Course content – PFLEGE-16
5. Module 4 · Understanding challenging behaviour
5.3. Case, consolidation & transfer
Two cases and what to take away
The detective work
Mr B. (dementia) becomes increasingly restless and aggressive every afternoon – the team is considering sedatives. One carer ‘investigates’ instead: she observes systematically and finds that the restlessness always begins after lunch and that Mr B. reaches for his leg at the same time. Suspicion: pain (osteoarthritis, worse after sitting). A trial of pain medication (after consultation) and movement/changes of position in the afternoon solves the problem – the restlessness disappears. The case shows how searching for the cause (instead of sedation) reveals and meets the real need (freedom from pain).
Mr Demir and the nights
Mr Demir (fictitious), 81, has lived in a care home for six months. For three nights he has been calling out, getting up and trying to leave his room. The night nurse says he “has turned aggressive” and the day team wants to ask for a sleeping medicine. The nurse in charge, Katrin (fictitious), asks the team to wait two days and to observe. They record that Mr Demir calls out mainly after midnight, often goes to the door of the bathroom and returns without using it, and drinks very little during the day. He also began a new medicine a week ago. Katrin reports this to the doctor, who asks for a urine check and reviews the new medicine. A urinary tract infection is found and treated, and the medicine is changed. In the meantime, the night staff keep a small light on, offer a warm drink, and greet him from the front, using his name. Within a few days the nights become calmer.
Analysis. (1) The first reaction was a label (“aggressive”) and a sedative. (2) The observation showed a pattern that pointed to the body: the visits to the bathroom door, little drinking and a new medicine. (3) The nurse did not decide on medicine herself. She reported and the doctor decided. (4) Small, safe changes, such as light, drink and a calm greeting, were made at the same time. (5) The case also shows that not every behaviour has a single cause. Fear in a dark, unfamiliar room may have added to the infection. (6) A sleeping medicine would have hidden the infection, and it can raise the risk of falls on the way to the toilet.
Why is challenging behaviour called communication?
What are the four areas of possible causes?
What four questions does the detective principle ask?
What does WHO say about drugs for distress?
Why can sedation be a legal matter in Germany?
Key messages
- Behaviour that challenges is a message about an unmet need or distress.
- Look at the whole iceberg: body, feelings, surroundings and relationship.
- Think of pain, infection, thirst, the toilet and medicines first, and report new or sudden changes.
- Observe and record what you see, then look for a pattern before you draw conclusions.
- Sedation is never the first answer. Medication is a doctor’s decision after causes have been looked for.
- In Germany, sedation that deprives a person of liberty is also a legal question (section 1831 BGB).
- Which label do you or your team use for a person (“aggressive”, “difficult”)? What might you see if you replaced it with a question?
- Think of a behaviour you found hard. Which of the four areas did you check, and which did you forget?
- How comfortable are you with reporting a suspicion of pain to the nurse in charge? What would help you do it?
- ☐ I make the situation safe and stay calm before I look for causes.
- ☐ I check pain, toilet, drink, food, infection and medicines first.
- ☐ I write down what I see, not what I think.
- ☐ I change one thing at a time and note what happens.
- ☐ I report suspected causes to the nurse in charge and I do not decide on medicine.
Exercise: Choose a challenging behaviour in your area of work. Become a ‘detective’: when/where/during what does it occur, what precedes it, what helps? What cause/need could lie behind it (think of pain!)? How could you meet that need instead of sedating?