Ageing: where should we live?

At home, supported by family caregivers, or in an institution?” A story that needs nuance—and a system that needs rethinking. An op-ed by Jérôme Schoenmaeckers, lecturer at HEC – ULiège Management School.

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I want to stay in my own home.” This refrain echoes like a mantra in European discussions on ageing. It signals both a deep attachment to autonomy and a certain rejection of institutionalisation—exacerbated by the Covid crisis and the excess mortality observed in care homes.

Victor Castanet’s investigative book Les Fossoyeurs, published in January 2022 and documenting abuses within French EHPADs (nursing homes for dependent elderly people), further accelerated this shift toward ageing in place. This desire to remain at home is not neutral. It is fed by anxieties (about dependency and abandonment) and by a poor grasp of the many realities of very old age. Thanks to the SHARE survey (“Survey of Health, Ageing and Retirement in Europe”) and several recent studies based on its data, this vision can be deconstructed, enriched, and—above all—reframed for the policy trade-offs ahead.

The SHARE survey is an essential tool for analysing issues related to loss of autonomy and end of life. By interviewing every two years tens of thousands of people aged 50+ across more than 25 European countries, it tracks changes in their health, living conditions, support networks, and care preferences. Thanks to its longitudinal design, it documents individual trajectories, such as entry into a nursing home or an intensification of family support. It makes visible the central role of informal caregivers, inequalities in access to care, and the effects of national contexts on end-of-life pathways. The data are comparable across countries, helping to inform public policy on ageing. Freely accessible to researchers via its website, SHARE offers a valuable basis for better understanding and anticipating dependency-related needs in Europe.

Better at home?

Voluntary entry into a nursing home—or a compelled placement in an institution—often prompts hesitation, not only for older people themselves, but also for their families. For the vast majority of those admitted, it is more than likely their last move. Recent research suggests the experience can be more positive than many assume. At first glance, the answer seemed obvious: people living in nursing homes reported substantially lower life satisfaction (an 8-point gap) than those still at home. However, once individual characteristics are taken into account—especially the level of dependency (the ability to wash, dress, or prepare meals unaided), as well as sociodemographic factors such as age, sex, education, and economic resources—the well-being gap between the two groups tends to disappear.

A major challenge in this kind of empirical analysis is selection bias. People who move into nursing homes often differ from those who do not. In the context of ageing, we can readily imagine that beyond a certain level of disability, staying at home becomes difficult; that such individuals receive less family support; or that they were already less happy beforehand. To probe further, we used more sophisticated methods to approximate a “fair comparison.” By matching people with similar health, family circumstances, and finances—one living in a nursing home and the other at home—the finding was stark: nursing-home residents were still slightly less satisfied with life overall.

But SHARE is more than a series of snapshot “photos” of a population. Its real richness lies in its longitudinal dimension, which follows the same individuals over time. For those whom we can observe and interview repeatedly, the results reverse. The longitudinal data reveal a paradox: once health conditions are accounted for, life satisfaction in a nursing home is no lower than at home. Better yet, some profiles—notably people who live alone or are highly dependent—can see an improvement in their subjective well-being after entering an institution.

This observation challenges certain received ideas. Nursing homes, often seen as places of retreat or loss, can in reality provide a more appropriate setting for people with reduced autonomy. For a senior losing mobility or requiring continuous assistance with daily activities, an institution offers a safe environment, round-the-clock care, and relief from physical and mental burdens.[1]

The results therefore show that, in specific cases, entering an institution is not a resignation but a solution adapted to a complex health situation. This calls into question the idealisation of “home.” We should move beyond a stigmatising view of the nursing home as a last resort and recognise that, where home support is no longer sufficient, it can be a concrete improvement in living conditions—bearing in mind that staying at home presupposes substantial support, often provided by family.

The importance of family caregivers

To remain at home, dependent older people need family caregivers able to support them day to day, especially with essential activities they can no longer perform alone: washing, dressing, eating, moving about. The pattern most frequently observed is this: when a partner becomes dependent, it is often his wife who provides daily care. A few years later, as the spouse grows old in turn, responsibility gradually shifts to the children (particularly daughters), who become the new caregivers—often informally and without institutional recognition.

Motivations for providing care are multiple. Far from pure altruism, they weave together various logics: attachment, expectations of reciprocity, family pressure, moral norms. European data highlight differences by kinship tie, caregiver sex, and family configuration. People help their biological parents more than in-laws, and are more inclined to help a same-sex parent. These preferences affect the fairness of how care is shared and raise the issue of an implicit familial duty. Some older people are well supported; others are nearly abandoned. The supposed “freedom to choose” where to live collapses in the face of the actual structure of available support. Family trade-offs around elder care rest on a delicate balance. Children (more often daughters) still provide most day-to-day help, but must now juggle other responsibilities, notably grandchild care—frequently relied upon by adult daughters to sustain their employment. This “sandwich generation,” caught between two streams of solidarity, faces invisible fatigue, persistent mental load, and painful choices between availability, work, and personal balance.

This gendered distribution of care is consistent across countries, though more pronounced in Southern Europe. It reflects not only persistent social norms but also an economic reality: women more often adjust their paid work to care for a parent. The investment has a cost—slower careers, reduced income, physical fatigue, emotional strain. Within sibling groups, the division of care gives rise to subtle, sometimes conflictual trade-offs. One child—often deemed the most available or emotionally closest—finds themselves on the front line. This burden may be experienced as a moral duty or as an unspoken inequality, made heavier when other family members do not contribute equitably. Such silent tensions can undermine family relationships and isolate caregivers. When helping a dependent parent is felt as compulsion, negative effects on the caregiver’s mental and physical health appear quickly.

Nursing homes: under what conditions?

Although ageing in place is increasingly favoured, it rests on conditions far from guaranteed: formal home-care services often lack resources, staffing, or continuity, while informal care (provided by relatives) is not always available, feasible, or desired. In this context, we need to revisit institutionalisation—not as defeat or failure, but as an option to consider lucidly, according to the person’s real needs and the quality of the care provided.

Not all nursing homes are alike. Quality varies widely by status (public, for-profit, non-profit), funding, and clinical staffing. In some countries, for-profit facilities are the majority, and quality differences are stark. This translates into gaps in mortality and resident satisfaction. The better-off can choose higher-quality settings, while those with fewer resources have limited options.

Mortality data show an apparent excess mortality among nursing-home residents. But this is difficult to interpret. It may reflect residents’ poorer initial health or institution-specific effects (lack of individualised care, emotional isolation, psychological impacts). The most recent work converges on an uncertain causality that depends on national contexts. In other words, it is not the nursing home per se that kills, but the conditions under which it operates.

Toward policies of solidarity-minded sobriety

Ultimately, the aim is not to pit two models against each other but to think in terms of a plurality of responses. Staying at home should be a real possibility, not a default constraint. Entering an institution should be a supported choice, respectful of the person and their story. Between these poles, alternatives are emerging: shared housing, intergenerational co-living, host families. These newer forms deserve support and evaluation.

The looming budget pressures in many European countries demand honest reflection: it will not be possible to universalise professional care or to build large numbers of high-quality nursing homes without trade-offs. But it would be dangerous to respond solely by valorising informal care with no reciprocity. Several avenues emerge from SHARE-based research:

• Support informal care without over-exploiting it: caregiver leave, respite arrangements, targeted and unconditional financial support. The point is not to monetise family affection, but to recognise that care has a cost—and that cost cannot fall solely on the shoulders of 55-year-old women.
• Raise the quality of existing institutions rather than just building new ones: through care standards, training, stronger inspection, and involvement of residents and families in governance.
• Back hybrid living arrangements: co-housing, intergenerational living, host families for older adults. These solutions are less costly and often more humane, but remain marginal for lack of regulatory recognition.
• Make “choice of living arrangement” an enforceable right: every dependent person should have access to neutral, well-informed support to choose among available options, plus help to see that choice respected.
• Base ageing policy on reliable, longitudinal data such as SHARE’s: too many policies offer ad-hoc responses to poorly defined needs. Only an analysis of life-course trajectories can pinpoint critical moments, at-risk profiles, and mechanisms of breakdown.

A Time of Life to Be Built

Findings from the SHARE survey reveal a fundamental paradox: the best place to grow old is not always the one we think we prefer, but the one that concretely meets our needs—taking account of our health, our entourage, our gender, our resources, and our life story. Research still has much to contribute. We must better understand transition trajectories, the differentiated effects of care types, and the impacts of institutionalisation on psychological well-being. We must also amplify the voices of those directly concerned, too often absent from public debate.

Old age should not be conceived merely as extra years to manage, but as a phase of life to be built collectively—with genuinely attainable choices, equitable supports, and dignified institutions. That means no longer opposing informal and professional care, home and institution, autonomy and protection. Above all, it means abandoning the belief that a preference for “home” is enough to guide a just ageing policy.

Beneath the question of where we live lies a certain idea of citizenship: a society able to care for its elders without infantilising them; to recognise the value of informal care without exhausting it; and to guarantee everyone a dignified, chosen, and meaningful end of life. A society where we do not merely die somewhere, but surrounded, heard, and respected. What we face is less a crisis of old age than a crisis of our imaginaries, our budgetary priorities, and our capacity to confront, together, the following question: what meaning do we want to give to the last part of our lives?

[1] This analysis does not address cases of institutional abuse that have recently made headlines—notably in France—nor the risks sometimes present in ageing at home when adequate support is lacking.