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Therapeutic first choice
The traps light up when you step in one. Three responses reliably escalate, and students use all three from the best of motives.
Pain deserves the first suspicion every time. Untreated pain is among the commonest drivers of agitation in dementia, and the person may be unable to say “my hip hurts”. Score it with PAINAD — breathing, negative vocalisation, facial expression, body language, consolability — and trial a scheduled analgesic rather than an as-needed one. Constipation and retention come next, and are checked, not assumed.
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DICE. Describe the exact behaviour with its context from the person who saw it. Investigate the person, the caregiver and the environment. Create a plan with the family and team, non-pharmacological first. Evaluate whether it worked and whether it is still needed.
The rules you cannot bend
Restraint and seclusion are last-resort emergency measures for imminent serious harm after less restrictive measures have failed — never for punishment, discipline, coercion or staff convenience, and never as a substitute for adequate staffing. An order from a licensed independent practitioner is required and PRN or standing orders are prohibited. A face-to-face evaluation is required within one hour for violent or self-destructive behaviour. Orders are time-limited: 4 hours for adults 18 and over, 2 hours for ages 9 to 17, 1 hour under 9. Monitoring is continuous, release happens at the earliest moment criteria are met, and both the person and the team are debriefed. A side rail raised to stop a person voluntarily leaving the bed is a restraint, whatever the order set calls it.
Trauma-informed personal care. Dementia can strip away the defences that kept old trauma contained, and the tasks of personal care map with uncomfortable precision onto the mechanics of assault. Assume a trauma history may be present in anyone. Ask the family neutrally whether anything about bathing, bedtime, darkness, uniforms or being touched is frightening, then build it into the plan: announce every touch, offer a same-gender caregiver, keep the person covered, go slowly, stop when asked and come back. Treat “no” as information rather than an obstacle.
Delegation. Assistive personnel may bathe, dress, groom, toilet, transfer, mobilise, feed a person you have assessed as safe to swallow, take observations and weights, offer orientation cues and familiar music, sit with someone on constant observation — and report changes. What may never be delegated is the nursing process: assessment, interpretation of a CAM or 4AT, the swallowing evaluation, teaching, evaluation of any intervention, clinical judgement about a change in condition, and the decision to initiate restraint. Tell them exactly what to report and how fast: “Tell me immediately if she seems more sleepy or more confused than this morning, if she has not passed urine this shift, or if she pushes your hand away during care.” That instruction is often what catches the delirium.