Crisis Prevention in Dementia Care: Identifying Early Warning Signs Before Escalation
Crisis in dementia care is often described as sudden, but in practice it is usually predictable. Changes in behaviour, routine tolerance, sleep, mobility or engagement tend to appear weeks before an emergency admission, safeguarding incident or placement breakdown. Providers that prevent crisis build structured early-warning systems into dementia transitions and escalation, aligned to their underlying dementia service models and day-to-day delivery.
Crisis prevention is not about “being vigilant” in a generic sense. It is about knowing exactly what to watch for, how to record it, who reviews it and when escalation must happen.
Why early warning signs are often missed
Early indicators of deterioration are frequently normalised as “just dementia”. Staff may adapt quietly to increased support needs without recognising the cumulative risk. Common reasons early signs are missed include:
- Inconsistent recording of low-level changes.
- Focus on incidents rather than patterns.
- High staff turnover leading to loss of baseline knowledge.
- Lack of structured review points.
Effective crisis prevention requires providers to make subtle change visible and reviewable.
Key early warning domains in dementia care
High-performing services monitor a defined set of domains that reliably indicate rising risk:
- Behaviour and emotional regulation (withdrawal, agitation, increased reassurance-seeking).
- Sleep and routine tolerance (night waking, daytime fatigue, resistance to usual activities).
- Mobility and falls risk (slower transfers, shuffling, loss of confidence).
- Nutrition and hydration (missed meals, weight change, dehydration signs).
- Communication (reduced speech, increased frustration, changes in comprehension).
These domains form the basis of proactive monitoring rather than reactive response.
Operational example 1: Preventing hospital admission through early hydration monitoring
Context: Staff notice a person becoming more lethargic, with reduced appetite and increased confusion in the afternoons.
Support approach: The service flags hydration and infection risk as early warning indicators and escalates to a same-week review.
Day-to-day delivery detail: Staff implement a hydration prompt schedule using preferred drinks and social cues. Daily notes record fluid intake, alertness and toileting patterns. A GP review is requested promptly rather than waiting for crisis.
How effectiveness is evidenced: Alertness improves within days, appetite returns and confusion reduces. Records show avoided hospital admission and timely intervention.
Operational example 2: Identifying escalating distress before restrictive practice risk
Context: A person begins pacing more frequently and showing signs of anxiety during busy periods.
Support approach: The team recognises this as an early distress indicator rather than challenging behaviour.
Day-to-day delivery detail: Staff adjust routines to reduce noise, introduce calming activity before peak periods and ensure familiar staff presence. ABC notes track triggers and responses daily.
How effectiveness is evidenced: Distress episodes reduce, no incidents occur and restrictive interventions are avoided entirely.
Operational example 3: Family-reported change triggers proactive review
Context: Family report their relative is “less like themselves” and more withdrawn.
Support approach: The service treats family insight as an early warning signal and triggers a multidisciplinary review.
Day-to-day delivery detail: Staff review engagement, sleep and activity levels. The plan is updated to reintroduce meaningful activity and increase social contact at preferred times.
How effectiveness is evidenced: Engagement improves, withdrawal reduces and family confidence increases, recorded through follow-up feedback.
Commissioner expectation: prevention over reaction
Commissioner expectation: Commissioners expect providers to prevent escalation where possible, reducing avoidable hospital use and safeguarding concerns. Evidence should show monitoring systems, early reviews and documented decision-making rather than reactive crisis management.
Regulator expectation (CQC): recognising deterioration early
Regulator / Inspector expectation (CQC): CQC expects providers to recognise and respond to deterioration promptly. Inspectors look for patterns in records, not just incident logs, and assess whether staff understand baseline versus change.
Governance systems that support early intervention
Strong governance embeds crisis prevention through:
- Regular review of early warning indicators.
- Thematic analysis of low-level concerns.
- Clear escalation thresholds and response times.
- Audit of avoided incidents and admissions.
When these systems are in place, crisis becomes the exception rather than the norm.