In Many Countries, Most Care-Home Residents Live With Dementia

In the countries that measure it, care homes have become, in large part, homes for people living with dementia. In Canada, 69% of residents of long-term care homes had dementia in 2015–16^[1]; in the United States, 41.1% of nursing home residents had a diagnosis of Alzheimer’s disease or another dementia in 2022^[2]; and a nationwide clinical survey in Taiwan found dementia in 87.1% of residents of long-term care facilities^[3]. Yet care homes are still often staffed, funded and inspected as if dementia were one need among many.

For many families, a move into a care home comes late, when needs for help with washing, dressing, eating and moving around have grown beyond what can be met at home. The person arriving often has advanced dementia alongside other health conditions, and may find it hard to say when they are in pain, frightened or bored. What their days are like then depends above all on the people around them: how many staff are on shift, and whether they have been trained to understand dementia. This study brings together evidence from several countries on how many care-home residents live with dementia, how often that dementia is unrecognised, what specialist provision exists and what the evidence says about the quality of the care they receive.

In several countries with data, more than half of care-home residents live with dementia

The share of care-home residents living with dementia is high almost everywhere it has been measured, but the figures vary widely, and much of that variation comes from how they were measured. A 2010 systematic review of 30 prevalence studies found a median of 58%; most of those studies covered only a few facilities, and most were from high-income countries^[4]. National figures since then sit around and above that level:

• Canada: 69% of long-term care residents had dementia in 2015–16, according to standardised resident assessments reported to the Canadian Institute for Health Information (CIHI). Counting all causes of cognitive impairment, the share was 87%^[1].
• Wales: in a national cohort of 9,571 residents of 673 care homes in late 2020, 59% had a recorded dementia diagnosis^[6].
• Taiwan: a two-phase survey of residents of a random sample of 299 of the island’s 1,607 registered long-term care facilities in 2019–20 (4,765 residents in 266 facilities completed the assessments), using screening, staging and clinical confirmation, found all-cause dementia, including very mild dementia, in 87.1%^[3].
• United States: 41.1% of nursing home residents and 44.1% of residents of residential care communities, such as assisted living, had a diagnosis of Alzheimer’s disease or another dementia in 2022, according to the National Center for Health Statistics^[2].
• Jordan: a neurologist assessed all 366 residents of the country’s nine licensed nursing homes and found dementia in 25%, which the authors note is lower than reported in many high-income countries^[7].

These are not points on one scale: Taiwan assessed residents clinically, Wales and the US count recorded diagnoses, and Canada uses a standard staff-completed assessment. Settings differ too: in the US, many people living with dementia now live in assisted living rather than nursing homes. Across 11,030 US nursing homes, the average share of residents with a dementia diagnosis (a facility-level average from a different dataset, so not directly comparable with the NCHS figure above) fell from 50.8% in 2019 to 44.6% in 2023, and in local markets where assisted living capacity grew, the share fell slightly more (0.1 percentage points for every 100 extra assisted living beds), which the authors suggest may reflect assisted living delaying or diverting moves into nursing homes^[8].

Many residents have dementia that has never been diagnosed

Recorded diagnoses undercount dementia in care homes, and the gap matters, because a diagnosis opens the way to care that fits. In an Australian study of 541 residents of 17 residential aged care facilities across four states, 65% had a dementia diagnosis in their medical records, but 83% scored in the range indicating likely cognitive impairment on a standard assessment. More than one in five residents had likely cognitive impairment with no dementia diagnosis, and 11% had moderate to severe impairment with no diagnosis recorded^[5]. The authors concluded that dementia may be under-diagnosed in Australian residential aged care and that health professionals need to do more to diagnose it there^[5].

A 2024 national survey of residential care homes in Portugal found the same pattern. Directors reported that on average 31.7% of residents had a formal dementia diagnosis and a further 22.3% showed signs of cognitive decline without one, so about half of residents (50.2%) had some degree of cognitive impairment. Diagnosis was least formalised in the largest group of homes identified in the study, especially in the non-profit sector and among lower-cost homes^[9].

Cognitive impairment is not the same thing as dementia, and neither study diagnosed residents itself, so these figures show the scale of possible under-recognition rather than a precise count. But the direction is consistent: national figures based on recorded diagnoses, such as those from the US and Wales above, are likely to be lower than the true share of residents living with dementia. For more on how diagnosis gaps are measured, see our study of dementia diagnosis rates.

Residents with dementia have high needs, and are more often given antipsychotics and restrained

People living with dementia in care homes typically need a great deal of support. Among Canadian long-term care residents with dementia in 2015–16, 82% needed extensive help with, or were dependent for, daily activities such as moving, eating and using the toilet, 40% had severe cognitive impairment, half showed responsive behaviours (actions that often express distress or an unmet need), and 31% showed signs of depression^[1]. A systematic review of 28 studies of nursing home residents with dementia found a weighted mean of 82% with at least one clinically significant neuropsychiatric symptom, most often agitation and apathy, and these symptoms tended to persist^[10].

How care homes respond to those needs shows in their quality indicators. In Canada, residents with dementia were more than twice as likely as other residents to be given antipsychotics without a diagnosis of psychosis (27% against 11%) and three times as likely to be physically restrained every day (9% against 3%)^[1]. These are unadjusted rates, so some of the gap reflects differences in residents’ needs. But they also changed quickly once providers paid attention: between 2011–12 and 2015–16, daily restraint use among Ontario residents with dementia fell from 17% to 7%, and potentially inappropriate antipsychotic use from 38% to 26%^[1]. Declines that large over four years suggest that much of this exposure is a matter of practice, and practice can change.

Antipsychotic prescribing to people with dementia, including national targets and trends in other countries, is covered in more detail in our study of antipsychotic prescribing.

Specialist dementia units are widespread, but the evidence for them is mixed

Many countries offer specialist dementia provision in long-term care: special care units, “memory care” floors, and small-scale, household-style homes. Few countries publish comparable national counts of how many residents live in them.

The evidence on whether specialist units improve outcomes is weaker than their popularity suggests. A 2023 systematic review of dementia specialty care units in long-term care included 38 US studies and 54 from 15 other countries. Results were mixed, and the review found no conclusive evidence of benefit for residents, families, staff or facilities, and no rigorous study designs testing which “special” features matter. The features that looked most promising were small-scale settings, staff educated in dementia, and multidisciplinary approaches to care^[11].

An older analysis of the 2004 US National Nursing Home Survey illustrates the mixed picture. Residents of special care units were more likely to receive specialised dementia care and behaviour management than residents of other units, and less likely to have bed rails (adjusted odds ratio 0.39 compared with regular units) or urinary catheters (0.33). They were also less likely to have pressure ulcers or hospital admissions than residents of regular units, but more likely to have falls (adjusted odds ratio 1.32)^[12]. This cross-sectional study shows associations, not effects of the units themselves.

Staffing and training shape the care residents receive

The quality of dementia care in a care home rests on its staff, and the evidence links staffing levels to the way distress is managed. A US study of 14,548 nursing homes certified for Medicare or Medicaid, surveyed in 2017–18, found 1,875 that had been cited by inspectors for inappropriate use of psychotropic medicines in residents with dementia. After adjusting for facility characteristics, including the share of residents with dementia and the presence of a special care unit, homes with more registered nurse hours per resident day had lower odds of such a citation (odds ratio 0.54), as did those with more nursing assistant hours (0.87) and more total nurse staffing (0.87)^[13]. The study was cross-sectional and cannot show cause and effect, but it fits the view that non-drug approaches to distress need enough staff, with enough time, to deliver them.

Staff working in dementia care also carry their own strain. A systematic review of stress and burnout among long-term care staff caring for people with dementia found moderate emotional exhaustion in pooled studies, and linked higher burnout to lower perceived adequacy of staffing, feeling unsupported, poor leadership, a poor care home environment and caring for residents showing agitation^[14]. Wider workforce figures are covered in our study of the dementia care workforce and training.

Training that is well designed and supported can change outcomes. The UK WHELD programme combined person-centred care training for care home staff with social interaction and pleasant activities, delivered through care-home “champions”. In a randomised controlled trial in 69 care homes, residents with dementia in homes using WHELD had better quality of life and less agitation and fewer neuropsychiatric symptoms than those receiving usual care, with modest effect sizes (Cohen’s d of 0.23 to 0.30) and lower overall health and social care costs (an estimated cost difference of £4,740, 95% confidence interval £3,156 to £6,129, in favour of WHELD)^[15]. In an earlier factorial study within the programme, in 16 homes, antipsychotic review alone halved antipsychotic use^[15].

Abuse and neglect in institutional care

Safeguarding is a real concern in long-term care, and people living with dementia may find it hardest to report harm. A systematic review and meta-analysis of abuse in institutional settings, cited by the World Health Organization, found that, across the four studies with staff reports, 64.2% of staff admitted to some form of abuse of older residents in the past year. There were too few studies to estimate an overall rate from residents’ own reports; where residents reported specific types (three or four studies each, with very wide confidence intervals), psychological abuse was most common (33.4%), followed by physical abuse (14.1%), financial abuse (13.8%) and neglect (11.6%)^[16]. These estimates rest on only nine studies, and they cover older residents generally rather than people with dementia specifically. The review’s authors called for better surveillance and monitoring of abuse in institutions^[16]. Countries that regulate care homes generally have routes for raising safeguarding concerns, typically through the home itself, the local authority or the regulator.

What the evidence asks of us

The figures make a simple case: in many of the countries with data, care homes are largely dementia-care settings, and they should be planned, staffed, funded and inspected as such. The evidence points to several things services, commissioners, regulators and governments can do.

• Count residents with dementia properly. Few countries publish a regular national figure for the share of care-home residents living with dementia, and those that do mostly count recorded diagnoses. Studies in Australia and Portugal show that many residents have cognitive impairment without a diagnosis^[5][9]. Routine, standardised resident assessment of the kind Canada reports through CIHI^[1] makes the need visible, and supports diagnosis where it would help the person.
• Staff for dementia care. Higher nurse staffing is associated with fewer citations for inappropriate psychotropic use in residents with dementia^[13], and staff burnout is linked to perceived understaffing and lack of support^[14]. Staffing levels set by funders and regulators should reflect how many residents live with dementia.
• Train every member of staff, and keep supporting them. England’s NICE dementia guideline (NG97) says care providers should give all staff training in person-centred, outcome-focused dementia care, with extra face-to-face training and mentoring for those delivering care, covering responses to distress, reducing the need for antipsychotics, promoting freedom of movement and minimising restraint^[17]. Trials such as WHELD show such training can improve quality of life at lower cost^[15].
• Put non-drug care first. NICE recommends psychosocial and environmental approaches as initial and ongoing management of distress, and antipsychotics only where there is a risk of harm or severe distress^[17]. Canada’s falling rates of restraint and inappropriate antipsychotic use^[1] show that measured, published indicators can drive change.
• Test what “specialist” means. Specialist dementia units are common, but rigorous evaluation is lacking^[11]. Funders of research and care should evaluate the features that look promising, such as small-scale living and dementia-educated staff, rather than the label.
• Monitor abuse and neglect. Abuse in institutional settings is common where it has been studied, and evidence is thin^[16]. Regulators and governments should measure it routinely, with methods that include residents living with dementia.

Related studies in the Dementia & Health research library cover end-of-life care, antipsychotic prescribing and the care workforce.

Language: this piece uses person-first language ("people living with dementia", "people with dementia"), as most dementia organisations and people with lived experience prefer, and uses clinical terms such as "Alzheimer's disease" or "mild cognitive impairment" only where a study, dataset or diagnosis refers to that specific condition.

Why we're publishing this

Most people who live in care homes in countries with data are living with dementia, yet the evidence about their lives is scattered across national statistics, regulators’ indicators and single-country studies. We have brought it together so that dementia charities, carers’ organisations, residents’ families and the people who plan care can make the case that care homes must be designed, staffed and inspected around dementia. The case belongs to residents living with dementia and the people who love and care for them; our job is to set out the evidence plainly.

How to read this data

The figures here come from several kinds of source, and they are not directly comparable. National figures from the US (the National Post-acute and Long-term Care Study, 2022) and Wales (a linked national cohort, 2020) count recorded diagnoses, which are likely to be lower than the true share of residents with dementia. Canada’s figures come from standardised resident assessments reported to CIHI in 2015–16 by participating provinces and territories, and are now some years old. Taiwan’s and Jordan’s figures come from clinical assessment of residents, and Portugal’s from a survey of care home directors. What counts as a “care home” also differs between countries. The specialist-unit and staffing studies are observational and show associations, not causes; the WHELD results come from a randomised trial in UK care homes. The abuse estimates come from a meta-analysis of only nine studies of older residents generally, not people with dementia specifically. Most of the evidence comes from high-income countries; data from low- and middle-income countries, where fewer people live in care homes, are sparse. We could not access Australia’s national statistics or the OECD’s long-term care chapter for this study.

Use this data

Free to cite with attribution to Understanding Aging. Charities, carers' groups, campaigners and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Important: This article summarises published research and statistics for general information. It is not medical, care or financial advice and cannot be used to diagnose, treat or predict anything about an individual. If you have concerns about your own or someone else's memory or health, please speak to a GP or another qualified health professional.

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