Douglas et al/Woods The nature of the behaviours challenging behaviours.More recently.positive pro- gramming methodologies(La Vigna Donnellan, When reviewing this area,it is important to note 1986)have used non-aversive methods in helping that there is an ongoing debate regarding the to develop more functional behaviours.Moniz-Cook definitions and basic terminology for 'non-cognitive (1998)suggests that behavioural analysis is often symptoms.The term currently favoured in the the starting point of most other forms of therapeutic psychiatric literature is 'behavioural and psycho- intervention in this area.Furthermore,she suggests logical symptoms of dementia,but most of the psy- that modern behavioural approaches can be wholly chology community still use the label 'challenging consistent with person-centred care.Behavioural behaviour'Emerson et al.1995).Within these therapy requires a period of detailed assessment in broader terms,further distinctions have been made which the triggers,behaviours and reinforcers(also (e.g.Cohen-Mansfield et al,1992;Allen-Burge et al, known as the ABC:antecedents,behaviours and 1999).Allen-Burge et al distinguish between consequences)are identified and their relationships behavioural excesses (such as disruptive vocal- made clear to the patient.The therapist will often isation or aggression)and behavioural deficits(such use some kind of chart or diary to gather information as lack of social interaction or lack of self-care). about the manifestations of a behaviour and the In Allen-Burge et al's terminology,until recently sequence of actions leading up to it.Interventions the main focus of treatment has been excessive are then based on an analysis of these findings. behaviours,because of the disruption they cause Emerson(1998)suggests focusing on three key both for the person with dementia and the carers. features when designing an intervention:taking It is relevant to note that,in many currently used account of the individual's preferences;changing approaches,the disruptive behaviours are often not the context in which the behaviour takes place;and addressed directly,but are taken as an indication of using reinforcement strategies and schedules that underlying distress or unmet need.For example, reduce the behaviour. Cohen-Mansfield(2000)has recently produced an The efficacy of behavioural therapy has been 'unmet needs model for agitation'.Her model demonstrated in the context of dementia in only a distinguishes three main functions of behaviours small number of studies(Burgio Fisher,2000).For in relation to needs:behaviours to obtain or meet a example,there is evidence of successful reductions need(e.g.pacing to provide stimulation);behaviours in wandering,incontinence and other forms of to communicate a need (e.g.repetitive questioning); stereotypical behaviours (Woods,1999).Meares and behaviours that result from an unmet need(e.g. Draper(1999)presented case studies testifying to aggression triggered by pain or discomfort).This the efficacy of behavioural therapy,but they noted model is particularly helpful in terms of therapy that the behaviours had diverse causes and because the focus on the patient's needs helps to maintaining factors,and advised that behavioural target interventions more appropriately (e.g.the use interventions must be tailored to individual cases. of pain relief,facilitation of communication). Non-pharmacological Box 1 Non-pharmacological therapies interventions Standard therapies An increasing number of non-pharmacological Behavioural therapy Reality orientation therapies are now available for people with dementia Validation therapy (Box 1).It should be noted that there are several areas Reminiscence therapy of overlap between these therapies and,in fact,each approach is rarely used in isolation (Ballard et al, Alternative therapies 2001).It is therefore important for a clinician to have Art therapy some knowledge of a number of these approaches, Music therapy enabling a combination of treatments tailored to the Activity therapy individual requirements of the patient. Complementary therapy Aromatherapy Standard non-pharmacological therapies Bright-light therapy Multisensory approaches Behavioural therapy Briefpsychotherapies Traditionally,behavioural therapy has been based Cognitive-behavioural therapy on principles of conditioning and learning theory Interpersonal therapy using strategies aimed at suppressing or eliminating 172 Advances in Psychiatric Treatment(2004),vol.10.http://apt.rcpsych.org/172 Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ Douglas et al/Woods The nature of the behaviours When reviewing this area, it is important to note that there is an ongoing debate regarding the definitions and basic terminology for ‘non-cognitive’ symptoms. The term currently favoured in the psychiatric literature is ‘behavioural and psycho￾logical symptoms of dementia’, but most of the psy￾chology community still use the label ‘challenging behaviour’ (Emerson et al, 1995). Within these broader terms, further distinctions have been made (e.g. Cohen-Mansfield et al, 1992; Allen-Burge et al, 1999). Allen-Burge et al distinguish between behavioural excesses (such as disruptive vocal￾isation or aggression) and behavioural deficits (such as lack of social interaction or lack of self-care). In Allen-Burge et al’s terminology, until recently the main focus of treatment has been excessive behaviours, because of the disruption they cause both for the person with dementia and the carers. It is relevant to note that, in many currently used approaches, the disruptive behaviours are often not addressed directly, but are taken as an indication of underlying distress or unmet need. For example, Cohen-Mansfield (2000) has recently produced an ‘unmet needs model for agitation’. Her model distinguishes three main functions of behaviours in relation to needs: behaviours to obtain or meet a need (e.g. pacing to provide stimulation); behaviours to communicate a need (e.g. repetitive questioning); and behaviours that result from an unmet need (e.g. aggression triggered by pain or discomfort). This model is particularly helpful in terms of therapy because the focus on the patient’s needs helps to target interventions more appropriately (e.g. the use of pain relief, facilitation of communication). Non-pharmacological interventions An increasing number of non-pharmacological therapies are now available for people with dementia (Box 1). It should be noted that there are several areas of overlap between these therapies and, in fact, each approach is rarely used in isolation (Ballard et al, 2001). It is therefore important for a clinician to have some knowledge of a number of these approaches, enabling a combination of treatments tailored to the individual requirements of the patient. Standard non-pharmacological therapies Behavioural therapy Traditionally, behavioural therapy has been based on principles of conditioning and learning theory using strategies aimed at suppressing or eliminating challenging behaviours. More recently, positive pro￾gramming methodologies (La Vigna & Donnellan, 1986) have used non-aversive methods in helping to develop more functional behaviours. Moniz-Cook (1998) suggests that behavioural analysis is often the starting point of most other forms of therapeutic intervention in this area. Furthermore, she suggests that modern behavioural approaches can be wholly consistent with person-centred care. Behavioural therapy requires a period of detailed assessment in which the triggers, behaviours and reinforcers (also known as the ABC: antecedents, behaviours and consequences) are identified and their relationships made clear to the patient. The therapist will often use some kind of chart or diary to gather information about the manifestations of a behaviour and the sequence of actions leading up to it. Interventions are then based on an analysis of these findings. Emerson (1998) suggests focusing on three key features when designing an intervention: taking account of the individual’s preferences; changing the context in which the behaviour takes place; and using reinforcement strategies and schedules that reduce the behaviour. The efficacy of behavioural therapy has been demonstrated in the context of dementia in only a small number of studies (Burgio & Fisher, 2000). For example, there is evidence of successful reductions in wandering, incontinence and other forms of stereotypical behaviours (Woods, 1999). Meares & Draper (1999) presented case studies testifying to the efficacy of behavioural therapy, but they noted that the behaviours had diverse causes and maintaining factors, and advised that behavioural interventions must be tailored to individual cases. Box 1 Non-pharmacological therapies Standard therapies Behavioural therapy Reality orientation Validation therapy Reminiscence therapy Alternative therapies Art therapy Music therapy Activity therapy Complementary therapy Aromatherapy Bright-light therapy Multisensory approaches Brief psychotherapies Cognitive–behavioural therapy Interpersonal therapy