The Hidden Shortage Behind Dementia Care

I still recall the first time I helped a hospice resident with dementia get through a meal in which she didn't even recognize the source of nutrition for her body, as she didn't recognize the fork or the other utensils on the table. She also didn't recognize me; however, trusted me anyway. That's a lot of what direct care looks like, where there aren't doctors or prescriptions given, but just a volunteer, like I was, who showed up continuously: nonetheless, these people who do it best get squeezed out of it.

CNAs make up about a third of the nursing home workforce, but they are the ones providing up to 90% of the actual care. Bathing, feeding, walking someone down a hall, and calming them down especially during the unsure moments like the one above. It's relentless work, and it's leaving. In Pennsylvania alone, turnover among direct care workers is somewhere between 44% and 65% a year. Additionally, researchers believe the state will be short more than 37,000 workers by the end of this year, and you'll also find almost 800,000 older adults across the country already on waiting lists for subsidized home care- because there is almost no one left to send.

But why? It's because the work is physically brutal and emotionally heavier than almost any higher paying job, and pay is exceedingly low, and promotions barely exist. And the workforce for this job skews heavily toward immigrant women and women of color, many of whom qualify for the same public assistance programs as the people they're caring for. Nearly half rely on programs like Medicaid or SNAP just to get by themselves, while spending their days caring for someone else's family member.

This shortage is a serious public health issue. A CNA who sees the same resident every day is usually the first person to notice the small changes such as a new stumble or a shift in mood that signals something is wrong. That specific, early detection is nearly impossible to replace, and so are the consequences it has. Research already connects workforce instability in long-term care to higher rates of preventable ER visits and hospitalizations, the kind that could have been caught earlier if the same trusted worker had still been there.

Yet, none of this can fix itself. It requires proper wages,and training built specifically around dementia care. A handful of states have started building dementia-specific credentialing programs through community college, but that is nowhere near enough for how fast this population is aging.

Somebody, somewhere will be holding that fork steady in the future. We should be asking how that's going to happen, and whether we're doing anything now to make sure the answer isn't "no one."