With the dementia progresses, the basic physiological functions of the older adults gradually deteriorate, such as weakened activity capabilities in aspects like eating, excretion, and dressing and undressing. At this time, timely recognition and assistance from caregivers are particularly critical (25). The physiological needs scale comprises 14 measurement items. Analyzed by SPSS, the standardized reliability coefficient is 0.725, and the validity coefficient is 0.743, all conforming to the Fornell-Larcker standard. Relevant data are detailed in Table 5.

The overall data show that “basic support is more than enough, but personalized comfort is not enough.” Higher scores on basic items such as question 3 (73% agreement; mean score of 4.07) and question 11 (73% agreement; mean score of 4.03) indicate that standardized physiological support is provided. Integrating questionnaire data and interview insights, a comprehensive analysis was performed on items with a low degree of recognition (<50%) and low average scores (<3):

Despite residing in a professional dementia care institution, primarily due to cognitive decline, memory deficits, and emotional instability, the older adults continue to face physiological risks, including accidental injuries and challenges related to medication management (25). Simultaneously, they require a stable environment and consistent psychological support to mitigate internal feelings of insecurity and fear (26). The Safety Needs Scale consists of 10 measurement items, with items 1–4 representing the psychological safety dimension and items 5–10 reflecting the physiological safety dimension. The SPSS analysis results demonstrate that the standardized reliability coefficient of this scale is 0.832 and the validity coefficient is 0.726, indicating satisfactory reliability and validity. The detailed data are presented in Table 6.

The data from the table vividly illustrates an imbalance: physiological safety needs are met, whereas psychological safety needs are deficient. The scores for physiological safety items (Questions 5–10), including agreement rates and mean scores, are relatively high, indicating that the institution effectively ensures the residents’ physical safety through rigorous management protocols. In contrast, the deficiency in the psychological safety dimension is markedly more pronounced. Specifically, the low scores for Question 3 (Agreement: 24%; Mean Score: 2.43) directly point to the institution’s lack of a comprehensive psychological assessment and comfort system. Consequently, the negative emotions arising from factors such as aging and illness (27) are not effectively addressed or managed.

Following the admission to care facilities, older adults with dementia frequently experience emotional deprivation stemming from prolonged separation from their families, and they have a pronounced need for companionship and emotional support (28). In their daily lives, they mainly depend on interactions with other residents and caregivers to establish a sense of belonging (29). Furthermore, institutions often organize communication sessions, festive celebrations, and similar activities to provide residents with direct and accessible opportunities for emotional connection (30). The Belongingness and Love Needs Scale comprises 9 measurement items. Analysis using SPSS revealed a standardized reliability coefficient of 0.71 and a validity coefficient of 0.701, indicating satisfactory reliability and validity. Detailed data are presented in Table 7.

Statistical results demonstrate that the needs for belonging and love among the majority of older adults with dementia have not been adequately fulfilled. Combining interview data and quantitative analysis, the primary reasons are identified as follows:

Even with professional caregiving, cognitive decline may cause the older adults to feel neglected or devalued, which can erode their sense of self-identity and dignity (31). Considering their past roles as significant contributors within their families and society, as well as their extensive life experiences, they have a strong desire to be recognized as valuable and deserving of respect (32). Delivering personalized care, attentively listening to their concerns, and honoring their life habits and histories not only contribute to preserving their self-esteem but also strengthen their sense of belonging and security. This, in turn, fosters a more positive approach to life and enhances their overall quality of life (33). The Respect Needs Scale comprises 8 measurement items. SPSS analysis revealed a standardized reliability coefficient of 0.718 and a validity coefficient of 0.747, demonstrating robust reliability and validity. Detailed results are provided in Table 8.

The data indicates that while the majority of older adults with dementia perceive that they are treated with adequate respect in their daily lives, some have expressed concerns about insufficient protection of their personal privacy. Furthermore, to facilitate management and ensure safety, caregivers often congregate the older adults in public areas and encourage their participation in social activities, thereby reducing their solitary time. As a result, some residents feel that their need for solitude has not been fully satisfied. Notably, in Question 2, the relatively high degree of agreement and the relatively low average score may reflect the disparities in the care management approaches and the quality of personnel across different floors.

The older adults with dementia have previously held certain roles in society, and as a result, they desire to express their self-worth through creative activities such as painting, music, and vocational reenactments (34). These activities serve to awaken long-term memories, while also affirming their capabilities and wisdom. Personalized activities and motivation tailored to their interests can help them regain a sense of purpose and accomplishment in life (35). Therefore, in caregiving practices, fostering self-actualization not only enhances their overall quality of life but also supports their psychological well-being. The Self-Actualization Needs Scale consists of 9 measurement items. SPSS analysis revealed a standardized reliability coefficient of 0.806 and a validity coefficient of 0.746, demonstrating high reliability and validity. Detailed data are provided in Table 9.

Statistical analyses reveal that the majority of older adults with dementia can fulfill their self-actualization needs relatively well. However, observational and interview data suggest that most of these individuals depend on caregivers for activity planning, exhibiting no explicit preferences, as reflected in the low agreement rate for participating in planning daily activities (Question 8: Agreement: 27%).

Despite this, they often engage actively in activities arranged by caregivers and derive both enjoyment and a sense of accomplishment, evidenced by high agreement on items like showcasing creativity (Question 1: Agreement: 77%) and finding fulfillment in outdoor activities (Question 4: Agreement: 80%). These findings imply that in the context of a decline in cognitive and self-decision-making capabilities, individuals are more likely to adopt a passive pattern of acceptance (40). For instance, during semi-structured interviews, when asked, “What kind of activities would you like to participate in?” even when researchers provided several options (such as dancing, walking, or puzzle games)—most respondents answered, “Anything is fine. I’ll do whatever is arranged.”

Furthermore, the older adults with dementia articulated additional expectations regarding needs that were not encompassed by the questionnaire. These needs have been systematically categorized and are detailed in Table 10.

Based on the other needs added by cognitive seniors, there is a large gap in the need to go for companionship for cognitive seniors.

The analytical framework of this study is grounded in Maslow’s hierarchy of needs; wherein physiological needs represent the most fundamental and persistent requirements for older adults with dementia. Quantitative data reveals that satisfaction levels for the midday rest environment and assistive walking tools are merely 15 and 23%, respectively, (Table 5), indicating that these unmet physiological needs constitute negative “background factors” that may directly trigger behavioral abnormalities in the “proximal environment.” Specifically, noise disturbances during midday rest could lead some the older adults to leave activities halfway (e.g., 4F1 returning to their room to sleep during an activity) or fall asleep during group events (e.g., 6F4 and 5F3 dozing off while singing), which might stem from sensory overload resulting in an imbalance of environmental stimuli (36). Likewise, the insufficiency of assistive walking devices constrains patients’ autonomous activities, potentially inducing frustration or resistance to caregiving interventions (e.g., 5F1, who is unable to stand up independently, resisting the assistance of caregivers during lunch). From the perspective of Kitwood’s “Person-Centered Care” theory, this resistance can be interpreted as an attempt to maintain personal control after their autonomy has been environmentally deprived.

Such behaviors validate the “need suppression → behavioral compensation” mechanism, through which individuals with dementia convey their needs via abnormal actions when their physiological needs (background factors) are unmet. This reveals the chained inhibitory effect of basic need gaps on higher-level psychological needs; that is, when foundational physiological needs are not satisfied, older adults with dementia are unable to pursue higher levels of safety, belonging, and esteem in a typical manner.

The research reveals that a structural imbalance in care resources—specifically, the caregiver-to-resident ratio of approximately 1:4—is a core factor that constrains the efficacy of need response, which in turn can induce behavioral problems. The average daily working duration of up to 9 h means caregivers’ energy is primarily consumed by meeting basic physiological needs, leading to insufficient personalized interaction time (less than 2 h per person per day). This is reflected in the low satisfaction rate for emotional care provided by caregivers, which was merely 34% (Question 3 in Table 7). This imbalance between the supply and demand of care resources has given rise to anxiety and compensatory behaviors. For instance, 3F2 repeatedly wandered in the corridor due to an excessive delay in drinking water provision, and 5F1 refused care intervention because timely assistance for eating was not provided. The NDB model points out that “delayed proximal need response” will directly induces compensatory behaviors, and the research findings further corroborate this mechanism.

Although Kitwood’s theory advocates “personalized communication based on individual’s life history,” the high-intensity workload forces caregivers to adopt standardized processes (such as centralized medication administration and batch clothing changes), making it difficult to implement meticulous care (such as interaction designs targeted at the background of a former teacher like 5F1). This “de-personalized” process, driven by insufficient resources, effectively creates what Kitwood described as a “malignant social psychology” environment. Under these conditions, even if the institution intends to provide high-quality service, the anxiety and compensatory behaviors of the older adults with dementia can hardly be eliminated at their root as long as the fundamental issue of human resources remains unresolved.

Quantitative data reveals that privacy needs (at the level of esteem needs) are systematically undervalued in institutional care: only 44% of residents consider their privacy to be fully respected (Table 8), and significant generational differences were manifested in interviews–younger caregivers (aged 26–30) are more inclined to protect privacy, while older caregivers (aged 41–60) insist that “safety takes precedence over privacy” (see question 8 in Table 8). In traditional culture, eldercare paradigm emphasizes “care without privacy”, placing collective management above individual rights. For instance, although keeping room doors open throughout the day and centralized activity monitoring cloud ensure the older adults’ safety needs (background factors of NDB), they deprive their personal space and autonomy (proximal needs). Kitwood’s theory points out that disregarding privacy essentially erodes “personhood,” and the older adults maintain their subjectivity through resistant behaviors (such as 7F1 cautioning others against approaching the room) or self-seclusion (such as 6F2 refusing to interact with others). The NDB model further discloses that when safety (background needs) and privacy (proximal needs) are imbalanced, older adults with dementia may fall into an “anxiety-withdrawal” cycle (37). Admittedly, when providing essential assistance such as personal hygiene to the older adults who are unable to manage these tasks independently, the boundaries of privacy can become blurred and difficult to navigate. However, this challenge does not justify the systemic disregard for privacy observed in institutional care.

A seemingly contradictory yet highly insightful finding of this study is that despite a general deficiency in the mid-level need for “belongingness and love,” the older adults with dementia exhibit a relatively high degree of satisfaction with their self-actualization needs. Quantitative data reveal that creative activities, including painting and music, achieve a satisfaction rate of 70% (Table 9), with a significant proportion in the categories of “creative expression” and “personal hobbies” (Table 11). This phenomenon challenges the linear, hierarchical understanding of Maslow’s Hierarchy of Needs and reveals the unique nature of creative activities in dementia care.

This finding suggests that even in the context of cognitive decline, the older adults with mild to moderate dementia are capable of reinforcing their self-identity and sense of value through artistic endeavors. According to Kitwood’s theory, creative activities can evoke long-term memories via non-verbal channels (e.g., colors, melodies), thereby strengthening identity recognition and “personality persistence.” For example, veteran 5F1 demonstrated evident pride when recounting military experiences and instinctively stood at attention upon hearing a patriotic song, reflecting the supportive role of historical identity in maintaining self-worth.

The NDB model suggests that creative activities mitigate the sense of helplessness resulting from cognitive decline by fulfilling the “stimulus of meaning” within proximal needs. For instance, 5F2 (a former dance teacher) continuously laughed while instructing the researchers in dancing, revealing the positive modulation of artistic expression on the immediate emotional state. Therefore, for older adults with dementia, “self-actualization” is perhaps not an ultimate goal to be achieved only after satisfying all lower-level needs. On the contrary, creative activities centered on awakening identity function as a powerful therapeutic tool in their own right.

A core finding of this study is that the need for “belongingness and love” is the most severe and prevalent unmet need for older adults with dementia in institutional care. Evidence from semi-structured interviews and quantitative data reveals that satisfaction with care from family members was merely 24% (Question 9 in Table 7), and the frequency of unmet needs for family visits and companionship was 11 instances (Table 10), constituting a major point of conflict within the love and belonging dimension. The prolonged absence of family interaction causes patients to fall into a detrimental cycle of “feeling abandoned—self-doubt (38),” which directly gives rise to a series of compensatory behaviors aimed at combating separation anxiety and filling the emotional vacuum. For instance, resident 2F1 repeatedly apologized to everyone—including nursing staff, volunteers, and the families of other residents—because their daughter had not visited for five months; 6F1 consistently dresses neatly and waits at the elevator entrance daily for her children; and 6F3 meticulously prepares their appearance before visits, persistently inquires about their children’s whereabouts, and remains in a low mood afterward. All of these are ritualized actions to counter separation anxiety.

According to the NDB model, the insufficient frequency of family visits constitutes a proximal stimulus of “social interaction deprivation,” directly provoking agitated behaviors (e.g., repetitive inquiries about the whereabouts of children) and diminishing self-worth. Kitwood’s theory further elucidates that the disruption of family bonds accelerates the process of “social death,” compelling patients to reestablish social connections through attachment to objects (e.g., 6F1 carrying luggage) or emotional transference (e.g., 8F1 and 5F2 frequently inviting researchers to meals, 6F4 offering clothing as a friendly gesture), to forestall the disintegration of self-identity.

This “withdrawal–agitation” bipolar behavior (e.g., the coexistence of the withdrawn apology of 2F1 and the agitated inquiry of 6F3) markedly increases caregiving challenges, highlighting the exigency of social and emotional support. While the involvement of young volunteers temporarily bridges the companionship gap (Table 10), the absence of an institutionalized family interaction mechanism leaves emotional compensation fragmented and unable to fundamentally restore the hierarchy of belonging needs. Consequently, despite the fact that the higher-level need for self-actualization is largely satisfied through institutional activities (Table 9), the deficiency of fundamental family and social support still makes the need for belonging the key point of intervention.

Quantitative analysis indicates that the self-actualization need presents a cultural paradox within this study: despite the high recognition rate for creative activities (80%, Table 9) and a considerable proportion of “creativity manifestation” (Table 11), qualitative interviews reveal that approximately 70% of respondents exhibit a passive acceptance attitude toward activity participation. For instance, Case 5F2 (a former dance teacher) is willing to showcase her talent only when invited, indicating that the expression of self-actualization is contingent upon external environment. Drawing on the NDB model, group belonging partially fulfills the need for meaning; however, the standardized nature of institutional activity arrangements constrains individual autonomy in self-expression.

This inconsistency becomes particularly evident in collective activities: while 73% of the older adults residents participate in institutional events (Question 1 in Table 6), a mere 27% actively express their personal preferences, reflecting the emphasis on group harmony in traditional Chinese culture (e.g., Case 6F4 participating in a dance that she was not interested in after being persuaded by the caregiver). This phenomenon aligns with social learning theory (39), suggesting that individuals who have long been influenced by collective culture have their behavioral choices shaped more by group norms rather than driven by personal will.

The core of these issues lies in the fact that Eastern culture prioritizes familial and collective identity, while the West attaches greater significance to individual autonomy. This cultural characteristic necessitates a re-examination of the study’s theoretical frameworks:

Reconstruction of Maslow’s Hierarchy: This reveals the cultural plasticity of the hierarchy. In an Eastern cultural context, the needs for “self-actualization” and “belongingness and love” are not distinct or mutually exclusive. Instead, “self-actualization” is often achieved by successfully fulfilling one’s role within the collective, thereby reinforcing the “sense of belonging.” Becoming a cherished and contributing member of the family and group is the highest form of value realization. Therefore, Case 6F3’s constant anticipation and ritualized preparations for her children’s visits are not merely a longing for affection but are more profoundly a confirmation of her core identity as a “mother “the very foundation of her self-worth.

Cultural Definition of the NDB Model’s “Stimulus of Meaning”: For this population, a “meaningful stimulus” is more likely to be something that involves “contributing to the collective” or “affirming important social relationships” rather than “gaining an opportunity for self-expression.” This also explains why the rupture of family bonds (termed “social interaction deprivation” in the NDB model) has such a significant negative impact —it directly threatens the primary source of the elders’ identity and life’s meaning.

Relational Interpretation of Kitwood’s “Personhood” Theory: In a Western context, Kitwood’s “personhood” is often closely linked to individual choice and uniqueness. However, in this study’s cultural context, “personhood” is more of a relational construct. An individual’s identity and value are largely defined by their position and relationships within family and social networks. Therefore, what best awakens and sustains their “personhood” is not encouragement to “go do what you want to do,” but rather activities that reinforce their key social roles (such as having a former teacher give a lesson or a veteran sing military songs).

In summary, the residents’ passive participation in activities and their intense yearning for family connection are two sides of the same cultural coin. In light of the findings on “Family bonds and emotional compensation,” it becomes clear that in a collectivist cultural context, the “sense of belonging” transcends other psychological needs to become the absolute core of maintaining self-identity. This finding has transformative implications for care practices: the focus of intervention should perhaps not be on providing more “choices,” but rather on creating more opportunities for the older adults to assume meaningful social roles, contribute to the collective, and strengthen their family connections.

Among all intervention strategies, the highest priority should be given to adapting the physical environment and human resources, as satisfying physiological needs is the cornerstone for maintaining the emotional and behavioral stability of older adults with dementia. When basic needs such as physiological comfort are not met, older adults with dementia often express their distress through behaviors such as agitation, wandering, or resistance. Therefore, starting with optimizing the environment and supplementing resources can reduce the triggers for negative behaviors at their source, creating a stable foundation for subsequent higher-level interventions. The specific measures are as follows:

Institutional activities can, to some extent, alleviate the sense of loneliness resulting from the absence of family. By participating in these activities, older adults with dementia can establish new emotional connections with caregivers and other residents or evoke fond memories of their families through specific themes, thereby achieving a form of psychological compensation. For example, one resident found emotional solace by making flowers for her daughter during a craft activity. However, the effectiveness of this substitute compensation is limited. Especially for residents with strong family attachments, such activities cannot truly replace the sense of belonging and identity derived from familial bonds. Therefore, the key to mid-term intervention design is to more closely integrate institutional activities with family participation.

After satisfying the basic physiological and emotional needs of the older adults with dementia, the focus of long-term intervention shifts to rebuilding their personal dignity and transforming the institution from a mere ‘place of residence’ into a genuine ‘home.’ When the institutional environment lacks sufficient elements that reflect the residents’ previous professional and personal backgrounds, their sense of belonging is directly undermined. Personalized interventions based on “life stories,” which awaken long-term memories related to personal history, can effectively strengthen their “personhood” and combat the dissolution of self-identity. Therefore, more in-depth, personalized strategies must be implemented to help older adults with dementia make the leap from merely “surviving” to truly “living.”