Course content – PFLEGE-16
5. Module 4 · Understanding challenging behaviour
Behaviour is communication
‘Challenging behaviour’ (formerly ‘behavioural problems’) – restlessness, aggression, screaming, running away, resistance, calling out, night-time restlessness – is one of the greatest challenges in dementia care. The decisive change of perspective: this behaviour is not malice and not meaningless but a form of communication – the expression of an unmet need or of distress that the person cannot communicate in any other way. Because people with dementia can no longer put their needs and their suffering into words, they ‘show’ them through behaviour. The task of care is to decode the message behind the behaviour and to meet the underlying need – instead of merely ‘fighting’ the behaviour or ‘sedating’ it with medication.
Possible causes/needs behind challenging behaviour: physical distress (pain! – Course 14, hunger, thirst, urge to urinate, constipation, tiredness, illness/infection, side effects of medication), psychological distress (anxiety, loneliness, boredom, being overwhelmed, grief, loss of control), the environment (too many stimuli, noise, haste, unfamiliarity, darkness), or communication/relationship problems (misunderstanding, disrespectful treatment, being addressed from behind).
What this module is about. Why shouting, hitting or refusing are messages and not attacks, and how to search for the need behind them before anyone reaches for a sedative.
What you will be able to do afterwards. You can read a difficult situation as a message, work through a short checklist of possible causes, record what you observe and explain to colleagues why sedation is never the first answer.
Learning objectives of this module
- You understand challenging behaviour as communication.
- You look for the cause/need behind it.
- You meet needs instead of just ‘fighting’ the behaviour.
- You avoid premature sedation.
- You can work through the four areas of possible causes (body, feelings, surroundings, relationship) for a real situation and decide which one to check first (apply).
- You can record a behaviour with a simple observation form and draw a careful conclusion from the pattern (apply, analyse).
Looking for the cause instead of sedating
The most important principle: look for the cause/need instead of sedating prematurely. The common, problematic reflex in response to challenging behaviour is to give sedatives (sedation). This may ‘calm the person down’ in the short term, but it does not solve the problem (the need/distress remains unmet) and carries considerable risks: falls, further decline, confusion, loss of quality of life – and the person continues to suffer (merely ‘sedated’). In addition, many of these medicines are risky in old age (PRISCUS 2.0 list, Course 11). The better, professionally required approach is searching for the cause: why is the person behaving like this? When/during what does the behaviour occur (during personal care? in the evening? in noise?)? A particularly important, often overlooked point: pain is a very common, unrecognised cause of challenging behaviour in dementia (Course 14, Module 3) – always think of pain in cases of restlessness/aggression and, if appropriate, arrange a treatment trial. A urinary tract infection, constipation, hunger, thirst, boredom, anxiety or being overwhelmed may also lie behind it.
Once you have identified the cause, you can meet the need: treat pain, accompany the person to the toilet, give them something to eat/drink, offer occupation/exercise, relieve anxiety (validation, closeness, security), reduce overload (fewer stimuli) or adapt the environment. The ‘challenging behaviour’ often disappears when the underlying need is met. For care, this is the central competence: reading behaviour as a message, looking for the cause, meeting the need – instead of sedating. This requires observation, patience, creativity and knowledge of the person (life history, Module 5), but it is far more effective and more dignified than sedation. Medication (as prescribed by a doctor) may be necessary as a supplement in certain situations, but never as the first or only ‘solution’ instead of searching for the cause. This approach – understanding instead of sedating – is the heart of a dignified response to challenging behaviour.
The iceberg: what you see and what lies beneath
The word “challenging” is worth a second look. It describes how the behaviour feels to the people around the person: it challenges the team, the relatives and the routine. It says nothing about the person’s own experience. For the person, the behaviour is usually an attempt to cope, to protect themselves or to be heard. Figure 4.1 uses the picture of an iceberg. Above the water line is the small part you can see and hear. Below it lies the much larger part that explains it.
Figure 4.1 also warns you about a trap. If you work only on the tip, for example by telling Mrs Weber to calm down, the cause beneath stays where it is. The behaviour then returns, or it changes into something quieter, such as withdrawal. Withdrawal looks “easier” for the team, but the person may suffer just as much. So a quiet resident is not automatically a content resident.
Two more points belong to the foundations. First, behaviour that is new or suddenly much worse is a signal. A new infection or an acute confusional state (a sudden, often short-lived change in alertness and thinking, called delirium) can be the reason, and both need a doctor quickly. Second, safety always comes first: if a person is in danger or endangers others, you protect everyone calmly and call for help. The search for the cause follows straight after the situation is safe.