Why Challenging Behaviour in Dementia Is Communication

Behaviour described as challenging is almost always a person's way of communicating something they cannot put into words: pain, fear, an unmet need, or a reaction to their surroundings. When care teams understand what is being communicated, they can respond to the cause instead of containing the behaviour.

"There is no behaviour that challenges that does not have a meaning; it is our inability to understand the significance of that behaviour that is the issue." Pat Hobson, Co-Director, PMH Consultancy and Education

The problem with the label

When someone living with dementia becomes agitated, withdrawn or resists care, services often describe this as challenging behaviour. The label frames the behaviour as a challenge to the organisation rather than a message from the person. The response then follows the label: manage, contain, redirect, medicate.

This can lead to:

• staff trained in de-escalation without understanding why behaviour occurs
• restrictive practices used before less restrictive approaches have been explored
• environmental triggers going unrecognised
• care plans that record how often behaviour happens but not what it means

What might the behaviour be communicating?

• Pain the person cannot describe
• An unmet need such as hunger, thirst, tiredness or needing the toilet
• Fear or confusion, especially in unfamiliar spaces or with unfamiliar staff
• A reaction to the environment, such as noise, glare or crowding
• Frustration at a loss of independence or being rushed
• A wish to keep their identity, routines and autonomy

Five steps to understanding behaviour

PMH's Behaviours that Challenge™ model, developed by Pat Hobson and presented at the International Conference in Dementia in 2008, gives care teams a structured approach:

1. Observation before assumption: record what is happening before deciding why.
2. Understanding the person: interpret behaviour through their life history, personality and preferences.
3. Recognising triggers: look first at what is within the team's control.
4. Responding compassionately: choose proportionate, person-led responses and the least restrictive option.
5. Reviewing outcomes: measure whether the person's wellbeing improved, not just whether the behaviour stopped.

What changes when teams see behaviour as communication?

Teams become more confident, responses become more consistent, and the need for restrictive practice falls because staff have alternatives that address the cause. Care becomes something the person experiences as support rather than control.

Training and support

PMH's challenging behaviour training teaches the Behaviours that Challenge™ model to care teams and leaders. For organisation-wide change, our dementia care consultancy embeds the approach into care planning, supervision and governance.

Frequently asked questions

What is challenging behaviour in dementia? It describes behaviour services find difficult to respond to, such as agitation, withdrawal, repetition, resistance to care or a physical response. It is often called BPSD: read our guide to BPSD.

Is de-escalation training enough? De-escalation can help in the moment, but without understanding why behaviour occurs, distress tends to return.

Does this approach apply beyond dementia? The Behaviours that Challenge™ model was developed for people living with dementia and has since been extended to people with complex mental health needs, learning disabilities and autism.