It started with missing clothes.

An 82-year-old woman with moderate dementia began throwing her garments, and sometimes her bedsheets, from the window of her HDB flat.

Her children, both in their 50s and juggling full-time jobs, tried to adapt. They installed window grilles, hired a part-time helper and took turns staying overnight with her. But the episodes became more frequent and unpredictable. One afternoon, she left the flat unnoticed and was found hours later, disoriented and dehydrated, at a nearby void deck.

That incident shattered their fragile confidence. Out of concern for her safety and with no clear alternative, they took her to the Institute of Mental Health (IMH) – not because she was mentally ill, but because they no longer knew how to look after her.

They worried for her safety. They feared for their jobs. And they felt ashamed that what once seemed manageable now felt impossible.

This is not an isolated incident. Across Singapore, more families are turning to institutional care – not because they do not care, but because they are overwhelmed. Between 2016 and 2020, the number of nursing home beds increased by about 25 per cent, from 13,000 to about 16,500, reflecting the rising demand for long-term care services.

While population ageing explains the broader demand for institutional care, research shows that caregiver burnout is often the tipping point.

A 2018 Lien Foundation study found that over half of caregivers for persons with dementia in Singapore considered institutional care not out of preference, but because they could no longer cope. These are not failures of affection but collapses under pressure.

A 2022 survey by the National Council of Social Service found that 37 per cent of caregivers had to provide care by themselves, and over half were classified as “burdened” or “barely coping”, with lower quality of life scores across physical, psychological and social domains.

No wonder, then, that under these stretched circumstances – and given that it is unpaid work – some families may see caregiving as a burden. As a result, compassion can be lost.

Caregiving becomes regarded as something to be delegated or managed externally. Grandparents can be viewed as logistical complications. The guiding question is no longer “How can I help?” but “Can I manage?”

Institutionalising someone should not be the first or only option when caregiving becomes difficult. Nor should families feel like they must choose between self-sacrifice and collapse or guilt.

We cannot just expect more from families. We must also enable them. The modern family dynamic

In past generations, the family was the first and often only line of care. The elderly lived with their children. Those with mental illness were supported by siblings. Extended families rallied around children with special needs.

This was not considered heroic – it was expected. The burden was shared, driven by love, duty and cultural values.

This was possible because society’s structure made it feasible. Larger households, multigenerational living and strong norms of filial piety supported such care. Early public housing policies even encouraged extended family proximity. And in 1995, the Maintenance of Parents Act codified what had long been a moral norm: that families should care for their own.

Today, family dynamics have shifted. We live in smaller households. Most adults work full-time. Life expectancy has risen, as have the number of years people live with chronic illness or disability. So, more years are spent looking after the elderly and infirm than before.

As a result, many families are stretched thin, not just financially, and in terms of time available, but also emotionally.

When the responsibility becomes too overwhelming – whether for an elderly parent with dementia or a child with special needs – families often turn to structured support.

This can include daycare centres for eldercare or disability support, home nursing and home medical services, residential nursing homes, community-based dementia care, and crisis shelters or psychiatric services in more severe cases

However, the surging demand for such services brings its own problems.

Waiting times for placements can stretch from months to years. Similarly, demand for eldercare centres, home-based care and dementia services is expected to continue climbing in tandem with Singapore’s rapidly ageing population.

IMH bears some of the brunt of this pressure on services and support, as the most disturbed of these individuals – whether elderly or young – come for admission.

Helping fill the gap between family and institutional care are migrant domestic workers (MDWs). In 2024, more than 301,600 MDWs were employed in Singapore. While not all are caregivers, a substantial proportion look after elderly persons, individuals with dementia, or persons with intellectual disability. This marks a steady rise from 261,800 in 2019, reflecting an increasing reliance on domestic help for caregiving.

All these services are necessary and invaluable – but they were never meant to replace the emotional bonds of family.

Professional care offers consistency and structure. But it cannot replace the continuity, love and trust that come from a familiar face. Studies have shown that relational care – especially from family – has positive effects on mental health, recovery and behavioural outcomes. For individuals with dementia, familiar caregivers reduce confusion and improve emotional stability. In children with developmental delays, a stable caregiver relationship fosters resilience and trust.

It is clear to me – from the case of the elderly woman with dementia and the others we have seen admitted to IMH by caregivers at the end of their tether – that this growing reliance on institutional care is not due to apathy.

It is a signal that families want to care, but often lack the tools, training or respite to sustain that care over time.

What is needed today is a blended model, where professional services work alongside empowered families. Where social safety nets do not replace families but sustain them. And where compassion is not bureaucratised – it is lived out, face to face, at the dinner table and beside the hospital bed.

Supporting family caregiving

But to do that, there are key gaps to fill.

Early intervention is lacking. Currently, support often kicks in only when families are in crisis. We should not wait till then. Once a family is identified with special needs in elder or childcare, they can be provided with additional help in the form of community-based training.

Primary care practitioners and social workers can be trained to provide the necessary link-ups from the moment a diagnosis suggestive of long-term care is made.

Structured and planned respite care – which gives caregivers short breaks from their duties – is limited. Greater awareness, simpler application processes and flexible eligibility could help more families benefit.