Course content – PF23-Deeskalation
2. Module 2 · Understanding Behaviour (as Communication)
Behaviour is communication
The key to dealing with challenging behaviour is understanding that behaviour is communication. Aggression, restlessness, resistance or calling out rarely happen ‘for no reason’ or out of malice. They express something: a need, a state of distress or a feeling that the person cannot put into words, or does not want to. Behaviour is, in a sense, the person’s language – especially for people who cannot express themselves well verbally, for example because of dementia, aphasia or another communication impairment. The task of care is to decode this message: which need, distress or feeling lies behind the behaviour?
Common messages behind challenging behaviour are: pain (very common and often overlooked, especially when the person cannot say they are in pain); fear, for example of being touched without warning or of an unfamiliar place; unmet basic needs such as hunger, thirst, needing the toilet, feeling cold, tiredness or the need to move; being overwhelmed by too many stimuli or demands; loss of control and feeling patronised; being treated without respect; frustration at not being understood or not managing something; boredom; and illness-related causes such as dementia, delirium or mental illness. If you understand the message, you can address the cause – and the behaviour often settles.
Learning objectives of this module
- You understand behaviour as communication/an expression of needs.
- You decode the ‘message’ behind the behaviour.
- You know common causes (above all pain!, fear, needs).
- You address the cause instead of merely fighting the symptom.
The detective work: what lies behind it?
Finding the message behind the behaviour takes detective work: observing, asking and thinking with attention and empathy, because the cause is rarely obvious. Six questions help:
- Observe the behaviour and its circumstances. When, where and how does it occur, and what happened just before? Patterns give clues: ‘always during personal care’ may point to pain, fear or shame; ‘in the evening’ to tiredness or overstimulation; ‘only with certain people or actions’ to a specific trigger.
- Basic needs. Is the person in pain? Always check this first. Do they need the toilet? Are they hungry, thirsty, cold, hot or tired, or do they need to move? Meeting a simple need often resolves the behaviour.
- Feelings. Is the person afraid? Do they feel overwhelmed, crowded, controlled, offended, helpless or bored?
- Illness. Does dementia play a part, for example through disorientation or misperception? A sudden change may signal delirium – an acute confusion that often has a treatable cause and needs prompt medical assessment. A mental illness may also be involved.
- Environment. Is there noise, bustle, crowding or time pressure (Module 8)?
- Knowledge of the person. What do you know about their life story, preferences and earlier triggers? Ask relatives.
The answers show where to start: meet the need, ease the distress, avoid the trigger. Remedying the cause is more effective, more dignified and more lasting than fighting the symptom.
‘Messages’ behind behaviour
| Cause | Note |
|---|---|
| Pain (common!) | Always check first |
| Basic needs | Toilet, hunger, thirst, cold, movement |
| Fear/being overwhelmed | Things not understood, sensory overload, feeling crowded |
| Illness | Dementia, delirium, mental illness |
Table: Common ‘messages’ behind challenging behaviour. Source: own illustration, AI-assisted.
Pain – the overlooked cause
Pain deserves special attention. It is one of the most common and most overlooked causes of challenging behaviour, and treating it often resolves the behaviour. A person in pain who cannot say so expresses it through behaviour: restlessness, resistance (especially when moved or touched during care), irritability, aggression, calling out, groaning or withdrawal. This is often not recognised as pain but misread as ‘aggression’, ‘uncooperativeness’ or ‘just the dementia’ – and met with coercion, sedation or blame instead of pain treatment. The person then suffers twice: from the untreated pain and from the wrong reaction. People at particular risk are those who cannot express pain well: people with dementia, aphasia or other communication impairments, people with reduced consciousness, and very old or seriously ill people.
The rule is: with challenging behaviour, always think of pain. Consider it as a possible cause, especially when resistance occurs during movement or care. Assess it: if the person can still answer, ask them first. If they can no longer report pain reliably, observe facial expression, sounds, breathing, body tension and defensive movements, if appropriate with an observation scale such as BESD, the German version of the PAINAD scale. A score supports your judgement; on its own it neither proves nor rules out pain. If you suspect pain, pass your observations on to the doctor, who decides on a treatment trial. If the behaviour improves with medically ordered pain treatment, this suggests that pain was a cause. This rule links de-escalation with pain management and dementia care (Deutsche Alzheimer Gesellschaft, 2022).
The cause discovered
Mrs K. (dementia) has become increasingly restless and aggressive over several days and resists care violently. The team sees this as ‘the dementia getting worse’ and considers sedatives. An attentive care worker does some detective work. She notices that Mrs K. resists and grimaces especially when she is moved and when her right side is washed, and suspects pain. She reports this, and the doctor finds a painful cause, such as an injury or an inflammation. After pain treatment, Mrs K. becomes calm again and accepts care.
Sedation instead of detective work. The same situation, but nobody looks for a pattern. Mrs K.’s behaviour is recorded as ‘aggressive, dementia worsening’, and the doctor is asked for a sedative. She now sleeps through much of the day, eats and drinks less and is unsteady on her feet. During care she still grimaces and pulls away when her right side is touched. The painful cause remains untreated.
How to classify it: The behaviour was taken as a symptom of the dementia, not as a message. Pain was not considered, although Mrs K. showed clear signs during movement. A sedative does not treat pain and brings risks of its own, such as falls, more confusion and drinking too little. If medication is given mainly to calm a person down or keep them from moving, it can count as a freedom-restricting measure. Such a measure needs the consent of the person or, if they cannot give it, of their legal representative; if it is used regularly or over a longer period in a care home or hospital, it also needs the approval of the court (§ 1831 BGB). The right steps are: observe, think of pain, report the observations to the doctor and have the medication reviewed.
| Aspect | Case study: detective work | Version B: sedation |
|---|---|---|
| View of the behaviour | a message – possibly pain | symptom of ‘worsening dementia’ |
| Observation | grimacing during movement, right side | nothing systematic |
| Action | observations reported to the doctor | sedative requested |
| Cause | found and treated | remains untreated |
| Outcome | calm, accepts care again | drowsy, risk of falls, still in pain |
Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.
Exercise: In the case of challenging behaviour, do you do ‘detective work’ (when/where/how? which need/distress?)? Do you always think of pain too (especially in people who cannot communicate)? Do you address the cause – instead of merely fighting the symptom?
Show suggested approach
Choose one person whose behaviour you find challenging and go through the six questions in writing: 1. When, where and how does the behaviour occur, and what happens just before? 2. Could pain or an unmet basic need be involved? 3. Which feelings could play a part? 4. Is there an illness-related cause – and has anything changed suddenly (then inform the doctor promptly)? 5. What is the environment like? 6. What do you know about the person’s life story – and what could relatives add?
Write down one possible message and one small step to try out, for example offering a drink and the toilet before care, or announcing each step. If pain is possible: ask the person if they can still answer; otherwise observe in a structured way (e.g. with BESD) and pass your observations on to the doctor. Observe for a few days whether the behaviour changes and document it.
- Challenging behaviour is a message: a need, distress or feeling the person cannot put into words.
- Detective work – observing, asking about needs and feelings, using what you know about the person – uncovers the cause.
- Always think of pain, especially in people who cannot report it; ask first, observe if they cannot answer.
- Address the cause instead of suppressing the symptom – this is more effective, more dignified and more lasting.
Self-reflection (voluntary)
Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.
1. Think of a person whose behaviour you find hard. What might they be trying to tell you?
Show prompt
2. How do you notice pain in people who cannot tell you about it?
Show prompt
3. When has a quick explanation such as ‘that’s just the dementia’ stopped you or your team from looking further?
Show prompt
4. Which information about a person’s life story would help you understand their behaviour better?
Show prompt
References for this module
Arbeitskreis Schmerz und Alter der Deutschen Schmerzgesellschaft [Working group on pain and old age of the German Pain Society]. (2013). Hinweise zur Verwendung von BESD (Beurteilung von Schmerzen bei Demenz) [Notes on using BESD (assessment of pain in dementia)]. https://www.schmerzgesellschaft.de/fileadmin/pdf/BESD_Kurzanleitung_130626.pdf
Bundesministerium für Gesundheit [Federal Ministry of Health] (Ed.). (2007). Rahmenempfehlungen zum Umgang mit herausforderndem Verhalten bei Menschen mit Demenz in der stationären Altenhilfe [Framework recommendations on dealing with challenging behaviour in people with dementia in residential care]. https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Berichte/Bericht_Rahmenempfehlungen_zum_Umgang_mit_herausforderndem_Verhalten_bei_Menschen_mit_Demenz_in_der_stationaeren_Altenhilfe.pdf
Bürgerliches Gesetzbuch (BGB) [German Civil Code], section 1831 Freiheitsentziehende Unterbringung und freiheitsentziehende Maßnahmen [deprivation of liberty through placement and freedom-restricting measures], as in force in October 2026. https://www.gesetze-im-internet.de/bgb/__1831.html
Deutsche Alzheimer Gesellschaft [German Alzheimer Society]. (2022). Informationsblatt 18: Schmerz erkennen und behandeln [Information sheet 18: Recognising and treating pain]. https://www.deutsche-alzheimer.de/fileadmin/alz/pdf/factsheets/infoblatt18_schmerz_erkennen_dalzg.pdf