Course content – PFLEGE-16
5. Module 4 · Understanding challenging behaviour
5.1. In depth: reading causes, not sedating first
Reading causes, and why sedation is not a first answer
Challenging behaviour: causes
| Area | Example |
|---|---|
| Physical | Pain!, urge to urinate, hunger, infection |
| Psychological | Anxiety, loneliness, boredom, being overwhelmed |
| Environment | Noise, sensory overload, unfamiliarity |
| Relationship | Misunderstanding, disrespectful treatment |
The detective principle
Responding to challenging behaviour is often like detective work: you observe closely, gather clues and look for the hidden cause. Systematic observation helps: When does the behaviour occur (time of day, during certain activities)? Where and in what situation (during personal care, at mealtimes, in noise, in the evening)? What precedes it (a trigger)? How can it be influenced (what calms, what makes it worse)? This systematic observation (often using an observation form) reveals patterns that lead to the cause. Example: a person always becomes aggressive during personal care → possible causes: pain on movement, fear of water, shame, being overwhelmed, disrespectful/hurried care → check specifically and adapt (gentler, calmer, in keeping with their life history, treat pain if appropriate). Or: someone is restless in the evening (‘sundowning’) → possible causes: tiredness/overstimulation at the end of the day, darkness/shadows, need for security, disrupted day-night rhythm → adapt the environment (light, quiet), calming rituals, daily structure (Module 6). This detective-like, understanding approach is the key: instead of fighting the behaviour as a ‘problem’, you understand it as a symptom and treat the cause. For care, this is demanding (it requires observation, patience, knowledge of the person, creativity), but far more effective and more humane than sedation. And it is often successful: many ‘challenging behaviours’ can be significantly reduced or resolved by recognising and meeting the underlying need – without any medication at all. This detective work is one of the most satisfying and important tasks in dementia care: it gives the person what they really need and improves everyone’s wellbeing.
The detective principle combines observation (Course 10), pain management (Course 14), person-centredness and creativity – and makes dementia care a demanding, understanding activity.
Why the body comes first
The table above lists four areas, but in practice you start with the body. There are two reasons. A physical cause can often be treated quickly, and a missed physical cause can do real harm. A person with advanced dementia may no longer be able to say “my tooth hurts” or “I need the toilet”. The need is still there. It simply shows itself as restlessness, calling out or resistance.
As general professional knowledge, a useful body check covers the following points. Is the person in pain, for example when moving, sitting or being touched? When did they last drink, eat and use the toilet? Is the bladder full, or is there constipation? Are there signs of infection, such as fever, a new smell of urine or a cough? Are the teeth, the mouth or the skin sore? Is the person too hot or too cold? Can they see and hear well, and are glasses and hearing aids in place and working? Did a new medicine start recently, or did a dose change? Nurses and doctors decide on any medical steps. Your role is to notice, to record and to report.
Pain deserves special attention because people with dementia often cannot report it in words. Look at the face (frowning, grimacing), at the voice (moaning, calling), at the body (guarding a limb, stiffness, rubbing a place) and at changes in habits (not eating, sleeping badly, refusing to walk). The module on pain management in this course series covers pain scales in detail, so here the main message is: when behaviour changes, think of pain early.
A stepwise path before any sedative
Figure 4.2 puts the principle of this module into a sequence. It does not replace professional judgement or the instructions of the doctor in charge. It shows the order in which a team can think. Each step is small, and several steps can be done in one shift.
Notice that step 6 does not say “never medication”. The original text of this module already makes this clear: medication may be needed as a supplement in certain situations, but not as the first or only answer. A person in severe distress, or in danger, has a right to relief. What matters is the order, and that the decision is taken by a doctor after the causes have been looked for.
What international guidance says
The World Health Organization (WHO) has a public fact sheet on dementia that is updated regularly. It states that when a person with dementia may harm themselves or others, non-drug approaches should be tried first. It adds that antipsychotic medicines, such as haloperidol or risperidone, may be considered only when clearly needed, with caution and close supervision (World Health Organization, 2026). The same fact sheet notes that physical and chemical restraints are widely used in care homes and hospitals, even where regulations aim to protect freedom and choice, and it calls for legislation based on human rights standards.
In Germany, professional guidelines for dementia, published by medical societies, follow the same direction: non-drug measures come first, and the use of antipsychotic medicines is limited. This course does not quote their wording, because the text of the current guideline could not be verified for this module. Treat this sentence as general professional knowledge, and ask your organisation which guideline or internal procedure applies in your setting.
In Germany: sedation can also be a legal question
Section 1831 of the German Civil Code (BGB) deals with measures that deprive a person of liberty. Paragraph 4 extends the rules to a person who lives in a hospital, a care home or a similar facility, if liberty is taken away over a longer period or regularly by mechanical devices, medication or other means (Bundesministerium der Justiz, n.d.-c). In practical terms, medication that is given in order to keep a person quiet or in their place can fall under this rule. Such measures then need the approval of the custodianship court (Betreuungsgericht) in the cases the law describes, and the law does not define “longer period” or “regularly”.
Do not decide such questions yourself. The point for your daily work is simple: sedation to manage behaviour is never a routine matter. It must be justified, ordered by a doctor and recorded, and your organisation has procedures for this. Module 11 covers freedom-restricting measures (freiheitsentziehende Maßnahmen, FEM) in detail.
Finally, a note on the person’s view. Pain, fear and boredom are not abstract. A person who is sedated instead of helped may still be in pain, only less able to show it. Understanding instead of sedating is therefore not only more effective. It respects the person’s dignity and their right to be taken seriously.