The Ever-Shrinking Eldercare Workforce
By Cynthia Lien
“I will take care of her to the very end,” he had vowed.
During this time, I was Erazo’s mother’s geriatrician. Through the eyes and voices of caregivers for people with dementia, I have learned the value of consistent, quality care at every stage of the illness. In reality, however, finding such care can be arduous.
For increasing numbers of Americans, caring for their aging parents themselves could become their only option. A tsunami of frail elders is surging ahead just as the primary supply of direct care workers — many of them low-paid, untrained, and undocumented immigrants — is being depleted by political and economic forces.
“We have this level of need that’s coming, that we do not have the workforce or the systems to meet,” said Nicole Jorwic, chief program officer at Caring Across Generations, a national advocacy group that supports the rights of caregivers and care workers. “As a society, it’s the back-burner issue, but we’re running out of time.”
The final wave of baby boomers is approaching 65 and the number of people living with dementia in the U.S. will balloon from nearly 7 million in 2025 to 14 million over the next 35 years. Adults newly diagnosed with dementia are projected to reach 1 million per year by 2060, nearly twice the rate in 2020.
This rapid growth in older adults, chronically ill and care dependent, is poised to push America’s long-term care system to a critical tipping point. Already, before the surge, there were not enough workers to care for the aging population — even if those like Erazo had wished to lean on them.
Families already shoulder the bulk of care for elders with complex needs. AARP and the National Alliance for Caregiving reported that 63 million family caregivers, mostly unpaid and unprepared, are providing “invisible labor,” struggling to balance care for their parents and children while holding down full-time jobs.
Isolated and stressed, they seek relief from direct care workers — about 30 percent of whom are immigrants who form the backbone of dementia care.
Direct care workers, which include nursing and home health aides, continue to face harsh burdens driven by decades of race, gender, and economic inequities. Nearly half of them, mostly women of color, rely on public assistance like Medicaid and the Supplemental Nutrition Assistance Program, according to the Public Health Institute, a national research and advocacy group. More than one-third live in low-income homes or near the poverty line.
At the brink of survival, many choose to leave care work because of low pay and poor working conditions, leading to critical worker shortages and alarmingly high job turnover rates in nursing homes and eldercare facilities. Workplace injury is nearly five times more common among nursing assistants that work in these spaces than for the average U.S. worker, often leading to extended leaves of absence or job transfers and further driving down worker numbers.
This deficit coincides with the explosion in demand for such workers, a need greater than “in any other single occupation in the United States” according to a 2025 Alzheimer’s Association report. The Public Health Institute estimates 8.9 million total direct care job openings from 2022 to 2032, but vacancies will be tough to fill.
Without a steady pipeline to recruit, retain, and grow a sustainable dementia care workforce, the shortage is “only going to get worse,” Jorwic said. “That same pressure is going to get put back onto families.”
While Erazo vowed to never place his mother into a nursing home, such homes are increasingly hard to find. The worker deficit coincides with more than 800 nursing home closures across the nation in the last 10 years, and nearly 600 more may be at risk of shutting down, leaving family caregivers to support older adults in their own homes and communities as dementia care needs escalate over time.
Many people with severe dementia living at home — the phase when care needs are most intense — are themselves ethnic minorities and foreign-born. Families depend on the comforting presence of a care worker who shares the same ethnicity, culture, and language as the elder. America’s harsh and restrictive foreign policies against immigrants could devastate the hundreds of thousands of noncitizen workers supporting elders in homes and facilities, about one-third of them undocumented, threatening an already strained workforce and families that lean on them.
Loss of a care worker due to deportation or being forced to flee the country out of fear could “disrupt a complete family system,” said Jorwic. Without the critical continuity and communication of a trusted caregiver, elders are at risk of hazardous medication errors and hospitalization, said Amanda Bergson-Shilcock, a senior fellow at the National Skills Coalition, an organization that advocates for U.S. worker education and training.
On top of existing challenges, recent federal budget cuts to Medicaid slashed funds to long-term care services that account for nearly one-third of the $781 billion annual cost of dementia care. The cuts instantly overturned moves in the Biden-Harris era that paved the way for better worker turnover rates, training opportunities, and staffing in nursing homes.
Without federal oversight, and the systems and supports to protect them, dementia care workers continue to face escalating burdens while their stories remain unseen. But care should not be a burden, said Jorwic. And for family caregivers, “our goal is to get to a point where there are enough systems and supports where care is a choice.”
Efforts to fill research gaps and shed light on the dementia workforce are emerging. In July 2025, the Public Health Institute launched the Universal Direct Care Workforce Initiative, a standardized framework for training, credentialing, and building America’s direct care workers.
“It’s a workforce under stress,” said Donovan Maust, one of the principal investigators of the National Dementia Workforce Survey, a database (launched in 2023 and backed by an $81 million National Institutes of Health grant) that gives researchers the opportunity to link Medicare claims data to surveys of dementia care workers and providers, offering critical insights into the workforce. Maust is hopeful that researchers can use the data to find solutions that have “positive downstream effects for the older adults receiving care.”
A more stable, supported, and better-trained workforce “will only have payoffs for everyone,” he said.
Cynthia Lien is a health writer and geriatrician in New York City. She is a fellow in Journalism and Health Impact at the Dalla Lana School for Public Health.
This article was originally published on Undark. Read the original article.
