Worldwide, the development of long-term care systems which ensure a good quality of life for dependent older people, by considering their individual preferences, is a challenge.1 In order to achieve this, a comprehensive approach to assess older people care needs is essential.2 Both, formal and informal care systems, must be able to address dynamically those needs, through multidimensional, valid and reliable person-centered evaluation instruments.3–5 Whilst most needs assessment tools focus on specific needs, such as physical, social or psychological,6 the Camberwell Assessment of Need for the Elderly (CANE) constitutes a comprehensive geriatric assessment which includes a wide range of needs. A previous literature review looked at instruments for assessing the needs of populations with chronic diseases. Out of sixty-three instruments found, only one evaluated a wide range of needs in an integrated way: the Camberwell Assessment of Need (CAN). This tool focused on middle age adults and is the predecessor of the CANE.6

The CANE assesses the extent to which formal and informal care systems manage to meet the needs of older people.3 Needs are divided into four dimensions, covering a total of 24 areas: the Physical Dimension, includes areas of Physical Health, Medication, Eyesight/Hearing/Communication, Mobility/Falls, Self-care and Continence; the Environmental Dimension, containing Accommodation, Looking after home, Food, Caring for someone else, Money, and Benefits; the Social Dimension, focused on Company, Intimate relationships, Daytime Activities, Information, and Abuse/Neglect; and lastly, the Psychological Dimension, including areas of Psychological Distress, Memory, Inadvertent self-harm, Deliberate self-harm, Substance abuse/dependency, Behavior, and Psychotic symptoms and delirium. For each area, the evaluator can identify if a need is present or not and whether a need is met or unmet. A “met need” is defined as a situation in which a person, who has difficulties in an area, is receiving appropriate help.7 On the other hand, an “unmet need” exists when either the adequate level of evaluation or care is not being received.7 This approach makes possible the identification of assistance gaps and relevant areas for interventions to take place, and especially, it shows priorities of the person from their own perspective. In addition, the final average of met and unmet needs indicates in which grade the needs are being covered for a group of people, allowing comparisons with other groups. Furthermore, this questionnaire considers three perspectives of needs which can be compared: older people's, their caregiver's, and the reference health professional's views on needs. Evidence shows that these perceptions may differ8 since professionals and caregivers may be ignoring some needs of the older person.7–10 Finally, the presence of unmet needs is an element that must be addressed, as it has been associated with both, a decrease in quality of life, and an increase in disruptive behavior and depressive symptoms in the older population.11–13

Over the last two decades, different lines of research have been developed with the CANE questionnaire, assessing the needs of older people in a variety of countries, with different levels of morbidity, functionality, and of those who use several types of services (long-stay institutions, day center, primary care, memory clinics, among others). However, a review on the patterns of needs found within these diverse contexts has not yet been carried out. In a recent meta-analysis8 about the needs of older people with dementia living in the community, it was found that their most prevalent total needs were mainly in the areas of memory, food, looking after home and money. That is, most of the support required by people with dementia was located in the environmental dimension. However, nothing was mentioned about which areas of needs were met or unmet. In fact, the authors concluded about the relevance of examining the variation of met and unmet needs separately.

Therefore, the main objective of this review was to describe met and unmet needs of dependent older people living in the community or in institutions, evaluated through the CANE instrument, and which factors are associated with those needs.

Almost all the included studies had a cross-sectional design, except one.15 All of them used non-probabilistic samples, were written in English language and most came from Europe, with some exceptions.16,17 Regarding sample sizes, most of the studies comprised a small sample (within a range of 44–407 participants)18,19; except for Hoogendijk20 and Stein21 (with a sample of 1137 and 1179 people respectively). In addition, most participants were women with an average age ranging from 69 to 87 years.22,23 As can be seen in Table 1, a large part of the studies (n=13) focused on older people living in the community (recruited through general practitioners’ centers, primary care, day centers, social systems, among others). Eight studies included institutionalized older people, mainly in residential care (n=6), mental health centers (n=1), or hospitalized (n=1) (see Table 2). Most institutionalized people had an average age over 80 years.15,23–27

All studies sought to identify the needs of the older person, and which factors could be associated with an increase in total or unmet needs. Nine studies analyzed the level of agreement between older people's own perspective of needs and their family caregiver views9,12,23,27–32 and five compared the older patient reports with those from health professionals.3,9,12,22,27 Finally, two studies aimed to evaluate the psychometric properties of a version of the CANE questionnaire, as well as its feasibility.3,30

Regarding participants’ cognitive status, four studies recruited only older people without cognitive impairment,12,19,20,22 while ten explicitly focused on people with some degree of dementia.16,23,26–29,31,32 However, all the analyzed studies in this review excluded older people with advanced dementia or communication problems that prevented them from answering the questions of the CANE. In addition, due to age inclusion criteria of the present study, those studies focused on early onset dementia ended up being excluded. Four articles were centered on different mental health problems, such as depression, bipolar affective disorder and schizophrenia9,12,21,22 and two studies specifically considered older people with physical health problems, such as fragility and arthritis.19,20 It should be noted that most of the articles did not report information on comorbidity and the general health status of the participant. Particularly, in the case of studies focusing on mental health problems, no morbidity was reported in the area of physical health. In the cases where morbidity was described,15,25 most of the participants presented a high level of comorbidity (diabetes, stroke, arthritis, cancer, chronic lung disease, among others).

This scoping review shows that the number of unmet needs tend to be higher on institutionalized older people compared to those living in the community. Even though the staff working at long term care facilities should have the skills required or at least have some training to address all types of needs, most unmet needs were psychosocial, while physical and environmental needs were mainly met. Nevertheless, this fact can also be explained because institutionalized people tend to exhibit a greater burden of morbidity, particularly cognitive impairment, which implies more needs to be addressed. In addition, a high number of unmet needs in institutionalized people can also be explained by the search of autonomy of the older person, who wishes to be part of the decision-making process and to receive individualized attention, expectation that may clash with the administrative and organizational demands of this context (as lack of time and resources).11,33

The review also shows a lack of agreement between the care recipient and their formal or informal caregivers, a phenomenon already observed in qualitative studies, which accounts for the subjective way in which needs are prioritized and perceived.5 A meta-analysis8 that explored the number of total needs of people with dementia, found that their informal caregivers reported higher level of total needs in 23 of the 24 areas of the CANE, with a significant disagreement in several of them. According to its authors, this discrepancy could be either due to real differences in perception, or because in some studies the participants had high levels of cognitive impairment so the CANE was answered only by the caregiver, who tend to report higher level of needs particularly when the care recipient had a more serious condition. In addition, the differences on needs reported between the care recipient and their caregivers can be explained as psychosocial needs tend to be more complex and dynamic so caregivers might have difficulties in assessing and addressing them.6 The fact that psychosocial needs were systematically less satisfied compared to environmental or physical needs is consistent with previous evidence showing that older people refer that the psychosocial aspects of their needs, such as facing the demands associated with aging, finding meaning and purpose, being accepted and respected, receiving accompaniment, among others; are usually ignored.5,11,34–36 Another possible explanation for the lack of agreement could be that, even though medical diagnoses tend to make some needs more obvious, they also make others needs less visible. For example, Houtjes et al.12 found that all participants in their study had major depression and, as expected, mental health professionals adequately identified their psychosocial needs, however, mental health workers reported fewer physical and environmental unmet needs compared to patients. The lack of coincidence between different care actors is an important issue considering that it could negatively affect patient's adherence to treatment, and the quality of the therapeutic relationship which depends largely on agreed goals.37,38

People with dementia tend to report more met and unmet needs on average than people without cognitive impairment, which shows how complex this disease is, and how it affects several aspects of a person's life.34,35 When compared to informal or formal caregivers, people with dementia report fewer needs. This could be explained for several reasons. First, cognitive impairment could affect individual's ability to detect their unmet needs. Second, while caregivers spot more “external” needs such as daytime activities,31 people with dementia may prioritize their needs differently, putting needs associated with their inner world (psychological discomfort) in first place. On the other side, reporting less needs may be due to a form of coping with the losses associated with dementia through denying or minimizing symptoms to maintain a sense of control.36 Likewise, it has been found that some older people in institutionalized contexts prefer to wait as long as possible to ask for help, for fear of being considered a burden and consequently discouraging needs report.33

According to this review, there is an association between mental health problems (especially depressive symptoms and cognitive impairment) and the presence of unmet needs, as well as informal caregiver's burden. Although it has not been established a causal relationship between mental health factors and unmet needs,39 this association could be explained as a mutual impact, where mental health problems represent a state of vulnerability in which the person experiences difficulties to meet their needs, which in turn can aggravate mental health problems of the older person and their informal caregivers.40

The CANE has been employed in a wide variety of countries allowing the exploration and comparison of needs and care provided on those contexts. For example, in this review the highest mean of unmet needs was found in older adults with dementia living in Chile.17 That country has an incipient formal care system where most families with a relative diagnosed with dementia do not have an optimal formal support network around this condition41 which consequently leads to a higher number of unmet needs when compared to other countries.

Within the limitations of this review, most of the selected studies were cross-sectional, with small convenience samples (with few exceptions). Therefore, the results do not imply causality and do not necessarily represent all dependent older people. Moreover, an assessment of the quality of the selected studies was not performed, which is necessary for further research. However, a strength of this review is associated with the consistency in the concept of needs assessed through the CANE instrument, which has good psychometric properties and was validated for most of the evaluated samples.

This review highlights the importance of making visible and includes older people's perspective on their needs, particularly those of a psychological and social nature. This becomes even more important in the case of older people who have some degree of dependence, depression or cognitive impairment, who should receive comprehensive care according to their level of autonomy, dignity and rights. Findings of this review indicate that professionals and informal caregivers could be assuming that older users have uniform needs, ignoring or minimizing some of them either because they move away from their own professional specialization or because they are more complex and difficult to cover in the daily routine. All these issues acquire great relevance, considering the association between unmet needs and their costs for the health system and public services.13 Further strategies and action plans which include these elements are required, as well as research that develops and supports interventions in this line.

This work was funded by the Vicerrectoría de Investigación, Pontificia Universidad Católica de Chile, Research Project: INTERDISCIPLINA II170053; the ANID - FONDECYT 1191726; the ANID - Millennium Science Initiative Program - ICS2019_024 and ICS13_005; and the ANID CONICYT Scholarship for postgraduate studies 22182112.

The authors declare no conflict of interest.