Understanding Distress in Older People: Practical Behaviour Support Without “Blaming the Person”

December 30, 2025

Distress in older people is frequently mislabelled as “behaviour” when it is actually communication: pain, fear, confusion, loss, boredom, grief, environmental overload, or an unsafe interaction. In tendering and quality assurance, commissioners expect providers to evidence safe, consistent responses and measurable reduction in avoidable incidents, not simply “manage” episodes. This article focuses on practical delivery and assurance, aligned with person-centred planning and risk enablement approaches. For wider frameworks, see our Person-Centred Planning mini-series and Safeguarding mini-series.

What “distress” looks like in ageing well services

In older people’s services, distress may present as agitation, repeated calling out, resistance to care, pacing, withdrawal, shouting, refusal of meals/medication, anger, tearfulness, or sudden changes in sleep. The same behaviour can mean different things for different people, and the same person can show different patterns depending on time of day, staff approach, or health fluctuations. A reliable service model treats distress as a “needs signal” and uses structured observation, compassionate responses, and consistent recording to identify patterns.

Common drivers of distress that are missed in day-to-day delivery

Teams often default to “de-escalation” without checking underlying drivers. In older people’s services, the most frequent missed drivers include:

Pain and discomfort: untreated pain, constipation, urinary retention/UTI, pressure areas, dental pain, poorly fitting aids, or discomfort from temperature/clothing.
Delirium and acute illness: sudden confusion, infection, dehydration, medication side effects or withdrawal.
Sensory and environmental stress: noise, glare, crowded spaces, unfamiliar staff, rushed care, lack of privacy, or confusing signage/layout.
Loss and identity: bereavement, reduced independence, fear of falling, feeling “done to”, or being spoken over.
Routine mismatch: waking, toileting, meals, bathing routines imposed rather than aligned to lifelong habits.

Operationally, this means the “first response” must include a brief health and comfort check, not just an interaction technique. Services that do this well embed a short “distress checklist” into daily practice, not a document that sits on a shared drive.

A practical support model: Prevent, Respond, Review

1) Prevent: build stability into ordinary routines

Prevention is not a separate “programme”; it is consistency in staffing, predictable routines, and dignity in delivery. Preventative actions typically include:

Known staff where possible (micro-teams in homecare; key worker consistency in care homes and supported housing).
Daily “wellbeing scan” (sleep, hydration, appetite, bowel pattern, pain indicators, mood) and escalation triggers.
Personalised routines: preferred times for personal care, culturally appropriate food, and meaningful daytime structure.
Communication adjustments: slower pace, single-step prompts, confirmation of consent, and choice presented in accessible ways.

2) Respond: calm, safe, non-confrontational interactions

When distress escalates, the immediate goal is safety and co-regulation, not “compliance”. Day-to-day response should include:

Approach: introduce yourself, reduce stimulation, use the person’s preferred name, and keep your tone low and steady.
Validate and reassure: acknowledge emotion (“I can see this is upsetting”) and explain what will happen next.
Offer control: choices that are real (where to sit, whether to pause, who helps, when to continue).
Keep dignity central: avoid “crowding”, stop non-essential tasks, and protect privacy if personal care is involved.

Where risk is present, staff should follow a clear least restrictive approach: space, time, and de-escalation first; only use restrictive interventions as a last resort, with documented rationale, proportionality, and review.

3) Review: use evidence to reduce repeat incidents

Without review, services repeat the same episodes with different staff. The review step should convert incidents into learning and prevention. A robust model includes:

Structured debrief within 24–48 hours (what happened, what worked, what didn’t, what we will change).
Pattern tracking (time of day, staff approach, location, tasks, health factors).
Care plan updates and team communication (handover notes that are specific, not generic).
Family/advocate input where appropriate, especially when distress links to identity, grief, routines, or trauma.

Operational examples (minimum 3)

Example 1: “Resisting personal care” driven by pain and rushed approach

Context: A homecare client begins refusing morning personal care and becomes verbally distressed when staff insist. Support approach: The provider introduces a “comfort first” check: pain scale prompts, bowel pattern review, and a slower care routine with choice (“wash now or after breakfast?”). Day-to-day delivery: Visits are re-timed to avoid early-morning rush; staff use single-step prompts and offer the client to hold the flannel to keep control. Evidencing change: Incident logs reduce over 2 weeks; MAR notes show improved analgesia compliance after GP review; care notes demonstrate reduced refusals and improved mood.

Example 2: “Agitation at sundown” linked to fatigue, noise and unmet daytime structure

Context: A care home resident becomes distressed daily late afternoon, pacing and calling out. Support approach: The team builds a structured late-afternoon routine: quiet space, warm drink, familiar music, and a staff member allocated for relational time. Day-to-day delivery: Staff reduce noise in communal areas, ensure adequate hydration, and offer a short walk earlier in the day to support sleep pressure. Evidencing change: ABC charts show reduced intensity/frequency; sleep and hydration charts improve; staff handovers include consistent prompts and the resident reports feeling “settled”.

Example 3: Distress during medication round driven by lack of explanation and sensory sensitivity

Context: A person becomes angry when approached with medication, pushing items away. Support approach: A communication plan is introduced: explain purpose, show the blister pack, offer water first, and give time. Day-to-day delivery: The same staff member supports medication at consistent times; staff avoid standing over the person; lighting is adjusted; the person is offered a preferred cup. Evidencing change: MAR records show reduced refusals; incident reports fall; the person’s satisfaction feedback improves; medication audit shows improved adherence.

Commissioner and regulator expectations (explicit)

Commissioner expectation: Commissioners expect a provider to demonstrate a structured behaviour support approach that reduces avoidable incidents, avoids unnecessary escalation to emergency services, and uses data (incident trends, repeat triggers, outcomes) to drive improvement. Evidence should include pattern analysis, care plan updates, staff competence records, and learning actions that change practice.

Regulator / Inspector expectation (CQC): CQC expects services to provide person-centred care and treatment, manage risks safely, and learn from incidents. Inspectors look for consistent recording, staff understanding of individual triggers, least restrictive practice, safeguarding awareness, and governance systems that identify themes and improve outcomes rather than normalise repeated distress.

Governance and assurance: making this “inspection-ready”

To make behaviour support defensible, governance must show that the provider knows where distress is happening, why, and what they are doing about it. A practical assurance model includes:

Monthly incident dashboard (themes, hotspots, times, tasks, response effectiveness).
Audit of care plans for “distress plans” and trigger-response guidance.
Training and competency checks (communication, de-escalation, pain awareness, delirium red flags, safeguarding).
Provider-led review of restrictive practice (any restraint/PRN use, proportionality, alternatives tried, lessons learned).
Quality meetings with actions tracked to completion (not “discussed and noted”).

What good looks like in practice

The strongest services normalise curiosity and compassion: “What is this telling us?” rather than “How do we stop it?” When prevention routines, calm responses, and robust review are embedded, distress reduces, staff confidence rises, and commissioning conversations shift from reassurance to evidence-backed performance.

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