duckling feet – pattering on the wet concrete

This morning’s walk was curtailed by the weather; I thought I would use the down-time to document something I heard last week.

I was at a meeting of the Yorkshire & Humber Strategic Clinical Network (YHSCN) for Older People’s Mental Health and Dementia (OPMH&D).*

One of the speakers, Professor Ian James from the University of Bradford was talking about a contentious area of health and care, particularly in relation to dementia, namely, ‘Behaviours that Challenge.’

This area is difficult, partially, as no one has as yet agreed on a name for the situation,  (behaviours that challenge, challenging behaviour, behaviour and psychological symptoms, distress…) also because it is equally unclear who has the problem or if there is a problem (or disease state) at all.

I’ll explain.

As with all the other over-wordy words of medicine, this has an abbreviation – BtC. I’ll use that, although somehow, reducing it to three letters makes things more difficult.

What are BtC?

Well, classically this is ascribed to situations where a person who has dementia interacts with the outside world in ways that are at odds with the desires or expectations of others. There are all sorts of BtC – someone who won’t sit-down when they are at high risk of falling, another person who won’t or can’t sleep at night, taking your pants off and peeing in the corner, shouting-out for mum.

All of these ‘behaviours’ to me have a common denominator – distress, and, it is this that links us to whether these are a condition or a natural response to difficult situations.

To explain more; If I imagine that I am in a room and I can’t find a way-out and I need the loo and cannot communicate this to the other people, either because I am fearful, too shy or simply unable and, I really need to go, I might go in the corner.

Is this reasonable adaptation to an impossible situation or a symptom of disease?

You decide.

What has become apparent is that in families and in particular care homes that are for whatever reason dysfunctional – that is, aren’t harmonious in some ill-defined way; for example, the leadership of the home is poor, there is significant staff stress and absence, or, the husband or wife have their own mental or physical health problems and are exhausted, struggling to support their spouse who has dementia – it is in these situations where BtC become more prevalent.

I have seen this myself countless times, when I have been called to see a patient who is described as either being aggressive, violent or unmanageable. Usually the intention is that I sedate. Yet, when I approach, using whatever means is necessary – sometimes slowly, hesitantly, at other times in a confident, ‘I’m the doctor’ manner, I rarely encounter the same response.

Nora 98, violent and aggressive becomes, Nora 98, who wants to hold my hand.

George 76, outbursts of uncontrollable behaviour, becomes, George 76, into trains.

Do you see the point?

Who is it who has the problem?

Are the behaviours challenging or are people challenged? Challenged to think beyond standard clinical models of patient and nurse, or to think outside of the medical box?

In the past BtC were frequently addressed by medication – often antipsychotics which worked by knocking people out (probably making them more fearful) and at times, killing them.

Now we are learning that language, behaviour, how we behave and relate to people living with dementia is probably more important than the medicine; care, compassion, empathy, time and understanding are often what is needed.

In care homes where staff have been supported and in particular, trained in understanding people, receiving lessons in person-centred care, the high levels of BtC disappear. No need for medicine, just some one-to-on teaching time – something that is rarely provided as standard for the carers working either out in the community or in care homes.

I realise it have come to the end of this blog and I haven’t even explained the title – overthink. I am afraid, this will have to wait until the next time, although I promise you it is fascinating.

Have a good day.

*Expertly organised by Colin, Penny and Carole.



  1. EXACTLY!!
    So many years since Prof Kitwood propounded person -centred care, but each carer ( bringing their own social, emotional and physical plus relationship history) learns, to whatever extent, anew – and in the family home , most often without a training course.
    Many people with dementia , particular!y younger onset, in some countries , have campaigned against the use of the term BPSD.
    Looking forward to the ‘Overthink’!

    Liked by 1 person

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