Bonaire

Diagnostic practice on Bonaire remains grounded in clinical assessment rather than technology-heavy investigation, with cognitive evaluation forming the core of case identification. There is no evidence of a population-wide screening or systematic case-finding program for dementia; instead, recognition relies on clinical judgment by general practitioners, prompted by patient presentation, caregiver concern, or functional difficulties observed in routine medical encounters. In this context, standard bedside cognitive screening tools such as the Mini-Mental State Examination (MMSE) and comparable instruments (MoCA) are typically used in Dutch Caribbean as part of initial assessment to structure clinical impressions and support referral decisions, rather than as formal diagnostic endpoints.

Neuroimaging in Bonaire’s dementia pathway is pragmatic and selectively applied rather than protocol-driven. Computed tomography (CT) and magnetic resonance imaging (MRI) are the main imaging modalities used when clinically indicated, primarily to exclude alternative or contributory causes of cognitive decline such as cerebrovascular disease, space-occupying lesions, normal-pressure hydrocephalus, or significant structural changes, and they are accessed through the island’s centralized hospital system. CT is generally more readily available and commonly used due to speed and practicality, while MRI is employed more selectively where additional structural detail is needed and local capacity allows. Positron emission tomography (PET) imaging, including FDG-PET or amyloid PET, is not part of routine dementia diagnostics on Bonaire and lies outside island-based capacity; in rare cases where it could meaningfully affect diagnosis or management, access would require off-island referral under the Caribbean Netherlands medical referral framework.

There is no indication that genetic testing, including APOE genotyping or other dementia, related genetic analyses, forms part of standard diagnostic pathways on Bonaire. Genetic testing is not referenced in local dementia pathway discussions, caregiver materials, or institutional descriptions of diagnostic services. In a small island context with limited specialist genetics infrastructure, such testing would be considered highly specialized and reserved for exceptional cases rather than general clinical use. For the vast majority of patients, however, dementia care on Bonaire proceeds without genetic testing as a diagnostic or prognostic tool.

Current dementia care documentation and policy discussions related to Bonaire do not indicate routine use of cerebrospinal fluid (CSF) biomarkers or blood-based Alzheimer’s disease biomarkers as part of standard diagnostic practice. The system’s emphasis remains on clinical assessment, caregiver engagement, and functional evaluation rather than on biomarker-driven diagnostic stratification. This reflects both practical constraints, such as laboratory infrastructure and specialist expertise, and strategic prioritization of service organization over advanced diagnostics. Where biomarker testing might be clinically indicated, such as in atypical presentations, early-onset cases, or diagnostic uncertainty, it would most likely require referral to off-island facilities. Such referrals are governed by medical necessity criteria and are coordinated through the broader Caribbean Netherlands healthcare framework. However, available sources suggest that in Latin America and the Caribbean biomarker testing is not embedded as a routine or expected component of dementia diagnosis, which could also apply to patients on Bonaire as well.

Dementia care on Bonaire is delivered through a highly centralized institutional model rather than a dispersed ecosystem of specialized memory clinics. Fundashon Mariadal functions as the backbone of the island’s healthcare system, covering acute hospital care, outpatient and inpatient services, diagnostics, short term rehabilitation, long-term and elderly care, as well as medicines supply. As a result, dementia-related assessment, treatment initiation, and ongoing medical follow-up are embedded within general healthcare structures rather than separated into dementia-specific units. This integration supports continuity of care but also means that dementia competes for capacity with a wide range of other medical needs, particularly in an ageing population.

Mental health care related to dementia, especially behavioral and psychological symptoms such as agitation, depression, anxiety, psychosis, or severe caregiver stress, is provided by Mental Health Caribbean, which serves the entire Caribbean Netherlands. Mental Health Caribbean operates largely through an ambulatory and home environment-oriented model, which is particularly relevant for dementia patients whose symptoms are closely tied to living context and caregiver dynamics. Access to these services requires referral from a medical doctor, reinforcing a structured gatekeeping system but also ensuring that mental health input is clinically integrated with broader medical care.

Non-clinical, community-based dementia support is primarily provided by Fundashon Alzheimer Bonaire, which occupies a central role in day-to-day lived experience of dementia on the island. FAB delivers counselling, caregiver education, support groups, training programs, and limited day-care activities, and acts as a practical anchor for families navigating the system. In a small island context where formal services are concentrated and specialist availability is limited, FAB’s role extends beyond support into informal coordination, early problem identification, and sustained caregiver engagement.

Treatment costs for dementia on Bonaire are largely absorbed within the public healthcare system for individuals who are legally residing or working on the island and therefore insured under ZJCN. Out-of-pocket costs are generally limited for covered services, including consultations, diagnostics available locally, medications within the entitlements package, and basic long-term care services. The key cost-differentiating factor is whether required care can be delivered on-island or necessitates referral elsewhere.

When specialized diagnostics, treatments, or care services are not available locally, patients may be referred to contracted providers outside Bonaire, including in Curaçao, Aruba, St Maarten, Colombia, or the European Netherlands. Such referrals are governed by formal medical necessity criteria and contractual arrangements, which typically cover the cost of care but introduce logistical, administrative, and personal burdens for patients and families. In this sense, financial access is relatively well protected, but practical access can still be challenging due to travel, coordination, and caregiver disruption.

Caregiver experience is unusually well documented in the Bonaire context compared with many small jurisdictions. The Dementiemonitor Bonaire 2025 provides structured insight into caregiver burden, quality of life, and perceived gaps in support, and was developed in collaboration with Alzheimer Nederland and Nivel. The underlying data include a 2024 caregiver survey that captures lived experience rather than purely clinical outcomes, highlighting the centrality of informal care in the island’s dementia response. These findings reinforce the importance of FAB as a sustained support actor. FAB’s ongoing activities, support groups, training sessions, counselling, and meaningful engagement opportunities, address both emotional and practical dimensions of caregiving. In a system where families are the primary long-term caregivers and institutional capacity is finite, caregiver resilience is effectively a core pillar of dementia care. Bonaire’s explicit attention to caregiver perspectives therefore represents not just a social support function, but a strategic element of system sustainability.

Dementia policy on Bonaire has developed through a locally driven, bottom-up process rather than through a fully embedded national framework imposed from the European Netherlands. FAB has been a key policy entrepreneur in this space, formally presenting a national dementia policy proposal to the Bonairian authorities, a step acknowledged in ADI member documentation. This advocacy culminated in the adoption of a dedicated policy document, Beleidsplan Dementie Bonaire (2019), which marked the first structured attempt to articulate dementia as a cross-cutting public issue rather than solely a clinical or family matter. The plan framed dementia as a growing demographic and social challenge, emphasized the centrality of informal caregivers, and recognized the need for coordination across health, social care, and community actors in a small-island context. While the 2019 plan did not establish a comprehensive national dementia strategy in the European sense, with binding targets, earmarked funding lines, and statutory obligations, it nevertheless provided a shared reference point for institutions and civil society. Its importance lies less in regulatory force and more in agenda-setting: dementia became visible as a policy domain requiring deliberate planning, awareness, and service alignment rather than ad hoc responses.

Since the adoption of the 2019 policy plan, policy momentum has shifted toward operationalization rather than the production of new high-level strategies. The current focal point is the development of a formal dementia care pathway (Zorgpad Dementie) tailored to Bonaire’s institutional realities. This reflects a pragmatic recognition that, in a small and centralized system, improvements in coordination, clarity of roles, and predictability of patient and caregiver journeys may yield greater impact than broad strategic declarations. This pathway-oriented approach is supported by external programmatic funding, notably through Netherlands Organisation for Health Research and Development (ZonMw) subsidy tracks aimed at strengthening dementia care and support across the Caribbean Netherlands and wider Dutch Caribbean context.

These initiatives explicitly acknowledge the structural differences between European and Caribbean settings, including scale, workforce constraints, and cultural patterns of care. As a result, policy development is currently framed as iterative and adaptive, emphasizing learning, stakeholder workshops, and gradual institutional embedding rather than rapid system overhaul. The emphasis on a “dementia-friendly Bonaire” further signals a shift from purely medical policy toward societal adaptation, encompassing caregiver support, community awareness, and service accessibility. This aligns local policy discourse with broader Dutch and international dementia-friendly community concepts, while allowing for contextual customization.

In April 2024, The Netherlands Organisation for Health Research and Development (ZonMW) has announced a 450,000 EUR subsidy programme to improve dementia care and support in the Caribbean parts of the Kingdom, Aruba, Bonaire, Curaçao, St. Maarten, Saba and St. Eustatius, where growing numbers of people are affected by the disease. The funding aims to better align care and support with the needs of people with dementia and their families, thereby improving quality of life. Two types of grants are available: up to 100,000 EUR for projects that strengthen collaboration or care quality, and up to 50,000 for targeted training initiatives for dementia-care professionals. The first funding round opened in May 2024 on the ZonMW website.

Dutch State Secretary for Health, Welfare and Sport Judith Tielen has acknowledged that informal caregivers on Bonaire face structural overload, administrative burdens, and insufficient support, responding to findings from a report by Stichting Mantelzorg Bonaire. She highlighted that 22% of caregivers need administrative assistance, indicating a need for clearer information and reduced regulatory complexity. While emphasizing that primary responsibility for informal care policy lies with the Public Entity Bonaire, Tielen pointed to existing national support measures, including new social support legislation effective in 2025, tailored services such as respite and day care, caregiver training, and a recently opened support center. The report shows highly diverse caregiver needs, suggesting the importance of more customized support, and Tielen indicated that a targeted pilot programme on Bonaire could be launched under local leadership with backing from the ministry and potential lessons for Saba and Sint Eustatius.

Innovation in Bonaire’s dementia response is primarily organizational and social rather than technological or pharmaceutical. The most significant innovation is the deliberate effort to construct a formal dementia care pathway (Zorgpad Dementie) that clarifies roles, referral flows, and points of support across healthcare, mental health, and community services. This pathway-building process is closely linked to iterative learning through stakeholder workshops and practical testing rather than top-down implementation. A second innovative element is the structured use of caregiver monitoring as a policy and planning tool. Through the Dementiemonitor, caregiver experiences are treated as core system indicators rather than peripheral social data. This approach implicitly recognizes that caregiver capacity and wellbeing are essential to system sustainability in a context where institutional long-term care capacity is limited.

Finally, the positioning of FAB as a semi-institutional pillar of dementia care, providing day care, training, counselling, and ongoing engagement, represents an innovative blending of civil society and quasi-service delivery. FAB is not merely an advocacy group but an operational actor embedded in the care ecosystem.

A research conducted at Vrije Universitat Amsterdam reveals that the number of people with dementia in the Netherlands, including the island countries, is expected to double to over 610,000 by 2050, sharply increasing the demand for care at a time of staff shortages and policies that encourage people to live at home longer. Currently, informal dementia care is carried out overwhelmingly by women (73%), placing an unsustainable burden on them in terms of careers, income, pensions, and mental health. Research shows that if this pattern continues, more than half a million additional female caregivers would be needed by 2050, which is neither socially nor economically feasible. To achieve a fairer balance, the researchers argue for a cultural shift in which men take on a much larger role, an estimated 580,000 additional male informal caregivers, supported by greater use of volunteering, community support, and changes in professional practices that currently default to expecting women to provide care.