Course content – PF23-Deeskalation
3. Module 3 · Causes & Triggers
Why escalation occurs
Prevention and de-escalation need a clear view of causes and triggers. Causes are the underlying reasons and conditions. Triggers are the specific stimuli or situations that set the behaviour off at a particular moment. Causes (Module 2) can be physical (pain, illness, unmet basic needs, side effects of medication), psychological (fear, being overwhelmed, loss of control, offence, frustration, boredom), illness-related (dementia with disorientation and misperception, delirium, mental illness) or environmental (noise, bustle, crowding, time pressure, unsuitable surroundings). Often several act together. The framework recommendations of the German Federal Ministry of Health describe a similar idea: background factors that are hard to change, and nearby factors – such as pain, hunger, noise or changing staff – that can trigger behaviour and are easier to influence (BMG, 2007).
Triggers differ from person to person. Common ones are: certain care situations, especially personal care with closeness, exposure and movement; being touched or addressed without warning; feeling patronised, controlled or forced; disrespectful treatment; too many stimuli or demands; frustration at not being understood or at a need not being met; time pressure in care; misunderstandings; and individual triggers such as certain people, words or situations, often rooted in the person’s life story. Knowing these triggers through observation, documentation and relatives makes it possible to avoid them (Module 8). Addressing causes and avoiding triggers together prevents a great deal of challenging behaviour.
Learning objectives of this module
- You distinguish between causes and triggers.
- You know the most important causes (physical, psychological, illness-related, environment-related).
- You know common triggers.
- You use this knowledge for prevention.
How care itself can be a trigger
An important and self-critical insight is that care itself is often the trigger. This is easily overlooked, because people tend to look for the ‘blame’ in the person’s behaviour rather than in their own actions. Typical triggers in care are:
- The type of care. Intimate personal care in particular involves closeness, exposure, touch and shame. A person with dementia may not understand what is happening and feel attacked.
- The way it is done. Acting without warning or in a hurry, handling the person roughly, or deciding over their head and forcing them.
- Disrespectful communication. Talking down, ‘baby talk’, talking about the person instead of to them, not taking them seriously.
- Lack of relationship. An unfamiliar carer whom the person does not yet trust.
The good news: if your own actions are the trigger, you can change them. Announce and explain each step. Work calmly and without rushing, as gently and painlessly as possible. Speak respectfully and at eye level. Respect the person’s wishes instead of overriding them. Involve familiar people and build trust. If the person resists, pause, calm the situation and try again later or in a different way – without coercion. This is often one of the most effective ways to prevent challenging behaviour. It requires self-reflection (Module 12) and the willingness to see your own role as a possible trigger.
Causes & triggers
| Level | Examples |
|---|---|
| Physical | Pain, needs, delirium, illness |
| Psychological | Fear, being overwhelmed, loss of control, offence |
| Triggers (care!) | Unannounced, hurried, rough, patronising |
| Environment | Sensory overload, noise, bustle, crowding |
Table: Causes and triggers at a glance. Source: own illustration, AI-assisted.
Knowing and documenting individual triggers
Besides common triggers, each person often has individual triggers: particular stimuli, situations, actions, people or words. They are often rooted in the person’s life story – for example a touch or situation that recalls an earlier trauma or bad experience, or a word that offends – or related to personality or illness. One person reacts aggressively when touched from behind, another when feeling crowded or controlled, a third to certain noises. Such triggers are rarely obvious. They become visible through observation (when and in what situation does the behaviour occur?), documentation (over time a pattern emerges) and the knowledge of relatives, who often know the person’s history. Knowing the triggers allows targeted prevention (Module 8): you avoid them or arrange the situation differently, before the behaviour occurs. Avoiding is better than de-escalating afterwards. In practice: identify the triggers through detective work (Module 2); document them together with the approaches that have helped, so that the whole team acts consistently; ask relatives; and adapt care accordingly. This links prevention with person-centred, biography-oriented care and teamwork.
The trigger identified
Mr B. (dementia) often becomes aggressive during personal care – apparently for no reason. The team observes and documents carefully and identifies a trigger: he reacts aggressively when touched from behind or without warning. His relatives confirm that, as a former soldier, he was always very watchful and disliked unexpected touch from behind. The team changes its approach: it approaches him from the front, announces each step, moves slowly and keeps eye contact. In the following weeks, the aggressive reactions during care no longer occur.
Holding instead of observing. Mr B.’s care plan only says ‘aggressive during personal care’. Nobody records when exactly the reactions occur, and the relatives are not asked. To be quick, one carer washes him from behind while a second holds his hands. Mr B. shouts, pulls free and hits out; a carer is hurt. The team now considers asking the doctor for calming medication.
How to classify it: The trigger – being touched from behind without warning – was never identified, and the way care was given set it off again and again. An entry such as ‘aggressive’ labels the person but gives the team nothing to work with. Holding someone against their will is coercion. It can only be justified to avert an acute danger that cannot be averted in any other way (§ 34 StGB) – never as a routine way of getting care done. The incident should be documented and discussed in a case review; the team should then observe systematically, ask the relatives and adapt its approach.
| Aspect | Case study: trigger identified | Version B: holding |
|---|---|---|
| Documentation | when, where, what came before | only ‘aggressive’ |
| Relatives | asked – life story known | not involved |
| Trigger | identified: touch from behind | unknown, set off again and again |
| Approach | from the front, announced, slowly | from behind, hands held |
| Outcome | aggressive reactions stop | injury, medication considered |
Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.
Exercise: Do you know the causes and individual triggers of your residents? Reflect: is your own way of acting (unannounced, hurried, rough, patronising) sometimes the trigger? Do you document triggers and successful ways of handling? Do you avoid the triggers?
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Choose one resident and, for one to two weeks, note every situation in which challenging behaviour occurs: time and place, activity, who was present, what happened just before, what the person did and what helped. Then look for patterns. Ask relatives about the person’s life story, habits and fears.
Check your own actions honestly: was the care announced? Was it hurried, rough or done over the person’s head? Record the triggers you identify and the approaches that helped in the care plan so that the whole team uses them, and review them after a few weeks.
- Causes are the background; triggers set the behaviour off at a particular moment.
- Care itself is often the trigger – and your own actions are what you can change most directly.
- Individual triggers are often rooted in the person’s life story; observation, documentation and relatives reveal them.
- Documented triggers and helpful approaches let the whole team prevent behaviour before it starts.
Self-reflection (voluntary)
Voluntary · not assessed – your thoughts are not saved or evaluated. Think about each question first, then open the prompt.
1. Which of your own routines in care could feel like an ‘ambush’ to a person with dementia?
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2. How does your team record challenging behaviour – with labels or with observations?
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3. What do you know about the life story of the people you care for, and where could you learn more?
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4. Which situations make you yourself tense or impatient during care?
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References for this module
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
Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN). (2026). S3-Leitlinie Verhinderung von Zwang: Prävention und Therapie aggressiven Verhaltens bei Erwachsenen [S3 guideline: Avoiding coercion – prevention and treatment of aggressive behaviour in adults] (Version 3.0, AWMF register no. 038-022). https://register.awmf.org/de/leitlinien/detail/038-022
Strafgesetzbuch (StGB) [German Criminal Code], section 34 Rechtfertigender Notstand [necessity as justification], as in force in October 2026. https://www.gesetze-im-internet.de/stgb/__34.html