SPCD

Faculty of the Psychology
of Older People
Briefing paper
Alternatives to antipsychotic medication:
Psychological approaches in managing
psychological and behavioural distress in
people with dementia
March 2013
The authors
Dr Donald Brechin
Past Chair, Faculty of the Psychology of Older People.
Leeds & York Partnership NHS Foundation Trust
Dr Gemma Murphy
Clinical Psychologist, MHSOP, Tees, Esk and Wear Valleys NHS Trust
Dr Ian Andrew James

Consultant Psychologist, Northumberland Tyne and Wear NHS Foundation Trust
Jason Codner
University of Teesside
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Contents
Executive summary ..................................................................................................... 2

Introduction ................................................................................................................ 3
The policy context....................................................................................................... 4
What is needed now? ................................................................................................... 5
Equal access to services for people with dementia....................................................... 6
A stepped care model of assessment and intervention................................................. 6
Step 1: Recognition......................................................................................................... 8
Step 2: Assessment and treatment of contextual issues.............................................. 11
Step 3: High intensity interventions ............................................................................ 15
Step 4: Specialist interventions .................................................................................... 19
Summary ................................................................................................................... 22
Glossary .................................................................................................................... 24
References ................................................................................................................ 26
Appendix 1: Behaviour monitoring chart................................................................... 31
Appendix 2: Challenging Behaviour Scale (Moniz-Cook, 2001)............................... 33
1 Briefing Paper:
Executive summary
The Department of Health has stated that the use of antipsychotic medication for people
with dementia needs to be reduced in order to limit the risk of harm associated with these
medications in this frail and vulnerable group of people. The question is whether there are
any alternatives, and whether these can be effective in reducing reliance on antipsychotic
medications.
A number of initiatives have developed to support this work, including the Dementia
Action Alliance (DAA) ‘Call to Action’ in June 2011. As one of the partner organisations
within DAA, the British Psychological Society committed to reviewing the evidence for
evidence-based non-pharmacological alternatives to antipsychotic medication. The present
report is the product of this work.
The Faculty of the Psychology of Older People, which is part of the Society’s Division of
Clinical Psychology, has brought together an expert reference group to review the relevant
literature and to lay out the evidence in a clear and accessible manner. The Faculty’s work
highlights that there are evidence-based alternatives to antipsychotic medication for people
with dementia. It also shows that if these are organised in a staged approach (that is, a
stepped care approach) then access to these interventions can be increased and the
reliance on antipsychotics should be reduced. Therefore, the model is presented to assist
commissioners and providers of care when considering how to care for people with
dementia, particularly when their well-being is compromised and/or when there are
difficulties in managing aspects of the person’s behaviour.
This document is intended for use across the UK as a whole. There are, however, areas in
which different policy and guidance are relevant for different nations. Nevertheless it is
hoped that as this document is addressing assessment and interventions, that it will be
transferable across the home nations. Each of the home nations is aware of the rising
numbers of people with dementia. They are committed to providing a framework for
services to operate within to address this rise by improving the lives and services for people
with dementia (Department of Health, 2009; Department of Health, Social Services and
Public Safety in Northern Ireland, 2011; Scottish Government, 2010; NHS Wales 2011).
Dr Donald Brechin
Past Chair of the Faculty of the Psychology of Older People
On behalf of the Working Group
Alternatives to Antipsychotic Medication 2

Introduction
There are approximately 800,000 people currently living with dementia in the UK with
approximately a third of this number residing in a care home (Alzheimer’s Society, 2011). It
has been predicted that by 2021 there will be over one million people living with dementia. The
financial cost is expected to grow from an estimated £20 billion in 2010 to over £27 billion by
2018 (All-Party Parliamentary Group on Dementia, 2011).
The majority of people living with dementia are likely to experience the development of
behavioral and psychological difficulties at some point during their illness. It has been
suggested that these behaviours may be present in up to 90 per cent of people living with
Alzheimer’s disease (Robert et al., 2005). Such behaviour includes occurrences of hitting,
kicking, nipping, screaming, apathy, pacing, non-compliance, urinating in inappropriate places
and disinhibition (James, 2011) as well as confusion, calling out, repetitive questioning,
toileting difficulties, misidentifications and sexual challenge (Stokes, 2000).
A variety of terms are used to describe the phenomenology of where the person with dementia
engages in behaviour that challenges others and/or reflects a level of apparent distress for the
person with dementia. As such, a number of terms may be used to refer to these presentations
within this document. The terms ‘challenging behaviour’, ‘behaviours that challenge’ (Royal
College of Psychiatrists et al., 2007) and ‘behavioural and psychological symptoms of dementia’
(BPSD; Finkel et al., 1997) are the most commonly used in this field, but all have their
limitations and critics and well as their supporters. However, the key point from the
psychological perspective assumes these overt (or covert) changes in presentation represent
unmet needs rather than an inevitable consequence (symptom) of an illness. As such, they are
amenable to change if those needs can be identified and met.
It is important to remember that many of the behaviours identified as challenging are not
symptoms of dementia, rather they are symptoms of human distress, disorientation and
misperception. As such, it seems counterproductive to frequently treat such behaviours
through tranquilisation and sedation without first attempting to deal with the distress and
cognitive confusion. Indeed, it is important to recognise that because the behaviours are not
the inevitable consequences of a disease, we need to be careful not to treat them as if they are
– particularly if this involves using problematic drugs.
Current guidance recommends the use of treatments using a non-pharmacological approach
in the initial stages of managing these behaviours (NICE/SCIE, 2006; Banerjee, 2009; National
Dementia Strategy, 2009). Consequently, psychosocial and behavioral interventions are
recommended as a first line treatment of BPSD (NICE/SCIE 2006; NHS Institute for
Innovation and improvement, 2011; Banerjee, 2009).
A number of empirical studies have examined whether non-pharmacological approaches can
be used as alternatives to medication (Avorn et al., 1992; Meador et al., 1997; Schmidt et al.,
2000). Despite some mixed reviews (Nishtala et al., 2008; Forsetlund et al., 2011), it is evident
the best controlled of these studies has shown that regular input from a trained clinician can
lead to a significant reduction in the use of antipsychotics (Fossey et al., 2006). The protocol
underpinning the work of these clinicians has been published by the Alzheimer’s Society
(Fossey & James, 2008), and the work itself is being extended with a major non-
3 Briefing Paper:
pharmacological trial called WHELD (Ballard et al., 2009). This programme has undertaken a
major revision of non-pharmacological studies and is currently empiracally testing the use of
person-centred approaches, exercise regimes, social interaction and the use of systematic
medication reviews with respect to the well-being of people with challenges.
In practice, antipsychotic medication is often used as a first-line treatment for behavioural
difficulties rather than as a secondary alternative (Alexopoulos et al., 2005; Alzheimer’s Society,
2009), despite the evidence that antipsychotic drugs have a limited positive effect and can cause
significant harm to people with dementia (Schneider, Dagerman & Insel, 2006; Ballard, Lana,
Theodoulou, Jacoby, Kossawakowski, Yu & Juszczak, 2008; Banerjee, 2009). Interventions
offered should aim to lessen the distress and harm caused by these difficulties and increase the
quality of life of those living with dementia and their carers (Banerjee et al., 2007; Banerjee,
2009).
Implementing behavioural interventions instead of antipsychotic medication could lead to
savings of £54.9 million above the cost of the therapy in England alone, resulting in a reduction
in side effects such as the occurrence of incidence of stroke and falls (NHS Institute of
Innovation and Improvement, 2011), which would result in an increase in the quality of life of
people living with dementia.
The policy context

The four UK nations have all published strategies for the care of people with dementia and
their carers:
■ Living well with dementia: a National Dementia Strategy (England)
■ Scotland’s National Dementia Strategy
■ National Dementia Vision for Wales
■ Improving Dementia Services in Northern Ireland.
All these documents emphasise the need to promote a coordinated, evidence-based response
to the caring for the increasing numbers of people with dementia.
More recently, the Department of Health in England has stated that the use of antipsychotic
medication for people with dementia needs to be reduced. This is based on the work of
Banerjee (2009) who reviewed the use of antipsychotic medication in people with dementia on
behalf of the Secretary of State for Health. Professor Banerjee noted that of the 750,000 people
with dementia in the UK, around 180,000 (i.e. 20 per cent) will be prescribed antipsychotic
medication, of whom 36,000 may derive some clinical benefit. However, Professor Banerjee also
pointed out that these medications are associated with significant risks. Banerjee estimated that,
‘In terms of negative effects that are directly attributable to the use of antipsychotic medication,
use at this level equates to an additional 1,620 cerebrovascular adverse events, around half of
which may be severe, and to an additional 1,800 deaths per year on top of those that would be
expected in this frail population.’
Since Professor Banerjee’s report was published in 2009, there have been a number of
initiatives to address antipsychotic use. In June 2011, the Dementia Action Alliance was formed
and published a ‘Call to Action’, advocating that all people with dementia who are prescribed

antipsychotic drugs should have their medication reviewed and that alternatives to their
prescription should be considered.
In 2011, the Alzheimer’s Society responded to the call by publishing a best practice guide for
health and social care professionals. The document aims to assist practitioners by providing
practical tools for the assessment and management of behavioural and psychological distress in
dementia. This toolkit provides guidance on preventative strategies, alternatives to medication,
and safer medication prescribing. In Spring 2012, the Royal College of Nursing (RCN) also
published a best practice guide in relation to the use of antipsychotics in dementia, and
describes a number case examples of alternative approaches to medication use.
What is needed now?

The response to the Dementia Action Alliance’s call to action has been positive and has moved
understanding of this area of practice forward. As a partner within the Dementia Action
Alliance, the British Psychological Society (BPS) also committed to undertake work to further
the aims of the Alliance, and specifically to use the psychological expertise of its members to
provide information about working with people with dementia. The BPS committed to
summarise the information regarding evidence-based non-pharmacological interventions for
people with dementia. This work was taken up by the Faculty of the Psychology of Older
People, part of the Division of Clinical Psychology, in 2011.
The literature on psychosocial approaches for people with dementia is extensive, and is
featured in a number of individual publications and empirical reviews. Much of this evidence
also features in best practice guidance such as the NICE/SCIE Clinical Guideline 42 (NICE,
2006) and the Scottish Intercollegiate Guidelines Network guideline 86 (SIGN, 2006). As such,
the Faculty’s task is not to reproduce these documents and guidelines. Instead, the Faculty
decided to:
■ review the existing literature on the use of non-pharmacological interventions for people
with dementia;
■ produce a high level summary of this literature; and
■ present this information in a clear and accessible framework.
The underpinning assumption within the psychosocial literature is that distressed/distressing

behaviour represents an unmet need. As such, the therapeutic task is to understand what that
need is and to address it, in order to enhance the well-being of the person with dementia. If this
is successful, then the behavioral changes will reduce and/or the ability for other people to
cope with these behaviours will increase.
By focusing on the non-pharmacological literature, the Faculty is not implying that
pharmacological interventions have no role for people with dementia. There are a number of
documents and frameworks that describe the use of pharmacological approaches, and the
Faculty supports their use where appropriate. Rather, the role of the Faculty (and hence the
purpose of this document) is to summarise the psychosocial evidence base and advocate for
these approaches as part of a holistic package of care for people with dementia.
5 Briefing Paper:
Equal access to services for people with dementia
When adopting the interventions outlined below it is important to recognise core principles
that should be considered to maintain equal access to services as identified by the NICE
guidelines. These recommendations are summarised below;
■ The person with dementia should not be excluded from any intervention/services
because of their diagnosis, age (whether designated too young or too old) or coexisting
learning disabilities.
■ It is vital that health and social care professionals seek valid consent from the individual
living with dementia. This should entail informing the person of the options, and their
implications, together with checking that the person understands that they can withdraw
from a treatment at any time. In cases where the person lacks the capacity to make a
decision, the provisions of the Mental Capacity Act 2005 should be followed.
■ An assessment of the carer’s needs should be completed to inform the intervention plan
(Carers and Disabled Children Act 2000; Carers Equal Opportunities Act 2004). Carers of
people with dementia who experience psychological distress and negative psychological
impact should be offered psychological therapy, including cognitive behavioural therapy,
conducted by a specialist practitioner (e.g. clinical psychologist, qualified practitioner).
A further priority stipulated by the NICE guidance is the integration and coordination of
health and social care services, ensuring that joint planning is maintained and that there is a
shared responsibility for the provision and delivery of health and social care for the individual
living with the dementia and their carer.
A stepped care model of assessment and intervention

The introduction of the stepped care model in healthcare has provided a framework for
organising healthcare delivery in a targeted manner (e.g. from NICE clinical guidelines to the
Improving Access to Psychological Therapies programme). Given that there is a large body of
literature on psychosocial approaches to dementia, it seems sensible to use a stepped care
framework to identify which interventions should be tried and in which order.
The stepped care approach has been used recently in the treatment of care home residents’
suffering from anxiety and depression (Dozeman et al., 2012; Alpin et al 2012). In the present
context the stepped care model identifies the appropriate interventions that meet the
presenting need, reinforcing the message that antipsychotic medication can be implemented as
a secondary alternative. The model reinforces the need to ask ‘why the behaviour is occurring?’
and has been informed by research such as Moniz Cook, Swift, James et al. (2012), the work of
Cohen-Mansfield et al. (2007) on non-pharmacological interventions for BPSD; Guidelines
(Royal College of Psychiatrists, British Psychological Society and Royal College of Speech and
Language Therapists, 2007; NICE/SCIE 2006) and Government sponsored reports (Banerjee,
2009; European Union, 2009).
The steps describe the level of assessment and treatment input, identifying the
person/professional that can perform the task. The interventions range from the initial

identification and treatment of physical causes (Step 1), understanding the person in more
detail and getting the care environment right (Step 2), protocol-driven interventions tailored to
specific presentations (Step 3), and intensive individualised psychological formulation-led
interventions identified for more complex presentations (Step 4). While specific non-
pharmacological interventions are first mentioned at Step 3, they may occur at any step.
The model is not intended as a rigid pathway, but it is intended that step 1 is undertaken first.
After this, it is pragmatic to undertake the next steps in order, unless otherwise indicated.
Step 4: Specialist Interventions (Individualised formulation-led Interventions)

Individualised assessment, formulation and interventions
(Specialist practitioners and carers/care staff)
a a a
Step 3: High Intensity Interventions (Protocol-led interventions)
Interventions tailored to specific presentations and needs
(Experienced practitioners and carers/care staff)
Step 2: Low intensity interventions (Management of contextual issues)

Thorough assessment and general good practice in the care environment
(GP & carers/care staff) – Four weeks
Step 1: Recognition
Identification of difficulties, physical health and initial monitoring
Figure 1: The stepped care model
However, an individual with dementia may present with particular behaviours that require a
higher intensity of intervention and as such the person can be stepped up. The model provides
sign posts to interventions that meet individual need with the aim of preventing further
increase in distress for the individual and the carer. However there is the opportunity for
movement from one step to another if the behaviour continues to be unresolved.
7 Briefing Paper:
Step 1: Recognition
This step is focused on identifying that there is an issue for the person that may relate to the
dementia, and recommends taking initial steps to assess and treat commonly occurring causes
of distress and behaviour change. As such, all individuals should be initially assessed at this level.
Step 1: Recognition
Identification of difficulties, physical health and initial monitoring
Assessing Causes and Risks

Recognition of physical causes
■ Screen for treatable conditions that may be either causing or contributing to confusion and
distress, such as: delirium, pain, seizures, vascular events, diabetes, constipation, infections,
thyroid disturbance, poor sleep, sensory loss, alcohol misuse, other medical conditions.
■ Screen for presence of psychosis, depression, anxiety.
■ Screen for negative impact of medication, including interactions/side effects
(e.g. some statins causing agitation, Parkinson’s medication causing disinhibition).
■ If not a physical issue, proceed to step 2
Assess risk issues for client and carer(s).
Actions
■ Treat common physical causes and inform family/carers about signs, symptoms, preventative
measures for these conditions.
■ If a risk identified, step up (low risk = step 2, high risk = step 3 or 4)
■ Do not prescribe antipsychotics at this stage, unless psychosis evident in absence of
Dementia with Lewy Bodies.
■ Adjust medication if required to avoid unwanted interactions/side effects.
■ Ask carers to monitor behaviours for four weeks
(e.g. try to identify patterns – an example chart is given in appendix 1).
■ Provide good practice checklist – an attempt to understand the person/information
prescriptions/guided reading for carers.
■ Provide information for carers (e.g. Alzheimer’s Society website).
■ If carer distress is identified, signpost to voluntary organisations/dementia advisors.
If distress severe consider referral for carer’s assessment, referral to other support
(e.g. support group, local IAPT service).

Assessing the causes and risks
Objective 1 of the National Dementia Strategy in England states that an early comprehensive
assessment for people with dementia should include:
■ the person’s physical health;
■ depression;
■ possible undetected pain or discomfort;
■ side effects of medication;
■ individual biography, including religious beliefs and spiritual and cultural identity;
■ psychosocial factors;
■ physical environmental factors; and
■ behavioural and functional analysis conducted by professionals with specific skills, in
conjunction with carers and care workers (NICE 2007).
At this initial stage, the starting point should be an assessment in primary care (for example, by
a General Practitioner) to identify and treat any potential physical contributors. This should
involve screening for: delirium, pain, diabetes, constipation, infection, sleep disturbance, and
other medical conditions. Consideration should also be given to the person’s medication
regimen and the possibility of drug interactions and side effects. In recent years there has been
a particular emphasis on the identification of pain (Woods & Moniz-Cook, 2012), and the
realisation that it can play an important role in the distressed behaviour of people with
dementia. A useful tool for assessing pain in dementia, which is notoriously difficult to identify,
is the Abbey pain questionnaire.
Finally, the GP should assess for mental health issues such as psychosis, depression and anxiety.
At this point, the assessment in itself can be an enough to identify and relieve the presenting
difficulties.
Actions
The main focus is to treat common physical causes of the behaviours and adjust medication if
required to avoid unwanted interactions/side effects. It is not necessary to prescribe
antipsychotics at this stage unless there is evidence of psychosis (except for the case of
Dementia with Lewy Bodies – DLB) or there is severe distress for the client or immediate harm
to the client and/or others (note: relevant prescribing guidelines should be consulted).
The Alzheimer’s Society (2011) has produced guidance for health and social care staff that
outlines some initial interventions that can be considered at this step. These include:
■ Understanding the individual needs of the person with dementia, as it can affect people
in different ways. There is not a ‘one-size-fits-all’ care strategy.
■ Recognising triggers and early signs that may precede the behavioural difficulties is
crucial as in most cases simple approaches to early signs can prevent the symptoms
developing at all.
■ Watchful waiting – asking carers to monitor and record behaviours over four weeks (e.g.
try to identify patterns). Many difficulties will stop after this period without
pharmacological treatment.
■ Providing information leaflets, guided reading and good practice checklists (available
9 Briefing Paper:
from a number of sources, including the Alzheimer’s Society website). The use of these
types of information in a one-to-one setting to care givers has been found to reduce the
BPSD (Livingstone et al., 2005).
■ For people with significant language or communication difficulties, consider using the
Distress Thermometer and/or asking a family member or carer about symptoms; if
significant distress is identified, investigate this further.
If a degree of risk to the person or others is identified, consider moving on to step 2. If high
levels of risk are identified, move up to step 3 or 4 depending on the circumstances and the
judgement of the health/social care professional.
Needs of carers
At this stage, it is also important to identify potential carer needs. The difficulties faced by the
person with dementia will also impact on their families, and carer distress is one of the reasons
people’s relatives are admitted to long-term care (European Union report, 2009). Objective 3
of the National Dementia Strategy identifies the need to provide carers with good quality
information regarding the condition. However, the Alzheimer’s Society (2010) indicates that,
despite good information being available, ‘people report that their needs are not met or that
information is provided too late or not at all. A key problem is that people have to ask for
information, rather than it being provided proactively. Most people do not know what they
have to ask for.’ As such, carers should be routinely offered sources of information regarding
dementia, how it presents and how to manage it (for example, information leaflets from the
Alzheimer’s Society website), as well as where to seek help and assistance if required.
If carer distress is identified then consideration should be given to signposting to voluntary
organisations/dementia advisors. If the level of distress is severe, consideration should be given
to a referral for carer’s assessment (as required by the Carer’s Act), and/or referral to other
support (e.g. support group, local IAPT service). Carers who experience anxiety and/or
depression are entitled to evidence-based treatments under current NICE guidance for those
presentations.
The complex range of services and staff with whom people with dementia and carers are in
contact with can be confusing. It is unclear which professional can provide particular pieces of
information and no one professional has responsibility for providing the full range of
information. This leads to unhelpful gaps. While a more recent report (Health Foundation,
2011) highlights a further difficulty encountered by carer’s from services and staff in terms of
not sharing information with them about important developments in their relative’s life and
transition points between services.
When working with staff in wards and care homes it is important to acknowledge and support
their existing skills. This is because by virtue of the sheer prevalence of behaviours that
challenge, the staff are generally skilled in the treatment of most problematic behaviours they
encounter. These skills normally take the form of good communication and interactive styles,
verbal and non-verbal approaches. Accepting this existing skill-base, one might then start to
explore ‘why’ in this particular case the staffs’ normal approaches are not working effectively;
sometimes this may be due to an inconsistent approach between the members of the staff team
(James, 2011).

Step 2: Assessment and treatment of contextual issues
At step 1, common physical causes of the behavioural difficulties should have been ruled out.
Therefore, step 2 focuses on further understanding of the needs of the individual in their
environment and introducing general, good practice interventions within that environment.
By their nature, behavioural difficulties tend to require some form of interaction between the
person with dementia and a carer. For example, the carer may need to encourage the person to
get out of bed, take medication; or the carer may need to intervene to prevent a problem
behaviour becoming risky. As such, good practice requires the use of good interactive and
communication skills on the part of the carer. Indeed, audits of interventions carried out by the
Newcastle Challenging Behaviour Team (James, 2011) reveal that a key factor in determining
the resolution of problematic behaviours is the quality of the interaction of the carers with the
person with dementia. Further, those who interact well tend to be good communicators, taking
account of the needs and current perceptions of the person with dementia.
Staff and carers require some level of training and support to deliver interventions at this step,
but this is at the level of good dementia awareness rather than specialist training. In terms of
enhancing communication with the person with dementia, there is a growing literature on
improving carers’ communication skills (Levy-Storms, 2008; Eggenberger et al., 2013).
Assessing the presentation in context

Objective 1 of the National Dementia Strategy states that an early comprehensive assessment
for people with dementia should include:
■ the person’s physical health;
■ depression;
■ possible undetected pain or discomfort;
Step 2: Low intensity interventions (Management of contextual issues)

Thorough assessment and general good practice in the care environment
Assessing the presentation in context

Assess and review the following:
■ Behaviour records (what, when, who with, etc.).
■ Emotional status of the client (e.g. assessing emotions, moods, worries, beliefs).
■ Physical environment (e.g. overcrowding, privacy, noise levels).
■ Carer communication skills and style of interacting.
■ Communication (can the person communicate what they want,
and can others communicate with them?).
■ Design and layout of environment.
■ Social contact (opportunities to spend meaningful time with others).
■ Occupation (i.e. how is the person spending their time).
11 Briefing Paper:
Actions
■ Do not prescribe antipsychotics unless psychosis evident (in the absence of DLB).
■ Choose intervention on the basis of the assessment:
(i.e. general interventions within the care environment).
• Dementia awareness training for staff.
• Develop carer communication and interaction skills.
• Developing life histories.
• Engagement in meaningful activity/social programme (e.g. reminiscence group)
• Changes to the physical environment/layout.
• Frameworks to help understanding the emotional impact the person with dementia
can have on the carer and vice versa (eg. emotional triads; James, 2011).
■ Carers to monitor behaviours for four weeks - e.g. try to identify patterns
(see appendix 1 for an example form). If no change in behaviour, proceed to step 3.
■ side effects of medication;

■ individual biography, including religious beliefs and spiritual and cultural identity;
■ psychosocial factors;
■ physical environmental factors; and
■ behavioural and functional analysis conducted by professionals with specific skills, in
conjunction with carers and care workers (NICE 2007).
If assessment has taken place appropriately at step 1, then the first four points on the above list
should have been addressed. Practitioners should remain mindful of these areas, but at step 2
more emphasis is given to the next four areas.
Everyday experience tells us that people interpret situations and behaviour differently, and this
is just the same with behavioural changes in dementia. Research evidence also shows that there
can be low levels of agreement amongst senior staff regarding what constitutes behaviour that
challenges (Bird & Moniz-Cook, 2008), adding further complexity to the assessment process.
Therefore, it is important to have some objective understanding of exactly what is happening.
As such, the first task is to have clear records of exactly what is taking place, how often, and
whether this is causing difficulty and/or distress for those involved. There are specific tools
available to help with the recording of such information (e.g. Challenging Behaviour Scale;
Moniz-Cook, 2001 – Appendix 2), and the key areas to address include:
■ What is the individual saying or doing? What are his/her current beliefs about the present
situation? (e.g. Does Mrs Smith believe she is in her 30s, caring for young children and an
elderly mother? Does Mr Jones believe he’s a joiner, single, and currently living in a
hotel?). How is the person expressing themselves, are they angry; scared; crying;
confused?
■ When has the behaviour occurred? Consider at what time of day it is, what is going on at
the time (e.g. is it meal-time; bed-time; when the person requires assistance; when they
are alone/with others?)
■ Where has it happened?
■ How often is it happening?
■ Who is it causing distress for (i.e. the person themselves, others)?

It is also important to understand the context in which these behaviours are occurring,
specifically the environment in which the person is living in and what is going on.
■ What is the emotional status of the individual? Is the person communicating any
worries/fears/concerns, are they lower in mood? In situations where the individual is
unable to communicate what information do you know from their past to inform your
understanding and/or explain their behaviour?
■ What are the physical features of the environment? Overcrowding, lack of privacy, noise
levels, etc., can have a significant impact on an individual’s ability to interpret their
environment. If an individual is over or under-stimulated this can have a negative impact.
■ Communication. Can the person easily communicate what they want/need? If not, how
do they let people know if they are hungry, thirsty, in pain, lonely, afraid?
■ The design and layout of the environment can either assist or confuse. Is it easy for
someone to find their way around? It is easy to identify where the toilets are/where you
can get a drink? Where can the person find other people to speak to?
■ Social contact (opportunities to spend meaningful time with others) forming
relationships, sharing life experiences and their home environment help to allow a
shared ownership of the home, and create a positive sense of self.
■ Occupation (i.e. how is the person spending their time) is vital when we consider an
individual’s sense of self worth. Lack of meaningful occupation can lead to sensory
deprivation, boredom, isolation and low mood. It is important that the person living with
dementia continues to experience their identity, have a sense of purpose, and role in their
home environment.
A summary of methods used to obtain such information is provided in Fossey and James
(2008). The publication outlined non-pharmacological approaches to be used in the place of
psychotropic medication.
By assessing what is happening and the context in which it is happening, it is possible to
understand the current experiences of the person with dementia. An important feature of this
is an appreciation of his/her current beliefs and thoughts regarding his/her current situation,
because these cognitions will often drive the behaviours. In the case of Mrs Smith (outlined
above), her conviction that she has got children and a elderly mother may result in her forcibly
attempting to leave her care home of an evening to try to collect her children from school. Mr
Jones, believing himself single, may become sexually dis-inhibited when young female carers try
to give him a bath. Hence, by understanding the person’s beliefs and other contextual features
we will be able to relate and communicate with the person better.
Actions
As identified in step 1, it is not necessary to prescribe antipsychotics at this stage unless there is
evidence of psychosis (except for the case of Dementia with Lewy Bodies – DLB where
antipsychotics should not be used) or there is severe distress for the client or immediate harm
to the client and/or others (note: relevant prescribing guidelines should be consulted).
The findings from the assessment will determine the interventions that can be considered.
Outlined below are a number of interventions than can be considered.
13 Briefing Paper:
■ Improve staff communication with the person with dementia: Encourage staff to interact
with the person, getting to know them as a person and to have appreciation of the
person’s past. This is because people with dementia can become ‘time-shifted’ and their
current behaviours may be reflection of previous episodes and roles in their lives. Also
encourage staff to use good verbal and non-verbal skills, looking for clues to what the
person with dementia is thinking and trying to communicate. Support staff in attempting
to meet the person with dementia’s needs (Cohen-Mansfield, 2000; James, 2011).
■ Dementia awareness training: The use of staff dementia awareness training on the
management of the behaviour that challenges has shown reductions in the occurrence of
the behaviour for several months (Livingstone et al., 2005; Lai et al., 2009), and a
reduction in use of antipsychotics (Fossey et al., 2006).
■ Life Story: The development of a life-story booklet provides families and carers an
opportunity to deliver person-centred care by placing the individual and their biography
at the heart of their own care. A life story book explores the life history of the person with
dementia and can support the delivery of new ways of working with people living with
dementia (e.g. DoH-funded project with the Life Story network).
It provides people with a practical set of tools to help them engage with the real person
and see them beyond their illness, disability or diagnosis.
■ Use of memory/activity boxes: The use of these boxes promotes better quality
communication between the person with dementia and their carer. The box combines
life story work, reminiscence and cued retrieval techniques. Typically carers and friends of
the person with dementia are asked to populate the box with items that are known to cue
positive memories. The contents often include favourite books, possessions, memorabilia
ornaments, photographs, etc.
■ Meaningful occupation: Engagement in meaningful activity such as reminiscence group
work, can improve the mood of people with dementia, without any reported harmful side
effects (RCN, 2011; Woods et al., 2009). Such activities also increase levels of social
interaction (see below)
■ Social interaction: Increasing social contact is effective in enhancing well-being and reducing
distress (Levy-Storm, 2008). Eggenberger et al. (2013) provide a list of useful
communication strategies based on their systematic review of interactions with care home
settings.
■ Physical environment: Changes to the physical environment for the person with dementia
can trigger the onset of behaviours that challenge. Identifying the trigger can alleviate
distress for the person living with dementia (Pointon, 2001). The use of horizontal grid
patterns can reduce attempts to open doors (Hussain & Brown, 1987), blinds and cloth
barriers placed over doors/door handles (Namazi et al., 1989) have also been evidenced
as effective methods for reducing distress. Evidence suggests that making changes to the
physical environment to make it ‘dementia friendly’ is an effective intervention to reduce
distress in individuals living with dementia (RCN, 2011).
After two to four weeks (or the end of the intervention) some change should have occurred. If
there is no reduction in the frequency of the behaviour or the caregiver is experiencing
difficulties managing the situation, the assessment and plan should be reviewed and revised as
required. If no further chance is evident by four–six weeks, it would be appropriate to proceed
to step 3.

Step 3: High Intensity Interventions
At this stage, more intensive assessment and interventions are focused on specific needs and
presentations. These are less focused on the general environment, and more on specific
issues/needs that commonly arise in the context of dementia (e.g communication, memory,
interpersonal interactions). These assessments and interventions require specific training on
the part of those delivering them.
Assessing needs in relation to patterns of presentation

At this step, health and social care staff who are specifically trained and appropriately clinically
supervised in the chosen protocol-led intervention are to take the lead, in line with Objective 1
of the National Dementia Strategy. Although the strategy makes reference to ‘behavioural and
functional analysis conducted by professionals with specific skills, in conjunction with carers
and care workers’ (NICE, 2007), other suitable assessment and intervention protocols are
included here. A review of the clinical frameworks is provided by James (2011), highlighting
the work of Kitwood (1997), Kuniks et al. (2003) Volicer and Hurley (2003) and Cohen-
Mansfield (2000).
Step 3: High Intensity Interventions (Protocol-led interventions)

Interventions tailored to specific presentations and needs
(Experienced practitioners and carers/care staff)
Assessments and actions targeted at presentations rather than at the level of the individual
assessing needs in relation to patterns of presentation
■ Use of structured protocols to assess needs and determine interventions; e.g.
• TREA model – Treatment Routes for Exploring Agitation (Cohen-Mansfield, 2000);
• Dementia Care Mapping (Bradford Dementia Group); and
• Behaviour records (ABC charts) .
■ Systematic review of information from earlier steps (medical review, mental well-being,
history, physical environment, social and occupational environment) to identify potential
determinants of behaviour .
Actions
Tailoring the intervention to the diagnosis and presentation (agitation, boredom, vocalising),
and use of decision trees to guide choice of interventions.
■ Interventions could include: behaviour management advice, TREA, communication skills
training, aromatherapy.
■ Some interventions are particularly useful for improving quality of life and mood but are less
suitable for the acute treatment of agitated behaviours. However, these interventions may
form an important element of a combined treatment package: e.g. dementia care mapping,
reminiscence therapy, cognitive stimulation, music, psychomotor & exercise, staff training in
high quality interaction
■ If there is high risk to self or others, consider medication (in line with appropriate prescribing
guidelines).
15 Briefing Paper:
Specific assessment frameworks will be deployed at this step, some of which link to specific
intervention packages. For example, protocol decision trees are used in the TREA model,
directing the practitioner to investigate six domains: (1) pain or discomfort, (2) need for social
contact, (3) appropriate level of stimulation, (4) hallucinations, (5) depression and control,
and (6) poor communication (Cohen-Mansfield et al., 2007). The findings from the assessment
are used to determine a specific behaviour management intervention.
Kunik’s Model of Behavioural Problems (Kunik et al., 2003) describes a multidimensional
model of problematic behaviours. They suggest that there are three aspects that one must
examine when accounting for such behaviours, namely features associated with the person, the
caregiver, and the environment. Each of these aspects is then divided further into fixed and
mutable determinants. Fixed determinants are characteristics that are difficult or impossible to
change, while mutable characteristics can be altered via the efforts of therapists, family and
staff, etc.
Dementia care mapping (DCM, developed by the Bradford Dementia Group; Kitwood, 1997)
provides a structured framework for assessing interactions between caregivers and people with
dementia, recording the type and frequency of different classes of interaction. This information
is used to enhance the use of positive interactions and increase the well-being of people with
dementia.
Behavioural records can also support decision-making at this point, particularly ABC charts
(Antecedent, Behaviour, Consequence charts). These can identify patterns in behaviours and
likely triggers by recording what happens before, during and after an occurrence of the
behaviour, and can be helpful in determining the likely cause of the behaviours. At this stage, it
is important that these records are reviewed by someone with training in behavioural
assessment and management. Behavioural management programmes can then be derived from
this information in order to shape behaviour. Again, these should be designed by someone
experienced in the use of behavioural management techniques.
In addition, information ascertained from earlier steps (i.e. medical review, mental well-being,
history, physical environment, social and occupational environment) should be reviewed to try
and identify potential determinants of behaviours.

Action
Tailoring the intervention to the diagnosis and presentation (agitation, boredom, vocalising),
and use of decision trees to guide choice of interventions. This could include:
■ Behavioural management: Based on learning theories, behavioural management
approaches from a trained practitioner can be of value in helping direct and shape
behaviours that are harmful and/or distressing. Moniz-Cook’s et al (2012) Cochrane
review on functional analytical techniques identified 15 quality studies in this area,
showing an encouraging evidence base.
■ Staff training in improving communication and quality interaction and reminiscence
work has been demonstrated to produce improvement in the BPSD too (see step 2;
Woods, Spector, Jones, Orrell & Davies, 2009; Lai et al., 2009; etc.). A good example of a
person centred staff training programme was provided by David Sheard, in the BBC
documentary series Can Gerry Robinson Fix Dementia Care Homes? (BBC, 2009)
■ Treatment route to exploring agitation (TREA, Cohen-Mansfield, 2000): this approach
uses a decision-tree framework, which uses empirical data to identify the likely cause of a
particular behaviour (e.g. verbal agitation – pain, sensory difficulties, lack of social
contact, etc), and then suggests relevant interventions.
■ Aromatherapy, in particular Melissa essential oil, has been identified as effective in
reducing wandering and agitation in severe dementia in double-blind, placebo-controlled
trials (Robinson et al., 2007; Ballard et al., 2002). However, recent results have not been as
positive.
Other methodologies are useful in dealing with mood and quality of life issues, but do not
necessarily target agitated forms of behaviours. However, these methods can often be part of a
package of care:
■ Dementia care mapping (DCM): Randomised controlled trials show that this approach
was effective at reducing agitation in people with dementia (Chenoweth et al., 2009, cited
in Ballad & Corbett, 2010; Brooker, 2005)
■ Cognitive Stimulation Therapy (CST): Research trials have shown significant
improvements in a range of cognitive functions as well as a reduction in aggressive or
problem behaviours (NICE/SCIE 2006; Olazaran et al 2010; Ballard et al., 2011). A
comparison of the health economics of cognitive stimulation therapy versus antipsychotic
medication by the NHS Institute (NHS Institute, 2011) reported that £70.4 million in
health cost savings would be generated by the adoption of behavioural interventions over
antipsychotic use (p.9).
■ Psychomotor and exercise interventions that are performed several times a week for 30-
minute periods, that include walking, can produce improvements in mood and the
quantity and quality of sleep in people with dementia (Eggermont & Scherder, 2005).
The Seattle studies (Teri et al., 2008) have undertaken a major programme of work on
the impact of exercise on people with dementia, and demonstrated significant benefits in
terms of agitation.
■ Music as an active (client plays a part in music making) or receptive (client listens to
music) intervention in both individual and in group settings has some evidence of a
positive effect in reducing the occurrence of agitation, aggressive behaviour and
17 Briefing Paper:
wandering. (Vink et al., 2011). Cohen-Mansfield (2001) has produced a helpful
taxonomy for the non-pharmacological approaches. She used it in her systematic review
in which she identified 83 psychological interventions. Her classification is composed of
eight types of interventions: sensory, social contact (real or simulated), behaviour therapy,
staff training, structured activities, environmental interventions, medical/nursing care
interventions, and combination therapies.
■ Medication: The use of medications as an intervention for problematic behaviours is
beyond the scope of this paper, but traditionally attempts to manage these behaviours
involve the wide use of antipsychotic drugs (Schneider et al., 2006). Antipsychotic
medication in particular should not be used for mild to moderate BPSD because of severe
adverse risk reactions and the modest benefits (Ballard, Sharp et al., 2008; Banerjee,
2009). The widespread prescription of antipsychotics as a first line treatment for people
with dementia continues, even though both the evidence and recommendations from the
Committee on Safety of Medicines (the predecessor to the Commission on Human
Medicines) run contrary to this (Ballard, Sharp et al., 2008). The NICE/SCIE guidance
recommends that antipsychotic drugs be used for BPSD as a first line response only when
there is severe distress or an immediate risk of harm to person with dementia or others. If
antipsychotics are prescribed treatment should only be continued beyond 12 weeks in
exceptional circumstances. (See Ballard and Corbett, 2010 for a review of the
pharmacological interventions for BPSD.)

Step 4: Specialised Interventions
At Step 4, highly individualised assessments and interventions are undertaken that focus
specifically on the individual and use specific psychological frameworks to understand their
individual experience and needs. At this level, specialist training is required in specific
theoretical approaches, assessment techniques and tailored interventions. In many
circumstances when working at Step 4, the agents of change are the carers, and as such many of
the interventions involve getting the carers to adopt new approaches and a different style of
interaction with the person with dementia. To do this effectively, therapists with specialist
training are required because skills in family therapy, group therapy, CBT, psychodynamic
approaches are often useful when working with the carers.
Although primarily psychological in nature, these interventions will often occur in a
multidisciplinary setting and a range of specialist perspectives will be integrated into a
biopsychosocial formulation of the individual.
Step 4: Specialist Interventions (Individualised formulation-led Interventions)

Individualised assessment, formulation and interventions
(Specialist practitioners and carers/care staff)
The development of an individually-tailored intervention based around an individualised

biopsychosocial formulation
Assessing Needs
Specialist Practitioners
• Full functional analysis
• Biopsychosocial formulation
Actions
Management plan (routinely monitored) which may include:
• Psychological interventions
• Social and occupational interventions
• Medication (can include antipsychotics if indicated)
• Regular specialist reviews
Assessing needs
At this step only staff specifically trained and appropriately clinically supervised to deliver
idiographic formulations should take the lead at developing individually tailored interventions.
Specialist practitioners may do this from a range of models or perspectives, for example full
functional analysis or idiographic biopsychosocial formulation (such as Cohen-Mansfield’s
unmet need approach, 2000; Comprehensive model of psychiatric symptoms of progressive
degenerative dementia, Volicer & Hurley, 2003; the Roseberry Park model, Dexter-Smith, 2010;
Newcastle Columbo model, James, 2011). The end result, however, would be an individually
tailored intervention that is specific to the person with dementia, the carers and environment.
It is important to highlight that the above formulations are structural frameworks and it is the
skill with which they are employed with the carers (i.e. the process features associated with the
19 Briefing Paper:
models) that determine the success of the interventions. All of the models described above
contain descriptions of how they should be used and employed and it is important that these
protocols are used
(see James, 2011).
Often, but not exclusively, clinical psychologists can take a lead with these formulation-led
approaches. This is because while other professional groups produce formulations, (for
example, formulation features in the curriculum for psychiatrists’ training, Royal College of
Psychiatrists, 2010), psychologists receive the most in-depth training in psychological theory
and formulation. Thus, they are often well-placed to promote its use through practice,
teaching, supervision, consultancy and research. From an organisational perspective the
grounding, training and experience of a psychologist can provide mental health teams with a
unique coherent alternative to the medical model (Onyett, 2007) which can help teams take
the conceptual leap away from the use of antipsychotics.
Action
The interventions employed at this step may bear some similarities to those used at Step 3, but
they will be derived from the idiosyncratic formulation rather than a manual-based treatment
protocol from a single theoretical perspective. Although the list of actions appears shorter than
in previous steps, the reality will be that more professionals are involved in the care of the
person, deploying more specialist knowledge and expertise.
The formulation will have identified the clients’ needs and their current (hypothesised)
thinking patterns, and the interventions will be specifically tailored to meet a person’s needs
(i.e. to facilitate communication, reduce anxiety, promote independence, and relieve boredom
or pain). In those circumstances where the person’s needs cannot be met directly, the therapist
may attempt to substitute the need via the introduction of some alternative feature (for
example, if the person is asking for his deceased wife, a simulation presence DVD of his family
may be used). On occasions, the therapist also might try to shift the person’s perspective to
create a more achievable goal (e.g. to ask the person if he would like to see his sister). In some
circumstances, the therapist may have to concur with the client’s erroneous view of reality and
work from this perspective in order to reduce agitation or distress (for example, go along with
the person’s belief that his wife is still alive).
It is also essential at this stage that all aspects of a person’s care are reviewed. As such, the
management plan will need to be routinely monitored by the specialist team involved. The
reviews should include:
■ psychological interventions;
■ social and occupational interventions;
■ medication (can include antipsychotics if indicated) and
■ regular specialist reviews.
Carers
The needs of carers will again come to the fore at Step 4. As described in detail in Step 1, carer
needs should be assessed and signposting, support and treatment should be made available
(see page 8). However, it should also be borne in mind that the carer will probably be
intimately involved in delivery of the interventions at Step 4, and the professional team will be
engaging with the carer on a regular basis to this end. As such, the professionals involved will

need to be mindful of the carer’s state of well-being and their ability to cope with the situation,
so that support can be offered as required. In Moniz-Cook et al.’s (2012) Cochrane review there
are a number of examples of studies that have employed carer interventions to good effect.
Examples of successful programmes includes the STARs framework (Teri et al., 2005). The use
of CBT and acceptance and commitment therapy also show promise (Marriott et al., 2000;
Márquez-Gonzalez et al., 2010).
Prescribers
Wood-Mitchell et al. (2008) demonstrated that there are numerous factors that maintain
psychiatrists’ prescribing practices and, in some cases, their preferences for using medication.
On the positive side the psychiatrists seemed to be aware of best practice biopsychosocial
methods, yet were sceptical of their efficacy and the staff’s ability to carry them out effectively.
Such findings suggest that psychiatrists, GPs, and other medical professionals need to educated
in the use of non-pharmacological methods, and also be part of the broad training
programmes required to teach care staff to use the methods effectively.
21 Briefing Paper:
Summary
1. The majority, if not all, of people living with dementia are likely to experience
behavioural and psychological difficulties at some point during their illness. This is
because the behaviours reflect people’s attempts to fulfill their needs and thus they are a
natural consequence of being alive.
2 In the past the problematic behaviours were treated as if they were symptoms of
dementia, which suggested that they had a clear discernable aetiology. This view led to the
prescribing of specific types of medication for different behaviours (i.e. use of the medical
model). However, most clinicians now accept that the behaviours are products of a range
of biopsychosocial features (e.g. distress, disorientation, misinterpretation, psychosis,
pain, delirium, etc.), and are not unique to dementia. As such, it is evident that there is
no ‘magic bullet’ with respect to the treatment of the behaviours rather clinicians are
required to obtain a understanding of the biopsychosocial causes.
3. Current guidance recommends the use of non-pharmacological approaches in the initial
stages of managing these difficulties, but in reality antipsychotic medication is often used
as a first line treatment. Implementing behavioural interventions could lead to savings of
£54.9 million above the cost of the therapy, resulting in a reduction in side effects such as
the occurrence of incidence of stroke and falls in people with dementia.
4. The stepped care model discussed in this document reinforces the need to ask ‘why the
behaviour is occurring?’ and ‘who is it distressing for?’ (i.e. doing a good assessment).
This places the behaviour in the context of the person’s life history and the social and
physical environment in which they live, and shapes the intervention required. In the
future greater care will need to exercised in the prescribing of such medication outside of
accepted guidelines, because their limited effectiveness and numerous side effects may
lead families to question whether these drugs are being used in their relative’s ‘best
interests’.
5. The model is intended to guide the delivery of care, and it is generally intended that
individuals would work their way through individual steps (i.e. choosing the least
invasive/intensive interventions first). However, the person’s individual situation and
needs may require that they ‘miss out’ some steps and proceed to a higher step, and this is
entirely appropriate.
6. Do not prescribe antipsychotics unless (i) psychosis is evident (except in the case of
Dementia with Lewy Bodies), (ii) there is severe distress for the client; or
(iii) immediate harm to the client and/or others. If antipsychotics are prescribed they
should follow good practice using target, titration, and time, and should be reviewed with
a view to discontinuation at the earliest opportunity.
7. There is not a ‘one-size-fits-all’ care strategy: people are individuals and so the reasons for
their behaviour do vary. Therefore, watchful waiting, asking carers to monitor and record
behaviours over a period of weeks (e.g. to try to identify patterns) to test out strategies
and the success of individualised approaches is essential. Most behavioural difficulties will
stop after four weeks without pharmacological treatment (Alzheimer’s Society, 2011).

8. Clinical psychologists receive the most in-depth training in using psychological theory and
evidence, and have a great deal of experience in applying this knowledge in clinical
situations. As such, this staff group possess knowledge, skills and experience that
complements the medical model (Onyett, 2007), and can be instrumental in helping
teams take the conceptual leap away from the use of antipsychotics.
9. The stepped care model is applicable to acute and general hospital settings by helping to
provide a framework and guidance around improving the quality of care for people with
dementia and thus reducing the length of stay in hospital settings.
Up to 60 per cent of acute hospital beds are occupied by older people, approximately 40
per cent of whom have dementia. However, patients who have dementia experience many
more complications and stay longer in hospital than those without dementia.
10. When adopting the interventions outlined it is important to recognise core principles that
should be considered to maintain equal access to services. Namely that the person living
with dementia should not be excluded from any intervention/ services because of their
diagnosis, age (whether designated too young or too old) or coexisting learning
disabilities.
11. The integration and coordination of health and social care services should be promoted
to ensure that joint planning is maintained and that there is a shared responsibility for the
provision and delivery of health and social care for the individual living with the dementia
and their carer.
23 Briefing Paper:
Glossary
Alzheimer’s Society: The leading support and research charity for people with dementia, their
families and carers. It is a membership organisation, which works to improve the quality of life
of people affected by dementia in England, Wales and Northern Ireland through a range of
activities, by providing a network of local services, research, publications and factsheets.
Antipsychotic medications/drug: The name given to a group of medications that is usually used
to treat people with psychosis. It is also frequently prescribed to people with dementia to
manage the BPSD.
Aromatherapy: A form of alternative and complementary medicine based on the use of very
concentrated ‘essential’ oils from the flowers, leaves, bark, branches, rind or roots of plants with
purported healing properties. In aromatherapy these potent oils are mixed with a carrier
(usually soyabean or almond oil) or the oils are diluted with alcohol or water and rubbed on
the skin, sprayed in the air, inhaled or applied as a compress.
Behavioural and psychological symptoms of dementia (BPSD): The term given to people living
with dementia who experience development of behavioural and psychological difficulties at
some point during their illness. Also known as ‘behaviour that challenges’ and
‘neuropsychiatric symptoms of dementia’.
Cognitive stimulation therapy (CST): A brief treatment for people with mild to moderate
dementia. Treatment involves sessions of themed activities running a few times a week over a
period of several weeks. Sessions aim to actively stimulate and engage people with dementia,
whilst providing an optimal learning environment and the social benefits of a group. CST can
be provided irrespective of drug treatments received.
Dementia care mapping (DCM): An observational tool designed to assess the quality of life of
people with dementia with the aim of promoting patient focused holistic practices.
Dementia with Lewy bodies (DLB): Dementia is a syndrome (a group of related symptoms) that
is associated with an ongoing decline of the brain and its abilities. DLB is one type of dementia
where abnormal protein deposits develop in nerve cells in the brain. These deposits or
structures are known as Lewy bodies.
Formulation: A formulation aims to explain, on the basis of psychological theory, the
development and maintenance of the service user’s difficulties, at this time and in these
situations; summarise the service user’s core problems; suggest how the service user’s difficulties
may relate to one another, by drawing on psychological theories and principles; indicate a plan
of intervention which is based in the psychological processes and principles already identified;
and is open to revision and re-formulation (Johnstone & Dallos, 2006.
Improving Access to Psychological Therapies: An NHS programme rolling out frontline
psychological services, combined where appropriate with medication which traditionally had
been the only treatment available, across England offering interventions approved by the
National Institute of Health and Clinical Excellence (NICE) for treating people with
depression and anxiety disorders.
National Institute of Health and Clinical Excellence: Develops evidence-based guidelines on the
most effective ways to diagnose, treat and prevent disease and ill health. They produce

guidelines for professionals to inform practise as well patient-friendly versions of their
guidelines to help educate and empower patients, carers and the public to take an active role in
managing health conditions.
Reminiscence therapy: Involves the discussion of past activities, events and experiences with
another person or group of people, usually with the aid of tangible prompts such as
photographs, household and other familiar items from the past, music and archive sound
recordings.
Treatment routes for exploring agitation (TREA): An objective, systematic method for
developing individualised non-pharmacological treatment plans based on an analysis of the
agitated person’s unmet needs, past and current preferences, past role-identity, cognitive,
mobility, and sensory abilities/limitations, and possible causes for particular agitated
behaviours. The methodology calls for ascertaining the type of agitated behaviour and the most
likely aetiology, and then matching the intervention to the aetiology and to the participant's
characteristics.
Randomised controlled trial: Where people are allocated at random (by chance alone) to
receive one of several clinical interventions. One of these interventions is the standard of
comparison or control. The control may be a standard practice, a placebo, or no intervention
at all.
Social Care Institute for Excellence: Improves the lives of people who use care services by
sharing knowledge about what works. It is an independent charity working with adults, families
and children’s social care and social work services across the UK. It also works closely with
related services such as health care and housing. It gathers and analyses knowledge about what
works and translates that knowledge into practical resources, learning materials and services for
use by those working in care services. This includes managers, frontline staff, commissioners
and trainers. People and their families who use these services can also use these resources.
Watchful waiting: An active process that over a defined period of time involves an ongoing
assessment of contributing factors and simple non-drug treatments. It is the safest and most
effective therapeutic approach unless there is sever risk or severe distress (Alzheimer’s Society,
2011).
25 Briefing Paper:
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Appendix 1: Behaviour monitoring chart
Behaviour Chart for ………………………………………………
Behaviour displayed …………………………………………………
Please record any episodes of the above behaviour (day/night)

Aim – to record the frequency and the circumstances of the incident
Date & Time What was the person doing just before the incident?
Where did the What did you see happen? (actual behaviour)
incident occur?
Which staff were What did the person say at the time of the incident?
involved (initials)
Possible reason for the behaviour?
How did the person appear at the time of the incident? (tick all that apply)
Angry Happy
Anxious Irritable
Bored Physically unwell
Content Restless
Depressed Sad
Despairing Worried
Frightened Other (please state):
Frustrated
How was the situation resolved?
31 Briefing Paper:
Behaviour Chart for………Harry………..
Behaviour displayed ……………Hitting out………………
Care Home Liaison Behaviour Chart Please record any episodes of the above behaviour (day/night)
Aim – to record the frequency and the circumstances of the incident
What is a behaviour chart?
Date & Time What was the person doing just before the incident?
A behaviour chart is a chart to recognise challenging 28/01/2007 In their room being assisted to change after being
behaviours. An example of a chart already filled out is shown 1pm incontinent.
to the right of this page. Where did the What did you see happen? (actual behaviour)
incident occur? Harry started shouting and was hitting out at staff
What information does a behaviour chart give you? bedroom with a closed fist. He hit staff on the arm 3 times
A behaviour chart gives us a really detailed picture of causing a red mark.
Alternatives to Antipsychotic Medication

Which staff were What did the person say at the time of the incident?
challenging behaviours. It shows us how often the behaviour involved (initials) “get off me”, “I don’t want your help”
is happening and what is happening at the time of the SW, AN
behaviour. Possible reason for the behaviour?
Didn’t want staff to help with getting him changed. Embarrassed by
Who should fill out the behaviour charts? people undressing him.
How did the person appear at the time of the incident? (tick all that apply)
The behaviour charts need to be filled out by the staff member
who witnesses the behaviour following discussion with senior
staff on duty. Angry Happy
Anxious Irritable
Do I fill out a chart for every time the behaviour occurs? Bored Physically unwell
Yes please. We need to know how much of a problem it is Content Restless
(e.g. how often it happens). If you do not record it each time
we can miss important information. In addition if we don’t get Depressed Sad
completed charts it will lead us to think that there is no Despairing Worried
problem. Frightened Other (please state):
Frustrated
How long will we have to complete the behaviour charts
for? How was the situation resolved?
Staff kept trying to reassure Harry and carried on with the care
It will usually be between 3-8 days, or approximately 20 intervention. As soon as staff had finished he stopped being
completed charts. aggressive.
32
33
THE CHALLENGING BEHAVIOUR SCALE (CBS) FOR OLDER PEOPLE LIVING IN CARE HOMES
Name ……………………………………………………………
Age ……………… Sex … M / F Diagnosis of Dementia … Y / N / Don`t know
Residence …………………………………………… Date ……………………………
Checklist Completed By ……………………………………………………………………………
PHYSICAL ABILITY (delete as applicable)
1. Able to walk unaided / Able to walk with aid of walking frame / In a wheelchair
2. Continent / Incontinent of urine / Incontinent of faeces / Incontinent of urine + faeces
3. Able to get in or out of bed/chair unaided / needs help to get in or out of bed/chair
4. Able to wash and dress unaided / needs help to wash and dress
5. Able to eat and drink unaided / needs help to eat and drink
Over the page is a list of challenging behaviours that can be shown by older adults in residential or nursing settings.
For each behaviour listed consider the person over past 8 weeks and mark:
INCIDENCE: Yes / Never. If Yes move to Frequency
FREQUENCY:
4: This person displays this behaviour daily or more
3: This person displays this behaviour several times a week
2: This person displays this behaviour several times a month
1: This person displays this behaviour occasionally
DIFFICULTY:
Then for each behaviour shown mark down how difficult that behaviour is to cope with, when that person shows it, according to the following scale:
4: This causes a lot of problems

3: This causes quite a lot of problems
2: This is a bit of a problem
1: This is not a problem
N.B. If a person does not show a behaviour no frequency or difficulty score is needed.
If the person causes a range of difficulty with anyone behaviour, mark down the score for the worst it has been over the last few (eight) weeks.
Appendix 2: Challenging Behaviour Scale (Moniz-Cook, 2001b)
E.Moniz-Cook2001
Briefing Paper:
CHALLENGING BEHAVIOUR INCIDENCE FREQUENCY DIFFICULTY CHALLENGE
1 Physical Aggression (hits, kicks, scratches, grabbing, etc.)

2 Verbal Aggression (insults, swearing, threats, etc.)
3 Self Harm (cuts/hits self, refuses food/starves self, etc.)
4 Shouting
5 Screaming/Crying out
6 Perseveration (constantly repeating speech or actions, repetitive questioning or singing)

7 Wandering (walks aimlessly around home)
8 Restlessness (fidgets, unable to settled down, pacing, òn the go`, etc.)
9 Lack of motivation (difficult to engage, shows no interest in activities, apathy, etc.)
10 Clinging (follows/holds on to other residents/staff, etc.)
11 Interfering with other people
12 Pilfering or Hoarding (possessions, rubbish, paper, food, etc.)
13 Suspiciousness (accusing others, etc.)
14 Manipulative (takes advantage of others, staff, etc.)
15 Lack of Self Care (hygiene problems, dishevelled, etc.)
16 Spitting
17 Faecal Smearing
18 Inappropriate Urinating (in public, not in toilet, etc.)
19 Stripping (removes clothes inappropriately, flashes, etc.)
20 Inappropriate Sexual Behaviour (masturbates in public, makes inappropriate àdvances` to
others, etc.)
21 Sleep Problems (waking in night, insomnia, etc.)
22 Non-compliance (deliberately ignores staff requests, refuses food, resists self care help, etc.)
23 Dangerous Behaviour (causes fires or floods, etc.)
24 Demands Attention
25 Lack of Occupation (sits around doing nothing, etc.)
TOTALS Add scores (1 – 25) for each column 25 100 100 400
34
35
E. Moniz-Cook 2001
STAFF `PROMPT` SHEET
HOW OFTEN DOES THE PROBLEM / BEHAVIOUR OCCUR?
4: This person displays this behaviour daily or more

3: This person displays this behaviour several times a week
2: This person displays this behaviour several times a month
1: This person displays this behaviour occasionally
0: This behaviour is never displayed by this person
HOW MUCH OF A PROBLEM IS THIS BEHAVIOUR?
4: This causes a lot of problems

3: This causes quite a lot of problems
2: This causes a bit of a problem
1: This is not a problem
WE ARE INTERESTED IN THE WORST THE RESIDENT HAS BEEN OVER THE LAST TWO MONTHS.
If a person does not show a behaviour no difficulty (or problem) score is needed.
If the person causes a range of difficulty with any one behaviour, mark down the score for the worst is has been over the last
few weeks.
Briefing Paper:
Instructions for use of the Challenging Behaviour Scale
Background
1. This scale was initially derived as the Problem Behaviour Checklist (Inventory) and used in a staff training study.
Reference: Moniz-Cook, E.D., Agar, S., Silver, M., Woods, R.T., Wang, M., Elston, C. and Win, T. (1998) `Can Staff Training Reduce Behavioural Problems
in Residential Care for the Elderly Mentally Ill?` International Journal of Geriatric Psychiatry, 13, p.149-158.
2. On the basis of initial reliability and validity studies it was changed and re-labelled – The Challenging Behaviour Scale (CBS).
3. Reliability and validity studies were carried out in Continuing Care Hospitals and residential and nursing homes. Although you can use the scale for non-
demented institutional populations its global properties will be of little use. For example people with a depressive illness may present with self harm whereas
this is not often seen in dementia.
4. This scale was developed on the basis of staff report : hence eating problems do not feature strongly and were included under the `non-compliant` category.

You may wish to add some items of eating problems for your own use but the norms will have to be adjusted.
5. This is a global scale and although it has been subject to factor analysis, other scales for aggression, agitation and eating problems are more useful for
specific behaviours. This scale does have a category for àpathy` / depression / doing nothing which may be of use in monitoring.
6. The Incidence and Frequency ratings are useful in measuring àctual behaviour` if guidelines are followed (see later). The Difficulty and Challenging scores
are more measures of staff coping / management / perception. The Difficulty domain is only required to calculate Challenge scores whilst the Challenge
score is a measure of management difficulty or coping.
Contract
1. I would be grateful if you would supply me with information of use of this scale, (i.e. if you decide to use it and how). I wish to develop it further and keep a
database of it`s use.
2. Please do not circulate the Scale and Staff Prompt Sheet without my permission, as I am currently negotiating detail publication with a test agency.
3. Please refer to Moniz-Cook, E.D., Woods, R.T., Gardiner, E., Silver, M. & Agar, S (2001) `The Challenging Behaviour Scale (CBS): Development of a Scale
for Staff Caring for Older People in Residential and Nursing Homes`. British Journal of Clinical Psychology. 40 (3): 309-322 for detail of development,
reliability and validity. Please turn over for specific instructions.
Esme Moniz-Cook
Professor of Clinical Psychology & Ageing /Consultant Clinical Psychologist
University of Hull/Humber NHS FT
The Hull Memory Center
39-41 Coltman Street
Hull HU3 2SG
36
© E. Moniz-Cook 2001
37
CHALLENGING BEHAVIOUR SCALE INSTRUCTIONS
1. Use as a structured interview with at least 2 members of staff (one qualified and one unqualified), for individual clinical work or for `research` work / monitoring.
2. If you hand these out then make sure that one person who knows the person well (key worker), a qualified member of staff and one other do the checklist in a group.
3. If a staff member is stressed out this may influence the results (especially on some items and the Difficulty and Challenge rating).
4. Repeat testing is best done with the same staff group, but reliability is not bad if group is different as long as it is a group and not one person.
5. You need to wait approximately 8 weeks before you repeat testing because of wording of frequency items.
Scoring
1. Multiply each Frequency x Difficulty item to get a Challenge item score.
2. Add Challenge score to make total Challenge (do not add Frequency, add Difficulty and then multiply for Challenge).
By this method the maximum Challenge score is 400.
3. If you want to measure the (more reliable) actual behaviour use total Incidence and total Frequency on their own.
Notes
1. The Incidence and Frequency domain are fairly stable measures of actual behaviour. The Difficulty domain is not often used on its own but is used to calculate the Challenge
domain, which is a measure of staff coping / management. This latter domain (Challenge) is very sensitive and is only reliable if you follow the rules.
2. It is useful in assessing behaviour in whole environments, e.g. a ward – ask the person in charge to complete with at least the key worker and one other.
3. Measurement of individual cases – use as a structured interview with the same pair of staff pre and post / at least one staff member of the baseline pair.
Briefing Paper:
References for CBS
Moniz-Cook, E.D., Agar, S., Silver, M., Woods, R.T., Wang, M., Elston, C & Win, T. (1998) `Can Staff Training Reduce Behavioural
Problems in Residential Care for the Elderly Mentally Ill? `, International Journal of Geriatric Psychiatry, 13, 149-158.
Moniz-Cook, E.D. (1998) `Psychosocial Approaches To Challenging Behaviour In Care Settings – A Review`. Journal of f Dementia Care,
6 (5), .33-38.
Silver, M., Moniz-Cook, E.D & Wang, M. (1998) `Stress And Coping With Challenging Behaviour In Residential Settings For Older People`
Mental Health Care, 2 (4), 128-131.
Moniz-Cook, E.D., Gardiner, E. & Woods, R.T. (2000) `Staff Factors Associated with the Perception of Behaviour as `Challenging` in
Residential and Nursing Homes`. Aging and Mental Health, 4(1), 48-55.
Cole R.P., Scott, S. & Skelton-Robinson, M. (2000) `The effect of Challenging Behaviour and Staff Support on the Psychological Wellbeing
of Staff Working with Older Adults. Aging and Mental Health, 4 (4) .359-365.
Moniz-Cook, E.D Woods, R.T. & Richards, K. (2001) `Functional Analysis of Challenging Behaviour in Dementia: The Role of

Superstition`. International Journal of Geriatric Psychiatry, 16, p.45-56.
Moniz-Cook, E.D., Woods, R.T., Gardiner, E., Silver, M. & Agar, S (2001) `The Challenging Behaviour Scale (CBS): Development of a
Scale for Staff Caring for Older People in Residential and Nursing Homes`. British Journal of Clinical Psychology. 40 (3).309-322.
Moniz-Cook, E.D Stokes, G. & Agar, S. (2003) `Difficult Behaviour and Dementia in Nursing Homes: Five Cases of Psychosocial
Intervention`. International Journal Clinical Psychology and Psychotherapy, 10, 3, 197-208
Freeman - Asthill, L. (2004) `Staff training and challenging behaviour in a day hospital. ` Dementia 3 (3), 384-392
Lam, C.L. Chan, W.C. Cycbie, C.M. Mok, S.W. Li. & Linda C.W. Lam. (2006) `Validation of the Chinese Challenging Behaviour Scale:
clinical correlates of challenging behaviours in nursing home residents with dementia`. International Journal of Geriatric Psychiatry 21
792-799
Hoe, J. Hancock, G. Livingston, G. & Orrell, M. (2006) Quality of Life of people with dementia in residential care homes British Journal of
Psychiatry 188, 460-464
Orrell, M., Hancock, G.,Hoe, J., Woods B., Livingston, G. & Challis, D. (2007) A cluster randomised controlled trail to reduce the unmet
needs of people with dementia living in residential care International Journal of Geriatric Psychiatry 22 1127- 1134
Moniz-Cook E, Vernooij-Dassen M, Woods R, Verhey F, Chattat R, de Vugt M, Mountain G, O’Connell M, Harrison J, Vasse E, Dröes RM, &
Orrell M For the INTERDEM group. (2008) A European consensus on outcome measures for psychosocial intervention research in
dementia care Aging & Mental Health 12 ,1, 14- 25
Moniz-Cook E D (2010) National Institute of Health Research (NIHR) Research : Living well with dementia in care homes Alzheimers
Society Newsletter 97 (April), 6-7
Moniz-Cook (2010) Psychosocial Interventions for 'living well' in care homes Alzheimers Society Research ejournal Issue 11, pp 12 – 15
Updated January 2012
38
The British Psychological Society
St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UK
Tel: 0116 254 9568 Fax 0116 247 0787 E-mail: mail@bps.org.uk Website: www.bps.org.uk
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Executive summary ..................................................................................................... 2

Alternatives to Antipsychotic Medication 2

The policy context

Alternatives to Antipsychotic Medication 4

What is needed now?

The underpinning assumption within the psychosocial literature is that distressed/distressing

A stepped care model of assessment and intervention

Alternatives to Antipsychotic Medication 6

Step 4: Specialist Interventions (Individualised formulation-led Interventions)

Step 2: Low intensity interventions (Management of contextual issues)

Figure 1: The stepped care model

Assessing Causes and Risks

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Assessing the presentation in context

Step 2: Low intensity interventions (Management of contextual issues)

Assessing the presentation in context

■ side effects of medication;

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Assessing needs in relation to patterns of presentation

Step 3: High Intensity Interventions (Protocol-led interventions)

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Step 4: Specialist Interventions (Individualised formulation-led Interventions)

The development of an individually-tailored intervention based around an individualised

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Welsh Assembly Government (2011). National dementia vision for Wales.

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Behaviour displayed …………………………………………………

Please record any episodes of the above behaviour (day/night)

Possible reason for the behaviour?

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Age ……………… Sex … M / F Diagnosis of Dementia … Y / N / Don`t know

Residence …………………………………………… Date ……………………………

Checklist Completed By ……………………………………………………………………………

PHYSICAL ABILITY (delete as applicable)

INCIDENCE: Yes / Never. If Yes move to Frequency

4: This causes a lot of problems

1 Physical Aggression (hits, kicks, scratches, grabbing, etc.)

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STAFF `PROMPT` SHEET

HOW OFTEN DOES THE PROBLEM / BEHAVIOUR OCCUR?

4: This person displays this behaviour daily or more

HOW MUCH OF A PROBLEM IS THIS BEHAVIOUR?

4: This causes a lot of problems

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Alternatives to Antipsychotic Medication

Updated January 2012

Incorporated by Royal Charter Registered Charity No 229642 INF207/04.2013

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