This chapter considers the costs of long-term care for service users and their families, and the policies that are necessary for adequate financial protection. The main focus is on home care services due to the substantial gap in evidence regarding their affordability. Given the widespread preference for home-based care, particularly in Europe where the majority of long-term care users reside at home, understanding the financial implications of these services is crucial. While decisions about home care primarily prioritize users’ wellbeing, financial considerations also shape care arrangements. Overall, common protective mechanisms such as caps on out-of-pocket payments income-based and means tests seem unable to successfully protect long-term care users from experiencing catastrophic spending.

Population ageing coupled with a growing burden of disease and disability will cause long-term care needs to increase considerably around the world. Yet despite changing demographics, many countries do not invest adequately in long-term care systems. This chapter sets out the reasons that long-term care is often underprioritized by governments and begins to consider why countries need a re-think when it comes to the way they care for older adults.

This chapter explores how common challenges facing long-term care systems across the world have given rise to common trends in the development of long-term care service delivery - a focus on improving integration, the shift from residential care to home- and community-based care, the growing role of the private sector in care provision and the emergence of digital technologies with transformative potential. Recent developments in five countries (Germany, Japan, Sweden, Norway, and Romania) are used to exemplify and distil overarching lessons for strengthening long-term care service delivery.

This chapter examines the potential economic impact of investing in long-term care systems. Long-term care systems often indirectly burden informal caregivers, primarily women, leading to a significant loss of potential income and economic growth opportunities. Without adequately compensated, trained care professionals, it’s challenging for unpaid informal caregivers to increase their labour market participation. A comprehensive long-term care system must include support programs and policy changes that encourage both informal and formal caregivers to participate fully in the workforce, which is vital for economic growth and productivity.

This chapter reviews the strategies countries are employing to improve the quality of long-term care for older adults and assesses the impact of these approaches. Given that long-term care is a relatively new component of welfare systems, there is limited evidence on effective quality improvement measures. The scarcity of data on care quality in most countries further complicates the evaluation and comparison of these strategies. Despite these challenges, the chapter provides an overview of various quality improvement approaches, utilizing available evidence to understand their effects on the quality of long-term care.

This chapter examines the challenges in measuring long-term care needs to determine eligibility and the impact of eligibility rules on access to care and wellbeing, focusing on European countries with established long-term care systems. Eligibility rules are crucial for identifying individuals with the greatest need and ensuring equitable resource distribution, yet defining these rules is challenging due to the lack of a universal approach to measuring health and social needs. Consequently, some individuals with functional or cognitive limitations may be inadequately supported or face high out-of-pocket costs, leading to reliance on informal care or unmet needs. This can reduce their independence and increase the risk of costly hospitalizations. The chapter advocates for expanding eligibility rules to improve coverage, equity, and efficiency, highlighting their role in increasing access to care, reducing poverty due to care costs, and enhancing wellbeing.

This chapter concludes by summarizing the evidence presented in the book and considering the way forward by re-visiting the arguments in favour of investing in long-term care and the costs of inaction.

With global population ageing and shifting morbidity and disability patterns, the demand for long-term care is increasing. The chapter highlights the impact of demographic changes, particularly the rise in the older population and the growing need for dementia care, on long-term care demand. It advocates for a paradigm shift from institutionalized nursing homes to home-based care and stresses the need for policy support to enhance informal caregiving and develop a robust long-term care workforce. Additionally, it underscores the significance of recognizing long-term care as a social and human right and establishing a regulatory framework to ensure high-quality care.

The aim of this chapter is to illustrate how a robust long-term care system can positively influence the overall wellbeing of society, extending beyond the individual receiving care. Since the primary recipients of long-term care are often older or disabled individuals, it is sometimes viewed as a costly burden on society rather than an investment in the public interest or the common good. This chapter seeks to challenge such perceptions by emphasizing the positive and proactive social impact of a strong long-term care system on society as a whole. By highlighting these arguments, the chapter aims to provide further justification for countries to invest in their long-term care systems.

This chapter explores methods of financing long-term care. These include public financing, which involves government-managed programs funded through taxation and social insurance schemes, and private financing, which includes out-of-pocket payments and family contributions. The chapter also considers how resources are pooled and allocated, as well as policy decisions regarding public care coverage and financial protection. Short case studies illustrate the practical functioning of different financing models. Finally, the chapter considers the evolution of long-term care expenditure in the context of an ageing population.

This chapter explores the available evidence on how long-term care influences health systems. While the focus is primarily on high-income countries, the issues discussed are relevant to low- and middle-income countries facing rising demands for long-term care as populations age. Overall, the literature suggests a strong long-term care system has many positive consequences for the health sector and for the health and well-being of older people.

Delusional disorder is a mental illness characterized by the presence of one or more delusions for a period of at least one month. Delusional beliefs are based on the misinterpretation of external reality and are not made better with education or persuasion. The prevalence of delusional disorder in older adults is thought to be double that seen in younger adults. The occurence of delusional disorder is more common in later life when compared to other psychotic disorders such as schizophrenia. Seven subtypes of delusional disorder are recognized in the DSM-5. These include persecutory type, somatic type, jealous type, grandiose type, erotomanic type, mixed type, and unspecified type. Response to treatment of delusional disorder with antipsychotics is fair.

Chronic alcohol use disorder is an important cause of major neurocognitive disorder. There are several suggested mechanisms for how alcohol use disorder leads to major neurocognitive disorder. Medical treatment of alcohol use disorder can help limit the late effects of alcohol use. Alcohol-induced major neurocognitive disorder can be partially reversible with abstinence but this depends on the severity of the pathology.

Sundowner syndrome is a common neuropsychiatry syndrome seen in residents of long-term care. Several theories are proposed to explain the pathophysiology and contributing factors. Treatment options are also discussed.

Traumatic brain injury (TBI) is more common in older adults than any other age group. It is the most common fall-related injury in adults over the age of 65. The pathogenesis of TBI involves multiple mechanisms. Medications generally do not alter the course of the disease process but can treat the neuropsychiatric symptoms. Mood and anxiety disorders are commonly comorbid with TBI.

The potential of substance use disorders in older adults is often overlooked in a general health assessment. Substance use disorders have a high comorbidity with other psychiatric disorders. Physiologic changes in older adults make them more susceptible to the negative effects of alcohol use. With the proper support and resources older adults with alcohol use disorder can live a healthier, happier life free from alcohol. Cannabis use is increasing in all age groups including older adults. Be aware that older adults may be using cannabis to self medicate psychiatric conditions such as anxiety and depression or to treat chronic pain despite limited evidence for long term improvement. Older adults may be at risk of opiate use disorder due to chronic pain issues, multiple medical comorbidities, and psychiatric comorbidities. Treatment options for opioid use disorder such as medications, outpatient treatment programs, and psychosocial supports are often as effective in older adults as in younger patients.

Delirium as a complex neuropsychiatric syndrome characterized by disturbances in attention, awareness, and cognition that are not explained by a pre-existing neurocognitive disorder. The causes of delirium are varied. The most common causes of delirium in the long-term care setting are likely urinary tract infections, untreated pain, and medication side effects. The initial steps recommended in managing delirium involve identifying and addressing underlying medical conditions, reducing environmental triggers, and minimizing exposure to drugs. Besides treatment of the cause, management of delirium primarily involves psychosocial interventions. These can include environmental modifications such as addressing poor lighting, excessive noise, or lack of orientation cues.