OGNITIVE IMPAIRMENT, ESPEcially severe impairment or dementia, is one of the primary indications for nursing home placement. As many as 90% of patients with dementia reportedly become institutionalized before death. 1 However, most patients with dementia continue to live in the community until family caregivers are no longer able to care for them. 2 The decision to place a patient with dementia in long-term care is complex and is based on patient and caregiver characteristics and the sociocultural context of patient and caregiver. Yet most studies that have assessed the predictors of nursing home placement have focused primarily on the characteristics of either the patient, such as dementia severity or difficult behaviors, 1,[3][4][5][6][7][8] or the caregiver, such as subjective burden or health status, 9,10 and few studies have comprehensively investigated how both caregiver and patient characteristics influence nursing home placement. In addition, most studies that have investigated predictors of nursing home placement of Author Affiliations are listed at the end of this article.

Caregiver depression is a complex process, influenced by ethnicity as well as diverse patient and caregiver characteristics. Efforts to identify and treat caregiver depression will need to be multidisciplinary and focus on multiple risk factors simultaneously.

The findings emphasize the importance of incorporating both care recipient and caregiver function and service use patterns when targeting programs designed to prevent or delay institutionalization for people with dementia.

The findings suggest the practical importance and cost-effectiveness implications of early community-based service use, and they emphasize the role of timing when one is conceptualizing the proliferation of stress in the dementia caregiving career.