Autonomy is something we all desire. But what happens when a person’s desire for autonomy intersects with an impaired ability to make sound decisions because of dementia? This is one of the most difficult crossroads in dementia care. It asks us to balance dignity, choice, safety, and compassion—without losing sight of the person at the center of care.

The safety concerns are real.

• Falls are the leading cause of injury among adults age 65 and older, and more than 14 million older adults—about one in four—report falling each year. Dementia increases this risk through impaired judgment, visual-spatial changes, gait changes, and reduced ability to recognize hazards. Heat, rain, ice, poor lighting, and uneven surfaces may therefore require added supervision or environmental safeguards.

• Accidental poisoning is also a concern. One poisons-center study of 2,726 dementia-related cases found that many involved medication errors or accidental exposure to harmful substances. Another hospitalization study found that unintentional poisoning rates among people with dementia were about twice those of people without dementia. These findings reinforce the need for safeguards when memory, judgment, and problem solving are impaired.

And we are caring for a person, not a disease.

I am always a champion of seeing the person before the disease. We must never minimize the history, preferences, interests, and identity of the person in our care. At the same time, as an occupational therapist, I recognize the objective and subjective signs that indicate when someone may no longer be able to make safe decisions independently.

The goal is not to take control. It is to help people do what they want and need to do each day while providing the right level of support and supervision to protect health and safety.

How to strike the right balance.

We already understand this balance with another vulnerable population: children. Because executive functions such as judgment, impulse control, safety awareness, and problem solving develop gradually, caregivers support children’s cognitive limitations while still encouraging autonomy and choice.

We create the “just right” level of challenge for meaningful activity—not too easy, not too risky, and not beyond the person’s current capacity. I believe this same principle is a useful guide in dementia care.

A critical skill for care providers is understanding the stage of dementia: which cognitive skills have been minimized or lost, requiring support, and which abilities remain and should still be encouraged.

In early-stage dementia, a person may struggle to notice and solve problems, interpret written directions or warnings, navigate safely, or use sound judgment in unsafe conditions. As the disease advances, cognitive skills continue to erode, including the ability to recognize what is unsafe to touch, ingest, or access.

A dementia-capable approach honors preferences, routines, interests, and identity while matching safety measures to cognitive capacity. We may need to limit access to hazards, supervise higher-risk activities, simplify choices, adapt the environment, and select safer materials such as non-toxic supplies or knives without sharp blades.

Just as a child can feel autonomous while being protected, a person living with dementia can experience selfhood, purpose, and dignity while families and care partners quietly reduce risks in the background. The goal is not to remove personhood; it is to support autonomy within a safer structure.

Working together for the desired outcomes.

As dementia advances, the person becomes increasingly dependent on others. Well-being, independence, and safety are significantly shaped by the type of care received.

Professionals, provider leaders, families, and loved ones must align around the degree of safety measures to use. Are the priorities autonomy and choice first, even when risk is high? Or is it safety first, with restricted access, supervision, and environmental controls to reduce falls, accidents, and injury? Through open communication and shared decision-making, families and care teams can create an individualized approach that honors the person’s choices while providing the protection they need.

Dementia care deserves the same thoughtful balance of autonomy, freedom, and protection that we provide in childcare. From my experience, I believe both autonomy and safety carry equal weight, and I have found ways to prioritize both when designing care plans and environments.

When we keep the person—not the disease—as the focus of care, and use subtle restrictions delivered by skilled, compassionate staff, we find the sweet spot for living well, and safely, with dementia.

The contents of this blog are also featured in the Society for the Advancement of Gerontological Environments white paper. Please visit Home – SAGE to read more about the post-occupancy evaluation on the LiveWell community.