Rethinking responsibility in dementia care

Last year, I traveled to Japan to report on a small group home for older adults with dementia. Unlike large institutional nursing facilities, the home specialized in providing personalized care to just five to nine residents per floor. Across its three floors, 27 residents were supported by 25 care workers. Even overnight, staffing levels ensured at least one caregiver for every three residents. The difference with South Korea was striking, where a single caregiver often cares for five to eight dementia patients in a typical facility.

Residents were not confined indoors. After breakfast, they went out for walks in pairs or small groups accompanied by staff. Children from a nearby kindergarten visited regularly to draw with them, and the home hosted joint celebrations for Halloween and traditional holidays. When asked how the facility had lowered barriers with the community, an official said, “It is vital that older adults with dementia not remain isolated but engage with neighbors and spend their final years as members of the community.” The remark underscored a sobering reality in South Korea, where many dementia patients spend their remaining years in isolation at home or in care institutions.

Japan was not always a society accommodating toward dementia. Exhausted family caregivers sometimes committed homicides, and many elderly patients experienced abuse or neglect. As the population aged rapidly, projections indicated that by 2040 roughly 18 million people, about half of the elderly population, could be living with dementia. In response, the Japanese government began advancing comprehensive dementia policies in the late 1980s. In 2004, it replaced a term that carried connotations of foolishness with “ninchisho,” meaning cognitive disorder, in an effort to reduce stigma.

These sustained efforts have helped transform Japan into a society often cited for achieving coexistence with dementia. One example is the more than 8,000 dementia cafes operating nationwide. Once a month, older adults with dementia work there as servers, taking orders and interacting with customers. At other times, the cafes serve as community gathering spaces for families of people with dementia or children with developmental disabilities. Local governments and businesses actively support the initiative. Through the combined efforts of the government, companies, and affected families, awareness has grown that people with dementia or disabilities are not to be segregated but embraced as neighbors.

In South Korea, where the number of people with dementia has reached about 1 million, the situation looks different. In 2017, the government introduced the “state responsibility for dementia” policy, pledging to ease patients’ medical expenses and expand specialized facilities. While these measures reduced the financial burden for some patients with severe dementia, nearly a decade later few citizens feel that the caregiving burden on families has been significantly eased or that public perceptions of dementia have improved substantially.

The recently unveiled fifth comprehensive dementia management plan for 2026 to 2031 offers a similar outlook. Aside from a proposed public trust system to manage the assets of dementia patients, few new initiatives stand out. Although the plan lists 73 detailed tasks, most involve expanding existing programs, such as dementia relief hospitals and primary physician systems.

The most urgent priority is to strengthen support for elderly people living alone, who account for 52.6 percent of dementia patients, as well as for patients in rural and fishing communities where care infrastructure remains limited. Rather than relying solely on the sweeping slogan of state responsibility, policymakers should consider granting greater authority to local governments, which are most familiar with community needs. Better coordination of fragmented budgets across ministries could also help establish dementia-friendly villages comparable to those in Japan or Europe.