notably depending on somatic comorbidities and the presence or absence of family caregivers. An analysis (2017–2021) of treatment trajectories of patients with dementia during the last four years of life identified two basic constellations: in one, dementia was the predominant illness while overall physical health indicators were good (63% of cases). In the other, significant somatic diseases were present, to which dementia was added (37% of cases).

Especially in severe dementia, a protected living and residential environment is necessary, for example in the form of decentralized nursing units or small, clearly structured residential care groups. Ideally, dementia-friendly housing models allow an orientation toward everyday activities, thereby facilitating the mobilization of remaining competencies and opening emotional access.

In recent decades, dementia-appropriate care structures and housing forms have therefore been established that, on the one hand, provide continuous professional support and, on the other, enable community-oriented living for people with dementia—modeled on familiar living arrangements that convey safety, closeness, and security.

Even more than in physically caused care dependency, care for women and men with dementia must therefore focus on home structures that optimally combine living and care. Many behavioral problems and emotional disturbances in people with dementia are caused by environmental influences—that is, by a milieu not adequately adapted to the illness. Dementia-adapted housing makes it possible to mobilize the remaining resources and abilities of people with dementia, which substantially facilitates their care.

Diminished cognitive abilities must be compensated for through design measures, such as clear color markings that separate different residential areas. Spatial orientation is facilitated by manageable, homelike living areas. Open and freely accessible spaces (corridors, lounges) where something is happening and there is something to see, as well as selectable gathering and seating areas, motivate people with dementia to move more than closed rooms do. Communal kitchens with smells and visible utensils can prevent passivity, and a clear, everyday structure also has positive effects. Although neurodegenerative processes often lead to a loss of conscious self-identity, the implicit and emotional memory of people with dementia often continues to function for a long time, so familiarity can be supported by the presence of known things. This can be fostered by allowing residents to bring parts of their own home furnishings—and thus their life history—with them. Objects from the past or furnishings similar to those at home convey emotional security.

Suitable spaces for movement are also important, since perception and movement are closely linked. Wandering and “fidgeting” are often attempts to perceive oneself and the environment (to sense) and to remain in contact (in touch). Movement promotes thinking and reduces tension, whereas too little room for movement fosters anxiety and aggression. Therefore, longer indoor circular walking routes are sensible, as are spaces for movement created by specially designed gardens. Such spaces for movement will become increasingly important, as the share of older people with dementia without severe physical limitations is likely to continue to rise.