As-Needed Medication in Dementia Care

“Pro re nata” medications (PRN)—that is,medications that are administered on an as-needed basis—are an important component of medical care in assisted living (AL) residences. Within the United States, individual states differ in their regulations about who may administer PRN medications, but many AL communities depend on unlicensed support staff to provide some PRN support. A recent qualitative study looked at the kinds of knowledge needed by unlicensed staff for PRN decision making in dementia care.

In the state of Oregon, for example, where the study was conducted, unlicensed AL staff members are permitted to administer PRN medications, but only under specific written parameters. The goal of these parameters is to remove any sense of discretion from the decision making of unlicensed staff. This study, in which overnight AL staff were observed and interviewed by researchers, showed that the unlicensed staff needed to use a high degree of “tacit knowledge,” or practical knowledge gained from firsthand experience. Tacit knowledge, in contrast to explicit knowledge, is used without consciously thinking about applying it. Although the state laws forbid any specific discretion or judgment on the part of the unlicensed staff, in practice, staff members still rely on a large degree of tacit knowledge when administering PRN medication to residents with dementia.

A common theme that arose in the interviews was the importance of knowing the residents as individuals. Staff understood the importance of understanding how each resident shows symptoms of pain and distress. Many patients with dementia are unable to verbally express pain symptoms, for example, therefore, staff need to rely on other information they have about the resident to interpret signs of distress. Resident-specific knowledge about how to encourage the use of medicine to reduce distress—or to identify alternate ways of soothing distress—is also important knowledge for staff.

This study suggests that even when state-mandated training and RN oversight is in place, staff judgment and knowledge still has an important role in PRN administration. The author suggests that future research might look at the efficacy of the kinds of written parameters for PRN use specified in Oregon. Further, to reduce employee stress, the training of unlicensed AL staff could include examples like those mentioned in the study that call attention to and validate staff’s tacit knowledge.


Carder, PC. (2012). Learning about your residents’: how assisted living residence medication aides decide to administer pro re nata medications to persons with dementia. The Gerontologist 52(1) 46-55.

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