An accessible guide for care providers on capacity, best interests, restriction and complex decisions in dementia care.
This article provides general education for care providers. It does not replace assessment by the resident’s GP, community services, safeguarding team, mental capacity decision-maker, prescriber or emergency services where required. Resident-identifiable information should not be shared through website enquiries.
Dementia does not automatically mean lack of capacity
A dementia diagnosis does not automatically remove a person’s right to make decisions. Capacity is decision-specific, time-specific and may fluctuate. A person may lack capacity for one decision but retain capacity for another.
Support decision-making first
Before concluding that a person lacks capacity, staff should consider what support may help them decide. This may include timing the discussion better, using simpler language, reducing distractions, involving someone who knows the person well, or presenting choices in a more accessible way.
Best interests is not what professionals prefer
If a person lacks capacity for a specific decision, any best interests decision should consider the person’s wishes, feelings, values, beliefs, past views, family or advocate input where appropriate, risks, benefits and less restrictive options. Convenience for the service is not the test.
Where behaviour support overlaps
- Refusal of personal care
- Use of sensor mats, locked doors or one-to-one observation
- Medication discussions
- Risks linked to walking or exit seeking
- Family disagreement about care or contact
- Safeguarding concerns involving other residents
Restriction needs scrutiny
Restrictive practice may sometimes be necessary to reduce serious risk, but it should be proportionate, documented, reviewed and linked to the least restrictive available option. Where a person may be deprived of liberty, services should follow the relevant legal framework and local process.
Mini case example
A resident repeatedly tried to leave the home believing she needed to collect her children. The team considered locked doors and one-to-one observation. A better decision-making record separated the issues: her capacity to decide whether to leave, the risks of leaving unsupported, less restrictive options, family knowledge, walking routines, meaningful occupation and escalation arrangements. This made the plan clearer and more defensible.
Common documentation pitfalls
- Writing “lacks capacity” without naming the specific decision
- Not recording how the person was supported to decide
- Confusing an unwise decision with incapacity
- Using family preference as a substitute for best interests reasoning
- Not reviewing restrictions once risk changes
Sources and UK guidance basis
- Mental Capacity Act 2005 principles, including decision-specific capacity and least restriction.
- NICE NG108, Decision-making and mental capacity.
- NHS and SCIE Mental Capacity Act resources on best interests decision-making.
What this article cannot do
General articles can help teams think more clearly, but repeated incidents, safeguarding concerns, placement instability, complex family dynamics, prescribing questions or restrictive practice need case-specific review by the appropriate accountable professionals.
First Response Dementia Services provides focused dementia behaviour review, formulation and practical care planning support for care providers. The aim is to help teams understand the pattern, strengthen documentation and agree realistic next steps.