It is sometimes said that ordinary linguistic exchange, in ordinary conversation, is a matter of securing and sustaining joint attention. The minimal condition for the success of the conversation is that the participants should be attending to the same things. So the psychologist Michael Tomasello writes, ‘I take it as axiomatic that when humans use language to communicate referentially they are attempting to manipulate the attention of another person or persons.’ I think that this is an extremely fertile approach to philosophical problems about meaning and reference, and in this paper I want to apply it to the case of the first person. So I want to look at the case in which you tell me something about yourself, using the first person, and we achieve joint attention to the same object. But I begin with some remarks about how this approach applies to proper names and to perceptual demonstratives.

Introduction

This chapter draws on qualitative research using participatory methods to explore the experience of people with dementia who live alone. Drawing on data gathered in Sweden and the UK, the chapter highlights the distinct challenges of living alone with dementia and explores the different ways that people remain connected to neighbourhood places. We argue that the invisibility of such experiences to dementia policy and strategies (which typically assume the presence of a cohabiting carer or household member to provide support) needs to be addressed if dementia-friendly initiatives are to be truly inclusive.

Demographic projections show that the number of people living in single households will continue to increase steadily in many western and northern European countries and that older women are the fastest-growing section of the single householder population (Sundström et al, 2016; United Nations, 2017). The ageing population living alone in Europe also includes an increasing proportion of people with dementia (Prescop et al, 1999; Gaymu and Springer, 2010; Prince et al, 2015). In Canada, France, Germany, the UK and Sweden, between one third and one half of the population of people with dementia residing in a neighbourhood context live in single households (Ebly et al, 1999; Nourhashemi et al, 2005; Alzheimer's Society, 2013; Eichler et al, 2016; Odzakovic et al, 2019). Despite this increase in single householders with dementia, there is currently limited awareness of the particular challenges associated with living alone with dementia, even within emerging discourses and practices associated with dementia-friendly communities (Alzheimer's Society, 2013; Age UK, 2018; Odzakovic et al, 2018). As such, there is a danger that the creation of ‘dementia-friendly’ communities, and especially those based on communities of place, may rest upon a series of normative assumptions about dementia and about the relational context of people living with the condition.

Evidence from service-oriented research shows that people with dementia who live alone are more prone to (unplanned) hospitalisation (Ennis et al, 2014); are at greater risk of malnutrition (Nourhashemi et al, 2005); are likely to be admitted to long-term care at an earlier point in their journey with dementia (Yaffe et al, 2002); are often less well connected to formal services (Webber et al, 1994); and lack the advocacy of a co-resident carer (Eichler et al, 2016).

Introduction

Neighbourhoods have been integral to the rapid changes occurring within dementia care in recent years, although have not always been acknowledged as such. Dementia, like aged and mental health care before it has been absorbed into a project of deinstitutionalisation occurring within healthcare systems across much of the affluent west (Anttonen and Karsio, 2016). In the UK, deinstitutionalising dementia has involved large-scale reductions to hospital beds available to people with dementia and reduced duration of stay (Alzheimer's Society, 2009). In basic terms, it has meant the relocation of care and support from one type of material and social setting to another, and as such marks a changing geography of care. In many parts of Europe, this ‘re-placing’ of dementia care has not stalled at the shift to community-based support. The ongoing retrenchment of public services driven by a policy of fiscal consolidation (that is austerity) has led to widespread closures of traditional council-led day care services (Needham, 2014) alongside tightening of eligibility criteria for admission to care homes and for Continuing Health Care (RCN, 2012), resulting in significant reductions in collective forms of community-based provision. People with dementia are increasingly less likely to be clustered in designated care settings while segregated from the wider community. Instead, policy intentions have shifted to supporting people to age in place through a focus on Personalisation (DoH, 2019; Malbon et al, 2019; Manthorpe and Samsi, 2016). However, as with aged care before it, concerns have been raised over the extent of an existing neighbourhood infrastructure to adequately respond to such changes in dementia care (for example, Miranda-Castillo et al, 2010). The potential danger is that people living with the condition may become, in Rowles’ (1978) terms, ‘prisoners of space’; facing the prospect of social isolation and domestic confinement as their lifeworld constricts (Alzheimer's Society, 2013; Moyle at el, 2011).

The advent of the ‘dementia-friendly community’ (DFC), following in the wake of the age-friendly cities movement (WHO, 2007), might be read as a vehicle for policy to address these concerns. Interestingly in the UK, the approach differs between countries. In Scotland, dementia is a devolved matter, with the Holyrood government setting policy which acknowledges the importance of DFCs through the National Dementia Strategy (Scottish Government, 2017).

Introduction

This chapter explores what neighbourhoods mean for people living with dementia. While the built environment, and the economic and political apparatus they comprise of such as shops, services and localised campaigning, are certainly important, our attention focuses on how people living with dementia understand neighbourhoods as sites of relationally constituted ordinary or everyday social connection, engagement and interaction. The chapter outlines the nature of associations individuals have with the wider social sphere of their immediate locale and considers how these ostensibly geographical proximate (or local) social connections might support people to live as well as they might with dementia. In doing so, it considers why it matters to understand the socio-spatial dimensions of neighbourhoods as relational and interconnected phenomena and considers the importance of thinking about neighbourhoods as more than environments in need of intervention or modification in order to support people living with dementia.

How are neighbourhoods understood in the dementia literature?

In a review published in 2012, Keady and colleagues noted that a surprisingly small amount of literature has focused specifically on the importance of neighbourhoods for people living with dementia. The review identified three domains of activity: outdoor spaces, the built environment, and everyday technologies. The first examines how the outdoor environment can be better designed and/or modified to support people living with dementia. This includes work on the design of streetscapes and road layouts to better support mobility, as well as ongoing work to enable easier access to a range of different environments such as green and recreational spaces. A second attends to navigation and mobility of environments, such as shopping centres, hospitals, museums and grocery stores. The third investigates the use of technologies, including virtual realities, to support access to, or better develop, environments beyond the home (Keady et al, 2012). Since then, a considerable body of work has continued to investigate these areas (Sturge et al, 2021) and continues to provide evidence of the need to better understand why and how people living with dementia interact with their immediate environments outside of the home.

The rise in social inequality and the emergence of the new nationalism place us in a new world. The postwar system of social cohesion is gone; the potential for new disruptions to capitalism has grown. So we write this chapter with a good deal of fear and trembling for two reasons. First, the capacities of many advanced capitalist states to effectively manage their economies continue to diminish.

Adam Smith died in 1790, just before the French Revolutionary and Napoleonic wars. The long peace of the nineteenth century that followed rested on an implicit geopolitical deal. For decades after the Congress of Vienna of 1815 had established a framework for peace, no one wanted to challenge Britain, in part because they were exhausted from war but also because doing so might upset the balance of power in Europe and strengthen one’s rivals. Furthermore, the world’s leading economies subscribed to the gold standard – fixing their currencies to the price of gold – thereby ensuring a stable international payments system that steadied capitalism. The hope was that trade would now replace military conquest, and that peace and prosperity would be assured. The first half of the twentieth century crushed that hope. It was a time of war and economic catastrophe.

As sociologists, we view capitalism and its optimal needs differently from conventional economists. Ironically, however, our own perspective draws on the work of well-known early economists – sociologically astute, but often misunderstood or neglected in economics today. Those earlier economists provide us with most of the important building blocks for our argument. They also remind us that the foundations of economics are fundamentally different from the widespread contemporary belief that markets work best when political and social forces do not interfere with them. The historical perspective suggests that this contemporary view is wrong and that putting it into practice has caused serious economic damage.

Let us recall three events that challenged the political status quo in the early part of this century. The first took place in 2000, when Danes were asked in a national referendum whether they wished to join the European Monetary Union, abandoning Denmark’s national currency, the krone, for the euro. Every element of the political elite – both left and right – as well as most intellectuals and the media were in favor of a “yes” vote. But the vote failed, beaten by a vote of “no” most common among less-educated Danish men living outside metropolitan Copenhagen. This was a harbinger of things to come. The second event saw protestors commandeer Zuccotti Park in lower Manhattan’s financial district on a crisp fall day in 2011, setting up a makeshift tent city to protest economic inequality in the United States.

Storm clouds began to threaten the postwar political economy rather quickly. By the late 1960s, war-torn countries had made great strides in revitalizing their economies, while competition was heating up in world markets, challenging the United States’ economic primacy. Then, the price of oil skyrocketed in the 1970s, driving production costs higher. These years came to be dominated by stagflation – a toxic mix of inflation, sluggish economic growth, and high unemployment. On top of that, thanks to dramatic improvements in telecommunications and transportation, consumer demands began to change rapidly, and manufacturers raced to keep up. In 1909, Henry Ford had promised his customers that they could buy a Model T in any color so long as it was black; by 1973, the Ford Mustang came in three body styles, with five engine options, a choice of three transmissions, and more than a dozen colors.

We began this book by presenting the ideas of great economists that have been unduly neglected. Smith recognized that capitalism works best when people seek to catch those above them on the societal escalator. That requires a sense that they are at least on the escalator – something stressed too by Polanyi, who was well aware of the dangers that could follow if people were to feel themselves to be left out altogether. Keynes wanted the state to smooth out capitalism’s instabilities – notably, persistent unemployment – which often stemmed from the creative destruction that Schumpeter described. Hirschman understood that another way of ensuring that capitalism worked for everyone was to provide voice to all of its stakeholders.