Medicines Management in Dementia: Safe Showing, PRN Use and Deprescribing in Practice

January 22, 2026

In dementia services, medicines management sits alongside daily living support, not apart from it. Providers working within Medicines, Frailty, Falls & Safety priorities must show how medication processes reduce avoidable harm while still enabling dignity and choice across different Dementia Service Models. The difference between “compliant” and “safe” is often the quality of decision-making at the point of administration, the way PRN is governed, and how concerns are escalated and reviewed.

Why medicines risk looks different in dementia

Dementia changes how risks present and how teams must respond. People may not reliably report pain, dizziness, constipation, nausea or low mood. They may refuse medicines for reasons that make sense in their reality (fear, mistrust, sensory sensitivity, swallowing difficulty, timing, taste). Risks often cluster:

Polypharmacy and frailty increasing falls risk, delirium and dehydration
Anticholinergic burden contributing to confusion, constipation and urinary retention
PRN sedatives or analgesia masking unmet need rather than resolving it
Missed doses leading to avoidable deterioration (e.g., Parkinsonism, epilepsy, diabetes)

The operational aim is not “zero refusal” or “perfect adherence”; it is safe, proportionate practice that respects rights, documents reasoning, and triggers timely clinical review.

Core operational controls that commissioners expect

Commissioner expectation: audit-ready medicines governance

Commissioners typically expect to see a consistent operating model that can be evidenced without relying on individual staff memory. In practice this means:

A medicines policy aligned to the service model (domiciliary, supported living, extra care, residential) and clear staff authorisation boundaries
Competency-based training with observed practice (not just e-learning completion)
Routine audits: MAR accuracy, PRN use patterns, fridge temperatures, controlled drugs where relevant, and medication errors/near misses
Clear escalation routes to GP/pharmacist/mental health team and documented outcomes

Commissioners also look for how you prevent repeat issues: learning loops, supervision prompts, and service-level actions (e.g., changing how lunchtime meds are delivered because refusals spike when the dining room is noisy).

Regulator / Inspector expectation: safe care and treatment, rights and consent

Inspectors will focus on whether medicines are administered safely, whether people (and families) understand what is being given and why, and whether refusals, covert administration and PRN use are handled lawfully and ethically. They will also test whether staff can describe what “good” looks like for a person (e.g., “how do you know their PRN is working and not just sedating?”).

Operational example 1: Safe administration when refusals increase

Context: A supported living tenant with moderate dementia begins refusing morning medicines three days a week. Staff record “refused” but risks are increasing: hypertension medication is missed, and the person becomes more agitated mid-morning.

Support approach: The team treats refusal as information, not non-compliance. The senior support worker completes a short “refusal review” template covering timing, environment, approach used, observed distress signs, and any swallowing or taste issues. They involve the family to understand previous routines.

Day-to-day delivery detail: Staff adjust the routine so medicines are offered after breakfast rather than before, with one familiar staff member and reduced background noise. They use a calm, single-step explanation, offer water and (where safe and prescribed) explore alternative formulations with the pharmacy (e.g., liquids, patches). Staff avoid repeated persuasion that escalates distress; instead they step back and re-offer later within an agreed window.

How effectiveness is evidenced: The MAR shows a reduction in refusals from 3/7 days to 0–1/7 days. Incident logs show fewer mid-morning agitation episodes. A GP review confirms blood pressure stability and notes that the routine change likely reduced anxiety-driven refusal.

PRN: the highest-risk part of the system

PRN (as required) medication is often where dementia services fall short. The risk is not only “overuse” but also poor rationale and weak monitoring. Strong PRN governance includes:

Clear indications written in plain language (what staff should see/hear)
Non-pharmacological steps required first (and how these are recorded)
Maximum frequency and when to escalate instead of repeating PRN
Post-dose monitoring: what to observe, when, and what “effective” means
Monthly review of patterns: time of day, triggers, staff patterns, environmental contributors

Operational example 2: PRN used for “agitation” that is actually pain

Context: In a small residential unit, PRN anxiolytic use rises for one resident, mostly late afternoon. Staff describe “agitation” and pacing; PRN appears to “settle” the person, but they look drowsy at tea time.

Support approach: The service introduces a PRN decision checklist: identify likely trigger, confirm non-pharmacological actions tried, record pain and toileting checks, and note whether the person has eaten and hydrated. They liaise with the GP and pharmacist for a structured review.

Day-to-day delivery detail: Staff use a brief observational pain tool and notice the person rubs their hip and winces when standing. They introduce scheduled analgesia (clinically authorised), a warm pack and a quieter activity after lunch. PRN is only considered if distress persists after these steps, and staff must record pre- and post-dose observations including mobility, alertness and engagement.

How effectiveness is evidenced: PRN use falls from 10 administrations in two weeks to 1–2 per month. The resident’s afternoon engagement improves, and falls risk reduces because they are no longer sedated at peak movement times. Audit shows consistent completion of the PRN checklist and timely escalation when triggers recur.

Deprescribing and medication optimisation: a provider’s role

Deprescribing is a clinical decision, but providers play a key role because they hold the day-to-day evidence. A practical approach is to maintain an “optimisation prompt list” for GP/pharmacy reviews, including:

Falls, dizziness, daytime sleepiness, constipation, urinary issues, appetite changes
New confusion or sudden decline (possible delirium or medication side effects)
Repeated PRN use and whether it correlates with specific triggers
Drug interactions, duplicate therapies, or unclear ongoing benefit

When staff can describe patterns confidently (what happens, when, and after which medicine), clinicians can act faster and more safely.

Operational example 3: Reducing anticholinergic burden to improve function

Context: A person in extra care shows increased confusion and urinary retention episodes. They are also constipated, leading to repeated out-of-hours calls. Staff note the person has recently become more withdrawn and unsteady.

Support approach: The Registered Manager requests a medication review focused on anticholinergic burden and side effects, supported by documented observations from staff and family feedback. They prepare a short summary: bowel chart trends, fluid intake, sleep pattern changes, and mobility notes.

Day-to-day delivery detail: Staff implement a structured monitoring plan for two weeks ahead of the review: hydration prompts, stool charting, urinary output notes (without intrusive measurement), and simple “alertness and engagement” recording at set times. They also ensure consistent continence support and a quiet, unhurried toileting routine to reduce distress.

How effectiveness is evidenced: Following clinical review, one medication is adjusted and another is reduced with a clear taper plan. Over the next month, constipation incidents reduce, urinary retention episodes stop, and the person’s steadiness improves. The service documents this in a “review outcome” record and updates risk assessments and support plans accordingly.

Safety culture: errors, near misses and learning loops

Good services normalise reporting and learning. Common preventable issues include omitted doses due to shift handover gaps, transcription errors when hospital discharge summaries arrive, and PRN being given without adequate monitoring. Practical controls include:

Daily “meds check” in handover: high-risk medicines, recent changes, refusals to follow up
Post-discharge reconciliation: confirm what has changed, what has stopped, and what needs GP sign-off
Monthly themes review: what errors are happening and what system change prevents recurrence

What “good” looks like day to day

In strong dementia services, medicines are part of a broader support picture: staff understand why something is prescribed, can describe the expected benefit, notice side effects early, and know when to escalate. Refusals are explored with curiosity; PRN use is tightly governed; and clinical reviews are informed by robust day-to-day evidence. That combination protects the person, reassures families, and demonstrates credible quality to commissioners and inspectors.