What Geriatrics Could Learn From the History of Psychiatry

Global health policies and the World Health Organization consistently promote aging in place, reflecting the strong preference of older adults to remain in their home environments. Yet frailty, cognitive decline, caregiver exhaustion, and social vulnerability frequently make nursing home admission necessary and position institutional care as the default response to severe dependency. The COVID-19 pandemic exposed vulnerabilities of nursing home care and renewed debate about the sustainability of a nursing home-centered model. Drawing a historical parallel with psychiatry's asylum-based system, this article argues that nursing homes share structural, organizational, and symbolic similarities with former psychiatric institutions, whose development was strongly influenced by political, economic, and regulatory considerations rather than primarily by robust public health evidence. Psychiatry's deinstitutionalization illustrates how pharmacologic advances, patients' rights, public policy, and community-based alternatives can interact to reduce reliance on institutional settings. However, the analogy has clear limits: advanced dementia and severe frailty are generally progressive conditions that may require assistance and continuous supervision despite optimal care. The history of psychiatric deinstitutionalization suggests that moving beyond institutional dominance requires challenging established models and developing innovative responses adapted to the specific needs of older adults. The issue, therefore, is less whether nursing homes should be dismantled than whether they should remain the universal model of long-term care. Emerging alternatives, including hospital at home, coordinated community care, small-scale residential models, dementia villages, and adult foster families, may broaden options while addressing both older adults' needs and caregivers' constraints. Nursing homes should consequently become one component of a pluralistic long-term care ecosystem, supported by policy and resource allocation that promote models capable of combining intensive care, safety, autonomy, social inclusion, and caregiver support.