Non-pharmacological interventions in dementia alternative or otherwise,some of our interventions et al,1999;Ballard et al,2002)or through the input have to involve changes in the attributions,attitudes of a multidisciplinary team in a family care and interactions of family carers and paid care context (Hinchliffe et al,1995).Further analysis workers.It is here,indeed,that a fuller under- development and evaluation of these intervention standing of the carer's cognitions and affect models is required,if non-pharmacological inter- regarding the person in their care,and also of their ventions are to take their proper place in the real behaviour in relation to other members of the care world of dementia care. system,will prove invaluable. References Need for individualised Ballard,C.G..Bannister,C.Oyebode,F.(1996a) Depression in dementia sufferers.International Journal of formulations Geriatric Psychiatry,11,507-515. Ballard.C..Boyle.A..Bowler.C..et al (1996b)Anxiety disorders in dementia sufferers.International Journal of Having identified symptoms such as agitation, Geriatric Psychiatry,11.987-990. aggression,wandering and the like,it is tempting to Ballard,C.,Powell,I.,James,I..et al(2002)Can psychiatric identify the most effective therapeutic approach for liaison reduce neuroleptic use and reduce health service utilization for dementia patients residing in care facilities? each.However,the same label may become attached International Journal of Geriatric Psychiatry.17.140-145. to quite different behaviours,requiring quite Brooker.D.J.R..Snape,M..Johnson.E.,et al (1997)Single different interventions.Add to this the person's case evaluation of the effects of aromatherapy and massage on disturbed behaviour in severe dementia.British Journal unique social environment,their particular profile of Clinical Psychology,36,287-296 of physical health,their life history and so on,and Douglas,S..James.I.Ballard,C.(2004)Non-pharma it is clear that an individual assessment and analysis cological interventions in dementia.Advances in Psychiatric Treatment,10,171-177. of each person's situation is needed.Even if two Hinchliffe.A.C..Hyman.I.L..Blizard.B..et al (1995) people with dementia are both thought to be Behavioural complications of dementia-can they be showing agitation because of a high level of internal treated?International Journal of Geriatric Psychiatry.10.839- 847. arousal,what helps one may be quite different from Howard.R..Ballard.C..O'Brien.J..et al(2001)Guidelines what helps the other.One person's relaxing and for the management of agitation in dementia.International calming hand-massage may be another person's Journal of Geriatric Psychiatry.16.714-717. Proctor,R..Burns.A.,Stratton-Powell,H..et al (1999) invasion of personal space and confinement Behavioural management in nursing and residential (Brooker et al,1997).Evidence-based practice in homes:a randomised controlled trial.Lancet,354,26-29. dementia care entails establishing'what works for Scholey.K.A.Woods.B.T.(2003)A series of brief cognitive whom',rather than a standard approach;this may therapy interventions with people experiencing both dementia and depression:a description of techniques and require readiness to adopt a more empirical common themes.Clinical Psychology and Psychotherapy approach,using simple single-case designs,with 10,175-185. the person as their own control. Spector,A.,Thorgrimsen,L..Woods,B..et al (2003)Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia:randomised controlled trial.British Journal of Psychiatry.183.248-254 Implementing change Suhr.J.,Anderson,S.Tranel.D.(1999)Progressive muscle relaxation in the management of behavioural disturbance in Alzheimer's disease.Neuropsychological Rehabilitation. If it is indeed the case that effective non-pharma- 9.31-44. cological interventions must be based on individual Teri,L..Logsdon.R.G.,Uomoto,J.,et al (1997)Behavioral treatment of depression in dementia patients:a controlled assessment and formulation,with an understanding clinical trial.Journals of Gerontology Series B-Psychological of the role of the social environment in the Sciences and Social Sciences,52.P159-P166 development and maintenance of the problem, Woods.B.(2002)Editorial:Reality orientation:a welcome training alone,for family carers or for care-workers. return?Age and Ageing.31.155-156. Woods.R.T.(2001)Discovering the person with Alzheimer's will be of limited use.Input is also required from disease:cognitive,emotional and behavioural aspects. mental health professionals(including community Aging and Mental Health,5(suppl.1).S7-S16. mental health nurses and clinical psychologists,as well as psychiatrists)who have skills in dementia Bob Woods Professor of Clinical Psychology with Older care and the ability to work at a systemic level.Some People.University of Wales Bangor (Ardudwy.Holyhead models of how this might be achieved are already Road,Bangor,Gwynedd LL57 2PX.UK.E-mail:b.woods@ bangor.ac.uk),Co-Director of the Dementia Services being developed,for example through regular visits Development Centre Wales and Director of the Centre for to a care home by a mental health nurse (Proctor Social Policy Research and Development. Advances in Psychiatric Treatment(2004),vol.10.http://apt.rcpsych.org/ 179Non-pharmacological interventions in dementia Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ 179 alternative or otherwise, some of our interventions have to involve changes in the attributions, attitudes and interactions of family carers and paid care￾workers. It is here, indeed, that a fuller under￾standing of the carer’s cognitions and affect regarding the person in their care, and also of their behaviour in relation to other members of the care system, will prove invaluable. Need for individualised formulations Having identified symptoms such as agitation, aggression, wandering and the like, it is tempting to identify the most effective therapeutic approach for each. However, the same label may become attached to quite different behaviours, requiring quite different interventions. Add to this the person’s unique social environment, their particular profile of physical health, their life history and so on, and it is clear that an individual assessment and analysis of each person’s situation is needed. Even if two people with dementia are both thought to be showing agitation because of a high level of internal arousal, what helps one may be quite different from what helps the other. One person’s relaxing and calming hand-massage may be another person’s invasion of personal space and confinement (Brooker et al, 1997). Evidence-based practice in dementia care entails establishing ‘what works for whom’, rather than a standard approach; this may require readiness to adopt a more empirical approach, using simple single-case designs, with the person as their own control. Implementing change If it is indeed the case that effective non-pharma￾cological interventions must be based on individual assessment and formulation, with an understanding of the role of the social environment in the development and maintenance of the problem, training alone, for family carers or for care-workers, will be of limited use. Input is also required from mental health professionals (including community mental health nurses and clinical psychologists, as well as psychiatrists) who have skills in dementia care and the ability to work at a systemic level. Some models of how this might be achieved are already being developed, for example through regular visits to a care home by a mental health nurse (Proctor et al, 1999; Ballard et al, 2002) or through the input of a multidisciplinary team in a family care context (Hinchliffe et al, 1995). Further analysis, development and evaluation of these intervention models is required, if non-pharmacological inter￾ventions are to take their proper place in the real world of dementia care. References Ballard, C. G., Bannister, C. & Oyebode, F. (1996a) Depression in dementia sufferers. International Journal of Geriatric Psychiatry, 11, 507–515. Ballard, C., Boyle, A., Bowler, C., et al (1996b) Anxiety disorders in dementia sufferers. International Journal of Geriatric Psychiatry, 11, 987–990. Ballard, C., Powell, I., James, I., et al (2002) Can psychiatric liaison reduce neuroleptic use and reduce health service utilization for dementia patients residing in care facilities? International Journal of Geriatric Psychiatry, 17, 140–145. Brooker, D. J. R., Snape, M., Johnson, E., et al (1997) Single case evaluation of the effects of aromatherapy and massage on disturbed behaviour in severe dementia. British Journal of Clinical Psychology, 36, 287–296. Douglas, S., James, I. & Ballard, C. (2004) Non-pharma￾cological interventions in dementia. Advances in Psychiatric Treatment, 10, 171–177. Hinchliffe, A. C., Hyman, I. L., Blizard, B., et al (1995) Behavioural complications of dementia – can they be treated? International Journal of Geriatric Psychiatry, 10, 839– 847. Howard, R., Ballard, C., O’Brien, J., et al (2001) Guidelines for the management of agitation in dementia. International Journal of Geriatric Psychiatry, 16, 714–717. Proctor, R., Burns, A., Stratton-Powell, H., et al (1999) Behavioural management in nursing and residential homes: a randomised controlled trial. Lancet, 354, 26–29. Scholey, K. A. & Woods, B. T. (2003) A series of brief cognitive therapy interventions with people experiencing both dementia and depression: a description of techniques and common themes. Clinical Psychology and Psychotherapy, 10, 175–185. Spector, A., Thorgrimsen, L., Woods, B., et al (2003) Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial. British Journal of Psychiatry, 183, 248–254. Suhr, J., Anderson, S. & Tranel, D. (1999) Progressive muscle relaxation in the management of behavioural disturbance in Alzheimer’s disease. Neuropsychological Rehabilitation, 9, 31–44. Teri, L., Logsdon, R. G., Uomoto, J., et al (1997) Behavioral treatment of depression in dementia patients: a controlled clinical trial. Journals of Gerontology Series B – Psychological Sciences and Social Sciences, 52, P159–P166. Woods, B. (2002) Editorial: Reality orientation: a welcome return? Age and Ageing, 31, 155–156. Woods, R. T. (2001) Discovering the person with Alzheimer’s disease: cognitive, emotional and behavioural aspects. Aging and Mental Health, 5 (suppl. 1), S7–S16. Bob Woods Professor of Clinical Psychology with Older People, University of Wales Bangor (Ardudwy, Holyhead Road, Bangor, Gwynedd LL57 2PX, UK. E-mail: b.woods@ bangor.ac.uk), Co-Director of the Dementia Services Development Centre Wales and Director of the Centre for Social Policy Research and Development