Course content – PF23-Deeskalation
The modules of this course – work through them in order.
11. Module 11 · Special Situations
Special situations and groups
Some situations and groups need particular attention. In dementia, challenging behaviour usually expresses a need or distress that the person cannot communicate otherwise – pain, fear, being overwhelmed, too many stimuli, disorientation. Look for the cause, validate feelings instead of correcting or arguing (Module 6), give safety and familiarity, reduce stimuli, stay calm and avoid coercion. In delirium (acute confusion), think of a treatable physical cause – infection, dehydration, medication, pain – and have any sudden confusion or deterioration assessed by a doctor; accompany the person calmly and without confrontation. In a mental illness or crisis (e.g. psychosis, severe depression, suicidal thoughts, panic), stay calm, give safety, take the person seriously and do not confront; involve specialist help where appropriate (doctor, psychiatric service, crisis service). If there is an acute risk of suicide or another acute crisis, get help immediately.
With addiction or intoxication (alcohol, drugs, withdrawal), aggression is more likely and behaviour less predictable: pay particular attention to your own safety (Module 9), stay calm, do not provoke and get help where appropriate. With children and young people or people with an intellectual disability, adapt your approach to age and individual abilities. The basics stay the same: understand the cause (Module 2), act calmly and de-escalate (Modules 5–7), prevent (Module 8), protect your own safety (Module 9) and, in delirium, mental crisis, suicidality or addiction, involve medical or specialist help. Above all: if behaviour or confusion changes suddenly, always think of an acute, treatable cause.
Learning objectives of this module
- You know the approach in dementia, delirium, mental crisis, addiction.
- In the case of sudden confusion, you think of delirium (treatable!).
- In certain situations, you involve specialist help.
- You apply the basic principles adapted to the situation.
In the case of sudden change, think of delirium
A potentially life-saving rule: if behaviour or confusion changes suddenly, think of delirium. Delirium is an acute disturbance of attention and awareness, usually with a physical cause that can be treated – unlike dementia, which develops slowly. It often shows as challenging behaviour: sudden restlessness, aggression, disorientation or hallucinations. But it can also be quiet (hypoactive delirium): the person becomes withdrawn, slow and drowsy and eats less – this form is often missed (NICE, 2023). In people with dementia, delirium is easily mistaken for ‘the dementia getting worse’. Yet it needs prompt medical assessment, because the cause – e.g. a urinary or chest infection, dehydration, side effects of medication, pain or low blood sugar – has to be found and treated; untreated, delirium can become dangerous. The key warning sign is suddenness: changes within hours or days, especially in someone who was previously more stable. Further signs are fluctuating attention and alertness, new hallucinations or delusions, a disturbed sleep-wake rhythm and sudden disorientation. In practice: observe and document the change, ask about possible causes (infection? fluids? new medication? pain? blood sugar?) and inform the doctor – do not just calm or sedate the behaviour. Until the cause is treated, accompany the person with de-escalation: calm, reassurance, orientation, familiar people, no confrontation (NICE, 2023). Recognised and treated in time, delirium often resolves.
Special situations
| Situation | Particular feature |
|---|---|
| Dementia | Understand need/distress, validate, reduce stimuli |
| Delirium (sudden!) | Treatable cause → clarify (emergency!) |
| Mental crisis | Calm, take seriously, involve specialist help |
| Addiction/intoxication | Own safety, do not provoke, help |
Table: Special situations and their particular features. Source: own illustration, AI-assisted.
When to involve specialist help
Care staff do not have to cope with everything alone – and should not. In certain situations, medical or specialist help in good time is essential. 1. Suspected delirium or sudden deterioration: the doctor looks for and treats the cause; care observes, reports and accompanies. 2. Mental crisis or illness (psychosis, severe depression, acute anxiety or panic, suicidal thoughts): involve a doctor, psychiatrist or crisis service as needed. In acute suicidality or danger to self or others, get help immediately – doctor, crisis service or emergency number 112 – and do not leave the person alone. 3. Physical violence or danger: call colleagues and management, and the police (110) if there is serious danger (Module 9). 4. Situations beyond your competence – too complex, too dangerous or too stressful: getting help from colleagues, management, a doctor or specialist services is not failure but responsible, professional practice. Knowing when and which help to involve – and not hesitating too long – ensures the right treatment and safety and relieves the team. It links dealing with challenging behaviour with observing the person's condition, working with doctors and recognising your own limits.
The delirium recognised
Mr K. has dementia and is otherwise calm. Within a day he becomes very restless, aggressive and confused and has hallucinations. The team could treat this as ‘worsening behaviour’ and simply calm or sedate him. An attentive care worker recognises the sudden change as a possible delirium. She accompanies Mr K. calmly and reassuringly and informs the doctor so that the cause can be found. A urinary tract infection is diagnosed; after treatment, the delirium and the challenging behaviour resolve. Thinking of delirium and getting a medical assessment uncovered the treatable cause.
Calmed, not clarified. The same day, but the team concludes: ‘His dementia is getting worse.’ Mr K. is given a sedative as needed several times over the following days, and the bed rails are raised every night ‘so that he does not fall’. He becomes quieter, sleeps a lot and drinks little. Nobody connects this with the sudden change. Several days later he has a high temperature and is admitted to hospital with a urinary tract infection and dehydration.
How to classify it: Calming the behaviour without looking for the cause treated the symptom, not the illness. The quiet, drowsy state was not an improvement: it may still have been delirium (hypoactive form), and the infection progressed. Medication given mainly to keep someone calm or in bed and bed rails raised every night can restrict liberty; if this happens regularly or over a longer period, it needs the person's own consent or, if they cannot give it, the consent of their legal representative plus court approval (section 1831(4) BGB). A sudden change should always lead to a medical assessment.
| Aspect | Case study: delirium recognised | Version B: calmed, not clarified |
|---|---|---|
| Interpretation | sudden change → possible delirium | ‘the dementia is getting worse’ |
| First action | calm accompaniment, doctor informed | sedative as needed, bed rails at night |
| Cause | urinary tract infection found and treated | remains undiscovered for days |
| Outcome | delirium and behaviour resolve | hospital admission |
| Law and dignity | no freedom-restricting measure | regular restriction without legal basis |
Table: Comparison of the two versions of the case. Source: own illustration, AI-assisted.
Exercise: If a person's behaviour or confusion changes suddenly, do you think of delirium and have it assessed? Do you know how to approach people with dementia, a mental crisis or addiction? And do you know when to involve specialist help – delirium, suicidality, violence, being overwhelmed – and do you get it in good time?
Show suggested approach
For a sudden change, use three steps: 1. Notice – what is new compared with the last days (restlessness, confusion, hallucinations, or unusual drowsiness and withdrawal)? Since when? Does it fluctuate? 2. Check – signs of infection (temperature, urine, cough), fluid intake, new or changed medication, pain, blood sugar if diabetic. 3. Report – inform the doctor and the team with your observations and document them.
In a mental crisis with signs of acute suicidality, do not leave the person alone and get help immediately (doctor, crisis service or 112). Find out which psychiatric services and crisis services are available in your region and how to reach them.
- A sudden change in behaviour or confusion can be delirium – think of a treatable cause and inform the doctor.
- Delirium can also be quiet: withdrawal and drowsiness are warning signs too.
- The basics stay the same in every special situation: understand, de-escalate, prevent and stay safe.
- Involving specialist help in good time – e.g. in suicidality, danger or overload – is professional, not failure.
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 changed suddenly. Was a physical cause considered?
Show prompt
2. Which special situations make you feel least confident – dementia, delirium, mental crisis or intoxication?
Show prompt
3. When did you last get help in time – and when did you wait too long?
Show prompt
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
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
National Institute for Health and Care Excellence (NICE). (2023). Delirium: Prevention, diagnosis and management in hospital and long-term care (Clinical guideline CG103; first published 2010, last updated 2023). https://www.nice.org.uk/guidance/cg103