Positive Risk-Taking and Medication in Dementia: Reducing Harm Without Over-Restriction

January 21, 2026

Medication is one of the highest-risk areas in dementia care because small errors can have outsized consequences: falls, delirium, aspiration, bleeding, missed treatment, or over-sedation. It is also an area where services can become overly restrictive, removing independence even when risk can be reduced through structured support. This article explains how to apply positive risk-taking in dementia to medication safety, aligned with practical dementia service models, so people can retain choice where possible while risks are managed defensibly.

Why medication becomes a “restriction trap” in dementia

Medication systems are often designed for control rather than enablement: locked trolleys, fixed rounds, standard prompts, and blanket “staff administer” rules. In dementia, the risk picture varies day to day. Someone may reliably take morning tablets with a prompt but become confused in the evening. A person may safely self-manage inhalers yet struggle with anticoagulants. Positive risk-taking helps services move from “one rule for everyone” to competence-led practice with clear safeguards.

Risk enablement principles for medicines support

Medication risk enablement should be built around four operational principles:

Competence is task-specific: assess what the person can do (and when), not what they “shouldn’t” do.
Risk controls must be proportionate: reduce harm without removing everyday autonomy unnecessarily.
Recording must evidence rationale: show what was considered, what alternatives were tried, and how decisions are reviewed.
Governance must detect drift: PRN creep, covert administration without safeguards, and missed-dose patterns must be visible.

Operational example 1: Safe self-administration with structured prompts

Context: A person with early-to-mid stage dementia living in supported housing wanted to keep control of their medication. Staff were concerned about missed doses after two incidents of confusion.

Support approach: The service introduced a staged self-administration plan. Morning medicines remained self-managed with prompts; higher-risk medicines (e.g., anticoagulants) were supported by staff at agreed times. A blister pack and clear labelling reduced complexity.

Day-to-day delivery detail: Staff used a consistent script at agreed times (“It’s your morning medicines time”) and visually checked the blister pack without taking over. If the person declined, staff applied a “second prompt” approach later rather than immediate escalation. A simple log captured “prompt given / taken / declined” to spot patterns.

Evidence of effectiveness: Missed doses reduced and the person reported feeling respected. The service could evidence that risk was managed through prompts and monitoring rather than blanket removal of independence.

Operational example 2: PRN medication without over-sedation

Context: In a care home, PRN anxiolytics were being used more frequently during late afternoons when one resident became distressed. Staff described it as “the only thing that works.”

Support approach: The service applied positive risk-taking to reduce medication reliance by strengthening non-pharmacological supports and tightening PRN governance. The GP/pharmacist review clarified indications and maximum frequency, and the team agreed a stepped response plan.

Day-to-day delivery detail: Staff documented the trigger, approach tried, and outcome before PRN was given. The plan required two non-drug strategies first (e.g., quiet space, familiar object, preferred music, short walk, hydration check). PRN decisions were discussed in handover and reviewed weekly by the senior. When PRN was used, staff recorded the resident’s alertness, mobility, eating, and sleep that day to monitor side effects and falls risk.

Evidence of effectiveness: PRN use reduced over four weeks, distress episodes shortened, and falls risk decreased. Governance records demonstrated that medication was used proportionately, not as routine restraint.

Operational example 3: Covert medication safeguards that remain person-centred

Context: A resident with dementia repeatedly refused a critical medication, creating clinical risk. The family asked staff to “just hide it in food.”

Support approach: The service applied a formal decision-making process rather than informal covert practice. Best-interest decisions were recorded, with clear time-limits, review points, and an emphasis on exploring alternatives first.

Day-to-day delivery detail: Staff trialled alternative formulations (liquid, different timing, different presentation) and used trust-based approaches with a consistent staff member. Only when alternatives failed did the service proceed with covert administration under a documented plan, with instructions on exactly how to administer (what food/texture, what not to crush, what to monitor). The plan required regular review and included how the service would keep the resident’s dignity intact (privacy, calm approach, no “tricking” language in front of them).

Evidence of effectiveness: The resident’s health stabilised and distress reduced because staff stopped escalating conflict. The service could evidence robust safeguards and review, reducing the risk of covert medication becoming unregulated restraint.

_toggle points commissioners and inspectors look for

Medication is also an audit hot-spot. Two expectations should be explicit in your operating model.

Commissioner expectation

Commissioner expectation: Commissioners expect providers to demonstrate safe medicines management with clear accountability, error reporting, and competence-based support plans. Where independence is supported (including self-administration), commissioners expect documented risk controls, monitoring, and escalation pathways rather than informal arrangements.

Regulator / Inspector expectation (CQC)

Regulator / Inspector expectation (CQC): Inspectors expect robust medicines governance: accurate MARs, safe PRN practice, learning from errors, and evidence that medicines are not used as a form of routine restriction. They will look for defensible decision-making where people refuse medication, including best-interest processes and review.

Governance that makes medication risk enablement defensible

Positive risk-taking in medicines fails when it is not governed. Practical controls include:

Competence-led self-administration assessments with review triggers (infection, hospital discharge, cognitive change).
PRN dashboarding (frequency by person, time of day, staff member) to identify drift.
Monthly MAR audits that check codes, refusals, omissions, and follow-up actions.
Medication incident learning loops (mini-RCA for errors, action owners, re-audit).
Pharmacy/GP review cadence for psychotropics, analgesia, anticoagulants, and polypharmacy risk.

How to write this into care planning

A defensible medication enablement plan should state:

What the person can do independently (and at what times of day)
What requires prompting versus direct administration
Known refusal triggers and de-escalation approaches
Escalation thresholds (missed doses, repeated refusals, side effects)
Review dates and responsible roles (senior, RM, clinician)

This keeps the approach practical for staff and auditable for commissioners and inspectors.

Practical takeaway

Medication safety in dementia does not have to mean removing control. With competence-based planning, tight PRN governance, and transparent decision-making, positive risk-taking can protect people from harm while preserving dignity and independence.