Behind every behaviour, there is an emotion, and behind every emotion there is an unmet need. Carers should view behaviour as a form of communication (Algase 1996).

When a person resists personal care, it is worth pausing and asking: What is this person trying to tell us? Consider both verbal and non-verbal communication. A person shouting for help may be expressing fear rather than aggression. We should be asking ourselves, is pharmacological intervention the most appropriate response to that?

When supporting people whose behaviour challenges us, medication may reduce the behaviour temporarily, but it does not always address the unmet need behind it. If the underlying fear, pain, confusion or distress remains unresolved, the behaviour may return once the effects of the medication wear off.

Research has consistently highlighted the role of unmet needs, pain, environmental factors and emotional distress in behaviours that challenge in dementia care (Algase et al 1996, Husebo 2011).

This reinforces the importance of understanding the meaning behind the behaviour rather than focusing solely on managing its presentation. In many situations, the first response should be a therapeutic and person-centred approach rather than immediately relying on medication. Medication certainly has a place in dementia care when clinically indicated, but therapeutic engagement should remain a fundamental part of assessment and intervention.

The importance of therapeutic engagement - building rapport and trust

Kitwood (1997) stresses on the importance of seeing the person first before the diagnosis. His concept of person-centred care highlights the importance of recognising each person's unique identity, life history, preferences, emotions and remaining abilities. He suggested that positive interactions that promote dignity, respect, inclusion and choice can support wellbeing, while negative interactions may contribute to distress and a decline in functioning. Building trust and a little friendship can help a person feel more relaxed, making the process feel less like a task and more like a shared activity.

Something as simple as knocking on the door and asking permission to enter demonstrates respect for privacy and autonomy. Introducing yourself and beginning with a person-centred conversation can help establish rapport and familiarity.

Seeking permission before providing care gives people choice and control, which can increase the likelihood of acceptance. Include them in the process, encourage them to choose what they would like to wear or decide how they want to be cared for. NICE Guidelines encourages carers to involve people living with dementia in decisions about their care for better outcomes.

When personal care is approached with patience and caution, there is more opportunity to identify factors that may contribute to refusal, fear or distress. Working at the person's pace, communicating throughout the process, and validating their feelings and concerns can provide reassurance and help maintain trust.

References

• Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K. and Beattie, E. (1996) ‘Need-driven dementia-compromised behaviour: An alternative view of disruptive behaviour’, American Journal of Alzheimer's Disease, 11(6), pp. 10–19.
• Husebo, B.S., Ballard, C. and Aarsland, D. (2011) ‘Pain treatment of agitation in patients with dementia’, BMJ, 343, d4065.
• Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First. Buckingham: Open University Press.
• National Institute for Health and Care Excellence (NICE) (2018) Dementia: Assessment, Management and Support for People Living with Dementia and Their Carers (NG97). London: NICE.
• Substance Abuse and Mental Health Services Administration (SAMHSA) (2014) SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: SAMHSA.