From threat to safety: A trauma-informed framework for de-escalation in dementia care

Behaviours that challenge (BtC) in people living with dementia are frequently managed through pharmacological approaches, despite guidance recommending non-pharmacological interventions as first-line treatment. Existing approaches, including Positive Behaviour Support (PBS), provide valuable frameworks for understanding behavioural escalation and informing person-centred care. However, the neuropsychological mechanisms through which perceived threat, emotional vulnerability, and prior life experiences contribute to behavioural escalation in dementia remain less explicitly articulated. This paper proposes that BtC may be understood as threat-based responses arising from the interaction between neurodegenerative change, environmental stressors, emotional vulnerability, and individual life experience. Drawing on neuropsychological evidence, PBS frameworks, formulation-based approaches, and trauma-informed care principles, we introduce the Threat Regulation Framework, a trauma-informed reinterpretation of behavioural escalation in dementia care. The framework extends existing approaches by providing five practical competencies for de-escalation centred on safety, emotional regulation, relational connection, predictability, and understanding behaviour as communication. Integrating trauma-informed approaches within dementia care may improve patient experience, reduce distress, and minimise reliance on restrictive or pharmacological interventions while supporting more compassionate and psychologically informed responses to behavioural escalation.