Restrictive practice, medicines, and safer team working

When distress is frequent or intense, teams can feel pressure to "just do something". That can lead to unsafe shortcuts such as unnecessary confrontation, over-reliance on medicines, or restrictive practice creeping into ordinary care. This is where calm team thinking matters most.

Non-drug approaches come first

NICE advises that before starting treatment for distress in people living with dementia, services should carry out a structured assessment to explore reasons for the distress and check for clinical or environmental causes such as pain, delirium, or inappropriate care. NICE also recommends psychosocial and environmental interventions as the initial and ongoing response.

This means frontline staff should not see medicine as the first answer to behaviour change. Good observation, pain review, routine adjustment, communication changes, activity, environment, and team consistency are central parts of safer support.

Important boundaries around medicines and restrictive practice

• Antipsychotics are not routine first-line treatment: NICE limits their use to severe distress or risk of harm and says they should be used at the lowest effective dose for the shortest possible time, with regular review.
• Valproate is not a routine answer either: NICE says not to offer valproate for agitation or aggression in dementia unless it is indicated for another condition.
• Medicines do not replace good care planning: staff observations should inform review, not be used to argue for sedation as a shortcut.
• Restrictive practice is high risk: blocking, holding, forcing, hiding medicines inappropriately, or using coercive language can all raise legal and safeguarding concerns.
• England and Wales use the Mental Capacity Act framework: Scotland and Northern Ireland use different legal frameworks, so local law and policy matter.
• Team consistency protects everyone: mixed messages across shifts often worsen the situation and increase risk.

Frontline care staff do not need to manage the legal or prescribing detail alone, but they do need to recognise when the situation is moving beyond routine care and needs senior review, lawful decision-making, and a more formal plan.

A review checklist for senior staff

Distress in dementia should not push teams into unsafe shortcuts. Start with assessment, unmet need, and practical care changes, and escalate for senior review before medicines or restrictive responses become the default.