In the face of a behavioral crisis in a person with cognitive disorders, every second counts. Whether you are a professional in a nursing home, a family caregiver, or a home caregiver, having a structured protocol can make all the difference between a worsening situation and a successful return to calm. Behavioral crises represent one of the major challenges in supporting individuals suffering from Alzheimer's disease, Parkinson's disease, or other neurodegenerative conditions.

Understanding Behavioral Crises Before Intervening

Before addressing the protocol itself, it is essential to understand what lies behind a behavioral crisis. Contrary to what one might think, these behaviors are never gratuitous or intentional. They constitute a mode of communication for a person who can no longer express their discomfort, pain, fear, or frustration in any other way.

Common Causes of Behavioral Crises

The triggers of a crisis are multiple and often combined. Understanding these causes allows for anticipating and preventing many difficult situations:

The Phases of Behavioral Escalation

A behavioral crisis generally does not occur suddenly. It follows a predictable continuum in several phases that every caregiver must learn to recognize:

The de-escalation protocol that we will detail aims to intervene as early as possible to avoid reaching the peak of the crisis or to manage this peak in the safest way possible when it is unavoidable.

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Step 1: Recognize Early Warning Signs

The first step of the de-escalation protocol is to develop active vigilance to the precursor signs of a crisis. The earlier the intervention, the more effective it will be, and the less likely the situation is to escalate. This skill is acquired through experience, but also through systematic observation and a deep understanding of the person being supported.

Carefully Observe Behavioral Changes

Each person has their own "crisis language." Some suddenly become silent and withdraw, while others become hyperactive. The important thing is to know the usual pattern of the person being supported. Here are the main signs to watch for:

• Changes in Eye Contact: Averted gaze may indicate discomfort or a desire to withdraw. A fixed or overly intense gaze may signal rising anxiety or focus on a source of stress. A sudden absence of eye contact in a usually communicative person is a major warning sign.
• Changes in Body Posture: Observe muscle tension (shoulders raised, clenched jaw), clenched fists, a withdrawn position (arms crossed, body hunched), or conversely an attacking posture (body leaning forward, abrupt gestures). These non-verbal signals often precede verbal or physical outbursts.
• Vocal Changes: A change in voice tone (higher, lower), an increase in volume, a rapid speech rate, or conversely unusual silences. Anxious repetitions of the same question or phrase are also early indicators of distress.
• Unusual Motor Behaviors: Aimless wandering, repetitive gestures (rubbing hands, tapping on the table), nervous manipulation of objects, repeated attempts to leave a place, opening and closing doors or drawers. These behaviors often indicate a search for something (an object, a person, a place) or an attempt to manage anxiety.
• Physiological Manifestations: Redness or paleness of the face, sudden sweating, rapid or shallow breathing, hand tremors. These signs indicate that the autonomic nervous system is activating in response to stress.

Use Prevention Tools and Knowledge of the Person

A deep understanding of the person is your best preventive asset. The more you know about their life history, habits, likes, and dislikes, the better you can anticipate risky situations and adapt your approach.

The life biography is not just an administrative document. It is a living tool that allows you to understand current reactions in light of the past. For example, a person who has worked in the military all their life may respond positively to clear and structured instructions. A former teacher may feel reassured by maintaining a "helper" role among other residents. A former factory worker may need concrete and repetitive tasks to feel useful and calm.

Step 2: Secure the Immediate Environment

As soon as you identify a rise in anxiety or agitation, your top priority is to secure the environment to prevent any risk of injury, both for the person themselves and for others present. This step should be carried out quickly but without haste that could worsen the situation.

Quickly Assess Potential Dangers

In a few seconds, do a visual scan of the environment. This quick assessment should become a professional reflex:

• Potential Dangerous Objects: Discreetly remove anything that could be used to harm - scissors, knives, pens, sharp objects, glass containers. If you are in a kitchen or care room, close drawers containing sharp materials. Position yourself between the person and these objects if you cannot remove them immediately.
• Obstacles to Movement: Clear the space to prevent falls - push back chairs, move small furniture, check for cables on the floor, slippery rugs, or objects lying around. An open space also allows the person to move without feeling trapped, which can reduce their anxiety level.
• Exits and Retreat Areas: Ensure that the person always has an accessible exit route. Never position yourself between them and the door. Mentally identify where you could take them if a change of environment becomes necessary - their room, a garden, a quiet room. The feeling of being trapped is a major amplifier of aggression.
• Protection of Other Vulnerable Individuals: If you are in a communal setting (dining room, common lounge), quickly assess if other residents are nearby and could be frightened or in danger. If necessary, calmly ask a colleague to accompany them to another room, or guide the person in crisis to a more isolated space.

Create a Safe and Decompressing Space

If the person agrees to move, gently guide them to a space more conducive to returning to calm. The characteristics of a good decompression space are:

• Calm and Low-Stimulus: Little noise, dim lighting, absence of foot traffic, comfortable temperature. Avoid spaces that are too large, which can disorient, or too small, which can feel suffocating.
• Familiar and Reassuring: Ideally, the person's personal room with their familiar objects, or a place they know well and where they have their habits. Familiarity reduces anxiety related to disorientation.
• With Soothing Elements: Access to a window with an outside view (nature is calming), presence of comforting objects (family photos, stuffed animals, soft music if the person is receptive), ability to sit comfortably.
• Secure but Not Confined: The door remains open or ajar, the person does not feel trapped. You are present nearby but without invading their space if they wish for a moment alone.

Step 3: Adopt a Non-Threatening Posture and Communication

Your non-verbal communication is as important, if not more so, than your words. A person in crisis, whose cognitive abilities are impaired, primarily reads body language, facial expressions, and tone of voice. Even the best words will be ineffective if your body sends signals of threat, fear, or annoyance.

The Body Language of De-escalation

Every detail of your posture matters. Here are the principles to absolutely respect:

Body Posture: Your entire body must communicate openness, relaxation, and kindness:

• Visible and Open Hands: Keep your hands clearly visible, palms open facing the person or upwards. Hands hidden in pockets or behind your back create distrust ("What are they hiding?"). Clenched fists, even involuntarily, are a signal of aggression.
• Arms Along the Body or Slightly Apart: Absolutely avoid crossed arms (defensive or judgmental posture), hands on hips (authority or annoyance posture), arms extended towards the person (stop gesture perceived as aggressive). Ideally, have your arms relaxed along your body, slightly apart, palms visible.
• Relaxed Shoulders, Neutral to Kind Face: Mentally check that your shoulders are not raised towards your ears (a sign of tension that the person picks up). Consciously relax your face - no frowning, no clenched jaw. A slight smile is possible if it is natural, but a forced or overly broad smile can be perceived as mockery.
• Calm and Deep Breathing: Your breathing influences that of the person. Breathe consciously in a slow and deep manner, through your belly. This breathing calms your own nervous system (you need it too!) and the person may unconsciously synchronize with your breathing rhythm. This is a powerful emotional co-regulation phenomenon.

Soothing Verbal Communication

Your words are important, but the way you say them is even more so. The tone, volume, and rhythm of your voice have a direct impact on the nervous system of the person in crisis.

The Tone and Pace of Voice:

• Calm and Steady Voice: Imagine you are speaking to a child frightened by a storm. Your voice should be reassuring, soft but not syrupy, warm but not artificial. Avoid an authoritative tone ("Calm down immediately!"), a condescending tone ("Come on, it's nothing..."), or a plaintive tone ("Please don't shout, you're scaring me...").
• Moderate Volume: Never shout, even if the person is shouting. Shouting back only escalates the situation. Conversely, speaking too softly may force the person (who may have hearing difficulties) to strain to hear, which increases their frustration. Find the optimal volume: clearly audible without being loud.
• Slowed Pace: Speak more slowly than usual. People with cognitive disorders need more time to process verbal information. A too-fast pace creates confusion and anxiety. Pause between sentences. Give the person time to respond before continuing.
• Warm but Emotionally Neutral Tone: You must communicate kindness and support, but without overplaying the emotion. A voice that is too emotional (trembling voice, tears in the voice) conveys your own anxiety and further destabilizes the person. Remain a stable emotional "rock."

The Choice of Words: Semantics matter. Always favor positive phrasing over negations:

• Use short and simple sentences - subject, verb, complement. No complex subordinate clauses, no convoluted phrases.
• Repeat if necessary with exactly the same words. Changing the phrasing can sow confusion.
• Avoid multiple questions or complex explanations: "Do you want to go to your room or would you prefer to stay here but then we need to lower the volume of the television a bit and maybe close the window because there is noise..." → Too much! "Do you want to go to your room?" [wait for the answer] then possibly offer an alternative.
• Ban negative terms: "Don't shout" → "Let's talk softly" / "Don't leave" → "Stay with me" / "Don't be afraid" → "You are safe here".
• Use the person's name with respect: "Mrs. Dupont, I am Marie, your caregiver" rather than "Granny" or other infantilizing diminutives.

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Step 4: Validate Emotions Without Judgment

This step is crucial and often overlooked: recognizing and validating what the person feels, even if it seems irrational, excessive, or based on erroneous perceptions of reality. This is counterintuitive for many caregivers who instinctively reassure by minimizing ("It's nothing", "There's no reason to worry") or reasoning ("But no one wants to hurt you").

Empathetic Listening in Crisis Situations

When a person is in distress, they first need to be heard, truly heard. Not judged, not reasoned with, not lectured. Just heard. This emotional validation is therapeutic in itself:

• Name the Emotion You Observe: "I see that you are very angry", "You seem scared", "This is really difficult for you right now", "You look sad". By naming the emotion, you do two things: you show that you are attentive to what they are experiencing, and you help them identify what they feel (which is not obvious when overwhelmed).
• Validate Without Minimizing: Never say "It's nothing" (this completely invalidates the feeling), "Calm down" (an order that does not work), "There's no reason to get angry" (a judgment that denies the person's emotional reality). Prefer: "I understand that this is hard", "You have the right to be upset", "What is happening to you is really frustrating". You acknowledge the person's right to feel what they feel.
• Reflect What You Hear (Active Listening): "If I understand correctly, you are telling me that you want to go home", "You are explaining to me that someone took your things", "You are telling me that you have an appointment and need to leave". This reformulation shows that you are really listening and gives the person the opportunity to confirm or clarify. It is also a way to buy time for the emotion to subside.

Therapeutic Validation Techniques

Therapeutic validation, developed by Naomi Feil specifically for individuals with dementia, is an approach based on a fundamental principle: entering the emotional frame of reference of the person rather than trying to bring them back to our objective reality.

"Validation does not mean lying. It means respecting the person's feelings and entering their emotional world, even if their perception of facts differs from the current reality."

The key principles of validation:

• Do Not Correct "Factual Errors": If the person believes it is 1960, do not try to convince them that we are in 2026. Enter 1960 with them.
• Look for the Underlying Emotion: If someone wants to "go home" while they have been at home or in a facility for years, they are not necessarily expressing a need for a geographical location. They may be expressing a need for security, a desire to reunite with deceased parents, a feeling of not belonging, a nostalgia for a time when they felt at home in their life. Explore: "When you think of your home, what do you think of? What do you miss?"
• Validate the Emotion Rather Than the Fact: "I see how much you love your home and how much you miss it. It is difficult to be away from home." is infinitely more helpful than "But you are at home, this is your room now!"

Step 5: Identify and Address the Underlying Cause

Once you have established an empathetic connection with the person and they feel heard, you can begin to methodically investigate the cause of their discomfort. Often, at this stage, the emotional intensity has already diminished thanks to the previous steps, making it easier to identify the problem.

The DICE Method for Identifying Causes

Use the acronym DICE (Pain, Infection, Constipation, Environment) to systematically explore the most common physiological and environmental causes:

In practice, systematically ask yourself:

• For Pain: Use a behavioral pain assessment scale if the person cannot express themselves verbally (Algoplus, Doloplus, ECPA). Observe behaviors: groaning, grimacing, rubbing an area, refusal to be touched. Check when the last pain relief was given if prescribed.
• For Infection: Take the temperature. Check the latest lab results if available. Observe any recent changes: increased confusion, unusual drowsiness, refusal to eat. When in doubt, contact the medical team for an evaluation.
• For Constipation: Check the care record: last documented bowel movement? Observe the abdomen (bloated, hard?), listen for complaints ("My stomach hurts"). Check recent hydration and diet. Constipation can generate major physical distress expressed through aggression.
• For the Environment: Conduct a sensory overview. Too much noise (loud television, multiple conversations, work, alarms)? Too bright or too dark? Inappropriate temperature? Too many people in the room? Immediately propose simple adjustments.

Targeted Interventions Based on the Identified Cause

Once the cause is identified, intervene appropriately and proportionately:

• If it is a basic physiological need: Offer something to drink (frequent dehydration), to eat (hypoglycemia), to go to the bathroom (never assume the person will go on their own), to rest (extreme fatigue). These simple interventions resolve an astonishing number of agitation situations.
• If it is environmental: Reduce stimuli (lower the volume, close the curtains, move away from noise), adjust the temperature (cover or ventilation), propose a change of space (garden, quiet room). The effect can be spectacularly rapid.
• If you suspect pain or infection: Immediately contact the medical team (nurse, doctor) for urgent evaluation. NEVER administer medication without a prescription, even a simple paracetamol, as you could mask important symptoms or create drug interactions.
• If it is emotional/psychological without an identified physiological cause: Continue emotional validation, propose soothing or meaningful activities, facilitate contact with loved ones if the person wishes and it is possible (phone call, video call).

Step 6: Propose Distraction and Redirection Strategies

When the immediate cause has been addressed but agitation persists, or when you cannot immediately modify the problematic situation (for example, the person wants to see their deceased mother), distraction and redirection techniques become essential. This is not manipulation but a benevolent reorientation of attention towards something more manageable or pleasant.

Positive Distraction

Distraction is a powerful tool when used with respect and empathy. It works because human attention is limited: one can only concentrate intensely on a limited number of things at once. By offering an engaging alternative, you allow the person to "unhook" from the source of their anxiety.

Redirection Rather Than Confrontation

When a person is fixated on a delusional idea (someone has stolen their belongings, they need to go to work, etc.) or an unrealistic request (I want to go home while "home" no longer exists), redirection is more effective than direct confrontation with reality:

• Technique "Acknowledge then Redirect": "Yes, I understand that you want to leave. This is important to you. Before that, come have a hot tea with me, it's chilly, then we will see about your departure." You do not say no abruptly, nor do you promise. You propose an intermediate step, and often, after a few minutes, the person has forgotten or calmed down.
• Alternative Choice Technique: "I see that you do not want a shower right now. Would you prefer to wash your hands first, or would you rather go for a walk in the garden?" You give the illusion of control (the person chooses), you avoid direct confrontation, and you redirect towards an acceptable option.
• Delay Technique: "That is a very good idea you are proposing. We will do it. But first, I really need your help with..." You validate the idea, you do not say no, you introduce a delay during which the emotion can subside.

Step 7: Evaluate, Document, and Debrief

The final step of the de-escalation protocol should never be neglected. It is crucial for organizational learning, continuity of care, and prevention of future crises. It is also a moment of care for the caregivers themselves.

Post-Crisis Evaluation

Once the situation has calmed down, take a moment to evaluate at three levels:

• The Person's Condition: How do they feel now? Are they tired, confused, ashamed? Do they need rest, comfort, reassuring presence? Were there any injuries (even minor ones like scrapes)? Does the person need to talk about what happened or would they prefer to "turn the page"?
• The Condition of the Interveners: How are you personally? Are you physically injured (bruises, scratches, bites)? Are you emotionally shocked, scared, angry? Do you need support, to talk, to take a break before resuming your work? It is essential not to deny your own emotional experience.
• The Effectiveness of the Intervention: What worked well in your management of the crisis? What did not work or may have worsened the situation? At what exact moment did de-escalation succeed? How long did the episode last? What learnings can you take from it for next time?

Structured and Rigorous Documentation

Comprehensive documentation is essential for several reasons: legal traceability, continuity of care between teams, adjustment of therapeutic strategies, legal protection for professionals in case of complaints. Systematically document in the person's file:

The Circumstances of the Crisis:

• Exact date and time (start and end)
• Location (room, hallway, dining room, etc.)
• People present (residents and professionals)
• Immediate context: what activity was underway? What time of day? Was there an identifiable triggering event?

The Factual Description of Behaviors:

• Behaviors observed objectively, without interpretation: "Mr. X hit the table with his fists" and not "Mr. X was angry" (emotion is an interpretation)
• Exact words spoken if relevant to understanding the situation
• Evolution of intensity: you can use a scale from 1 to 10 to quantify the level of agitation at different times
• Total duration of the episode

The Interventions Carried Out:

• Actions taken in chronological order: "1) Removing other residents 2) Soothing verbal communication 3) Proposing to return to the room 4) Calling the doctor"
• Who intervened and how: "Intervention by Ms. Durand, caregiver, then Mr. Martin, health manager"
• De-escalation techniques used: "Emotional validation, redirection to manual activity"
• Medications administered if applicable with prescription: name, dosage, time, route of administration

The Results and Necessary Follow-Up:

• Time needed for a return to calm
• Condition of the person after the crisis: calmed, tired, confused, ashamed?
• Possible injuries (accompanied person or professionals) with photographic documentation if necessary
• Medical follow-up put in place: scheduled consultation, clinical examination performed, prescribed tests
• Preventive measures considered to avoid recurrence

Team Debriefing: An Essential Moment

Ideally within 24 to 48 hours after the crisis, organize a debriefing with the involved team. This collective time serves several essential objectives:

• Mutual Emotional Support: Allow everyone to express their experience, emotions, and difficulties faced during the situation. Acknowledge that managing these crises is emotionally taxing. Normalize stress reactions. Identify who needs additional support.
• Collective Factual Analysis: Reconstruct together the sequence of events without judgment or searching for blame. Collectively identify triggering and contributing factors. Share each person's observations, as they may have seen different things.
• Learning and Continuous Improvement: What have we collectively learned from this experience? What can we improve in our practices, protocols, and organization? What skills do we need to develop? What resources are we lacking?
• Adjustment of the Care Plan: What concrete modifications should be made to the personalized care project for the resident? What changes in the environment, schedules, proposed activities? Which professionals should be involved (psychologist, occupational therapist, doctor)?

💝 For Family Caregivers: You Are Not Alone

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Taking Care of Yourself After a Difficult Intervention

Managing behavioral crises is emotionally and physically exhausting. Both professionals and family caregivers accumulate stress, sometimes traumatic, which can lead to burnout if not addressed. It is ESSENTIAL that you take care of yourself in order to continue caring for others.

Recognize the Legitimate Emotional Impact

It is perfectly normal to feel, after a difficult crisis:

• Fear or anxiety, especially if you have been threatened or hit
• Guilt ("Could I have done better?", "Is it my fault?", "Did I react poorly?")
• Anger or frustration towards the situation, sometimes even towards the person (even if you know rationally that it is not intentional)
• Sadness for the person, for what they are experiencing, for what they have become
• Physical and mental exhaustion, a feeling of being "drained"

These emotions are legitimate. Do not deny them, do not judge yourself for feeling them. They are a sign that you are human, empathetic, and that this work affects you. It is healthy.

Concrete Self-Care Strategies

• Talk About It: To a trusted colleague, your supervisor, or a mental health professional (work psychologist if available). Putting words to what you experienced already reduces the traumatic impact. Do not stay alone with difficult emotions.
• Take a Break: Even if it is just 10 minutes. Give yourself a moment to breathe away from the care environment. A short walk outside, a moment in a quiet space, a glass of water sipped slowly mindfully.
• Practice Emotional Regulation Exercises: Square breathing (inhale for 4 counts, hold for 4 counts, exhale for 4 counts, pause for 4 counts, repeat) / Cardiac coherence (inhale for 5 seconds, exhale for 5 seconds, for 5 minutes) / Very short meditation or mindfulness exercises.
• Recognize Your Limits: If you regularly feel overwhelmed, it may be a sign to rethink the organization (more staff, better training, revision of protocols) or consider professional psychological support for yourself. It is not a weakness to ask for help; it is a strength.
• Celebrate Successes: When a de-escalation works, when you manage to calm a person, when you handle a difficult situation with professionalism, recognize your competence. You and your team are doing remarkable work under often difficult conditions.

Conclusion: De-escalation, an Art and a Science in Service of Humanity

Managing behavioral crises in individuals with cognitive disorders is both a relational art - mobilizing your empathy, creativity, and human sensitivity - and a science based on evidence and proven protocols. The 7 steps of this de-escalation protocol provide a solid structure to rely on during the most challenging moments:

1. Recognize early warning signs
2. Secure the immediate environment
3. Adopt a non-threatening posture and communication
4. Validate emotions without judgment
5. Identify and address the underlying cause
6. Propose distraction and redirection strategies
7. Evaluate, document, and debrief

But beyond the technique, what truly makes the difference is your humanity, your empathy, and your ability to see behind the disruptive behavior a suffering person trying to communicate in the only way they can still manage. Every successfully managed crisis is a victory - for the supported person who regains their calm and dignity, for you who develop your skills, and for the overall quality of care that improves.

⚠️ Important: For Behavioral Disorders Related to Mental Health

If you are supporting a loved one whose behavioral disorders are linked to mental health issues (depression, anxiety disorders, personality disorders, etc.) rather than a neurodegenerative condition, our program JOE may be a valuable complementary tool.

JOE offers exercises for stress management, emotional regulation, and maintaining cognitive functions that can help adults suffering from anxiety-depressive disorders or behavioral difficulties.

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Never forget: you are not alone. Whether you are a professional or a family caregiver, resources exist to train, support, and accompany you. At DYNSEO, we deeply believe that the quality of life of individuals with cognitive disorders depends on the competence and well-being of those who support them.

Take care of yourself to be able to take care of others. You are doing extraordinary work under often difficult conditions. Your dedication deserves recognition and support. 💙