Aim The aims of the present study were: (i) to describe palliative care needs and symptoms of older adults anticipated to be in the last year of their life in Flemish nursing homes (Belgium); and (ii) to evaluate whether these needs differ between residents with and without dementia. Methods A cross‐sectional study was carried out in 2014. Nurses and nursing assistants in 15 Flemish nursing homes (Belgium) completed the Palliative care Outcome Scale for 109 residents with palliative care needs. Results Pain, as well as other physical symptoms, was present in more than half of the nursing home residents according to caregivers. The most prominent needs occurred on psychosocial and spiritual domains, such as patient anxiety, support, finding life worth living and self‐worth. Caregivers reported that residents with dementia experienced fewer physical symptoms apart from pain than did residents without dementia (coeffficient –0.73, 95% CI –1.18–0.84; P = 0.001. Furthermore, residents with dementia received higher scores on the items “support” (coefficient 0.75; 95% CI 0.15–1.34, P = 0.015), “life worthwhile” (coeffficient 0.58; 95% CI 0.090–1.07, P = 0.020) and “self‐worth” (coefficient 0.58, 95% CI 0.13–1.03, P = 0.012). Conclusions According to caregivers, residents with dementia experienced fewer other physical symptoms (e.g. nausea) than residents without dementia. This, however, might be a result of an underdetection of other symptoms in nursing home residents with dementia. Furthermore, most challenges in nursing homes lie within the spiritual and psychosocial domains of palliative care, particularly in people with dementia. These aspects should be integrated in the professional education of caregivers. Assessment tools might be of help to improve the identification of needs and symptoms. Geriatr Gerontol Int 2016; ••: ••–••.