⚕️Care Handbook

Distressed Behaviour & Positive Behavioural Support

Behaviour that challenges in dementia is not “challenging behaviour” — it is distressed behaviour. It is communication. Understanding what the person is trying to tell us is the key to providing compassionate, effective support.

Language matters: “Distressed behaviour” not “challenging behaviour”

The term “challenging behaviour” places the problem with the person and can lead to a culture of control and containment. “Distressed behaviour” recognises that the person is in distress and that our role is to understand and relieve that distress — not to manage or suppress the behaviour. CQC inspectors look for person-centred approaches that address the underlying causes of distress.

Understanding Distressed Behaviour

People living with dementia may express distress through behaviours such as agitation, aggression, wandering, calling out, or refusing care. These behaviours are not intentional — they are the person's way of communicating an unmet need, a reaction to an environment that overwhelms them, or an expression of physical discomfort.

Common causes of distressed behaviour:

•Pain or physical discomfort (often unreported)
•Unmet needs — hunger, thirst, needing the toilet
•Overstimulation — noise, light, crowds
•Understimulation — boredom, lack of meaningful activity
•Fear or feeling threatened
•Inability to communicate needs verbally
•Medication side effects
•Infection (especially urinary tract infections)
•Depression or anxiety
•Disorientation in time, place, or person
•Unfamiliar environment or caregiver
•Past trauma or difficult memories

Positive Behavioural Support (PBS)

Positive Behavioural Support (PBS) is the recommended framework for understanding and supporting distressed behaviour. It is a values-led, evidence-based approach that aims to improve quality of life and reduce behaviours that cause distress, by understanding their function and addressing the underlying causes.

Primary Prevention

Reducing the likelihood of distressed behaviour by creating the right environment and meeting the person's needs proactively. This includes person-centred care, meaningful activities, consistent routines, good communication, and addressing physical health needs.

Secondary Prevention

Responding quickly and effectively when early signs of distress appear — using de-escalation techniques, reducing demands, changing the environment, or offering reassurance. The aim is to prevent escalation before the behaviour becomes established.

Reactive Strategies

Safe, evidence-based responses during a crisis that focus on keeping everyone safe while maintaining the person's dignity. These include giving space, reducing stimulation, and using last-resort interventions only when necessary and proportionate.

Key principle:PBS emphasises that behaviour serves a function. By identifying the “ABC” — Antecedent (what happened before), Behaviour (what the person did), and Consequence (what happened after) — we can understand patterns and develop proactive strategies. Use our ABC chart template →

De-escalation Strategies

These strategies are organised by the type of distressed behaviour. Always rule out pain, infection, and physical illness first.

Agitation and Restlessness

Possible Causes:

  • •Pain or physical discomfort
  • •Unmet needs (hunger, thirst, toilet)
  • •Overstimulation (noise, clutter, crowds)
  • •Boredom or lack of meaningful activity
  • •Infection (urinary tract infection common)
  • •Medication side effects

Recommended Approaches:

  • Rule out pain and physical causes first
  • Offer food, drink, or toilet
  • Reduce stimulation — move to a quiet area
  • Provide reassuring touch if appropriate
  • Offer a calming activity (music, walking, folding)
  • Use validation — acknowledge the person's feelings
  • Avoid restraint or coercion

Verbal Aggression (Shouting, Swearing)

Possible Causes:

  • •Fear or feeling threatened
  • •Frustration at inability to communicate
  • •Pain or physical discomfort
  • •Delusions or hallucinations
  • •Depression or anxiety
  • •Feeling rushed or patronised

Recommended Approaches:

  • Stay calm and keep a neutral expression
  • Do not argue back or take it personally
  • Give the person space — do not crowd
  • Speak softly and slowly
  • Validate the emotion: 'I can see you're upset'
  • Identify and address the root cause
  • Document using ABC chart
  • Consider referral to GP or community mental health team

Wandering

Possible Causes:

  • •Searching for something or someone (e.g., going 'home')
  • •Unmet physical need (toilet, food)
  • •Boredom or restlessness
  • •Disorientation in time
  • •Previous routine (e.g., going to work)

Recommended Approaches:

  • Ensure the environment is safe and secure
  • Identify the pattern — time of day, triggers
  • Provide purposeful activities and exercise
  • Ensure adequate supervision
  • Consider a 'wander guard' or alarm system
  • Register with the Herbert Protocol (police missing person scheme)
  • Ensure the person has identification on them
  • Walk with the person — don't try to stop them forcefully

Refusal of Care

Possible Causes:

  • •Not understanding what is being asked
  • •Fear or past trauma
  • •Depression
  • •Feeling too hot or cold
  • •Pain
  • •Not recognising the caregiver

Recommended Approaches:

  • Step back and try again later
  • Use simple, clear language — explain what you are doing
  • Build rapport before attempting care
  • Use a different approach or different caregiver
  • Ensure the environment is comfortable
  • Assess mental capacity for the specific decision
  • Document refusal and the reasons given

General De-escalation Steps

Whatever the type of distressed behaviour, these general steps apply:

  1. 1Stay calm — your emotional state affects the person. Take a breath before responding.
  2. 2Ensure safety — remove hazards, keep others at a safe distance, and call for help if needed.
  3. 3Rule out pain and physical causes — could the person be in pain, hungry, thirsty, or needing the toilet?
  4. 4Reduce stimulation — lower noise, reduce light, move to a quieter space if possible.
  5. 5Use calming communication — speak softly, slowly, and reassuringly. Do not argue or contradict.
  6. 6Validate the emotion — 'I can see you're upset' rather than 'Calm down' or 'There's nothing to worry about.'
  7. 7Give the person space — do not crowd or restrain. Back away to a safe distance.
  8. 8Observe and record — use an ABC chart after the incident to identify patterns and triggers.
  9. 9Review — what happened, why, and what could be done differently next time? Update the care plan.

ABC Behaviour Chart

ABC charts (Antecedent–Behaviour–Consequence) are an essential tool for understanding patterns in distressed behaviour. By systematically recording what happens before, during, and after episodes of distress, you can identify triggers and develop proactive support plans.

Use the interactive ABC chart template

Further Reading

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Important Notice

Care Handbook is a guidance resource only. It does not replace your organisation's policies, formal training, or current CQC standards. Always follow your employer's specific procedures and consult your line manager or the relevant professional body if you are unsure. Restraint and restrictive practices must only be used as a last resort and must be proportionate, lawful, and in line with your organisation's policy.