Intellectual impairment alone can make institutionalization necessary. Even supportive families may find disruptive behavior, such as nocturnal wandering or paranoia, intolerable. If 24-h care is required, nursing home placement may be appropriate. But mildly to moderately demented patients can often function quite well in their own familiar environment, especially if families have been taught coping strategies for dealing with dementia and periodically get some respite (see RESPITE CARE in Ch. 25). Physicians and other care providers must be supportive not only of the patient but of the family as well.

Consideration must be given to whether potential caregivers are willing and able to perform the tasks necessary to keep the older person at home. Strongly motivated families usually can perform elaborate and detailed care, but they may be indifferent or become resentful or worn out from assuming such responsibility. Home care often involves a long-term commitment and may prove an unremitting burden to a family. Physicians should watch for and be ready to intervene if elder abuse is suspected (see Ch. 111). The very old may be cared for by equally aged spouses or elderly children whose own frailty or impairment may preclude providing the necessary care, regardless of how much they may wish to do so.