Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 10, 197 – 208 (2003) Difficult Behaviour and Dementia in Nursing Homes: Five Cases of Psychosocial Intervention Esme Moniz-Cook, 1 * Graham Stokes 2 and Sharon Agar 3 1 Department of Clinical Psychology, School of Medicine, Robert Blackburn Building, University of Hull, Cottingham Road, Hull HU6 7RX, UK 2 Premier Health NHS Trust, Staffordshire, UK 3 Department of Clinical Psychology, University of Sheffield, UK Psychosocial interventions in five people, who presented with uncooperative and difficult behaviour at mealtimes and during assistance with self-care tasks, are described. In four cases, a single case experimental design was used. The results are discussed in the context of ‘rementia’ and a broadly defined functional analytic perspective to assessment and intervention. In contrast to the standard neurogenic- disease paradigm, a person-centred holistic model of dementia is proposed for the understanding and amelioration of distress in people with dementia who are seen as difficult or ‘challenging’. Copyright  2003 John Wiley & Sons, Ltd. INTRODUCTION While estimates vary, the prevalence of disruptive behaviour in nursing homes is significant (Beck and Shue, 1994). There is a general consensus that behavioural problems can impact on staff morale and the quality of life of both staff and residents (MacPherson, Eastley, Richards, & Mian, 1994; Hallberg and Norberg, 1995, Moniz-Cook, Woods, & Gardiner, 2000). The use of pharmacotherapy in the management of disruptive behaviour in residential and nurs- ing homes is widespread (McGrath and Jackson, 1996; Thacker and Jones, 1997). This is despite con- cerns about over-prescription (Nygaard et al., 1994); potential addiction, dependence and adverse side effects (Solomon, Shackson, & Brown, 1995; Gash and Chhabra, 1996); their possible misuse (Ray, Federspiel, & Schaffner, 1980; Hesse, Driscoll, & * Correspondence to: Esme Moniz-Cook, Senior Clinical Lecturer, Department of Clinical Psychology, School of Medicine, Robert Blackburn Building, University of Hull, Cottingham Road, Hull HU6 7RX, UK. E-mail: E.D.Moniz- Cook@hull.ac.uk Contract/grant sponsor: Northern and Yorkshire Executive. Jacobson, 1993); their association with increased cognitive decline or ‘sensitivity’ and poorer well- being (Holmes, Fortenza, Powell, & Lovestone, 1997; McShane et al., 1997; Ballard, Grace, McK- eith, & Holmes, 1998; Ballard et al., 2001b); an increased risk of falls (Cooper, 1994); the restricted nature of their efficacy (Barnes, Veith, Okimoto, Raskind, & Gumbrecht, 1982; Schneider, Pollock, & Lyness, 1990; Bridges-Parlet, Knopman, & Steffes, 1997; Ballard et al., 2001a) and the strong case for behavioural and environmental intervention prior to resorting to medication (Murphy, 1989; Her- rmann, Lanct O ot, & Naranjo, 1996; Howard, Ballard, O’Brien, & Burns, 2001). One reason for the relatively thin literature on the efficacy of alternative psychosocial interventions in response to challenging behaviour in demen- tia relates to the range and complexity of these behaviours and the associated difficulty in defi- nition, aetiology and measurement. For example, it is possible that the aetiology of aggressive behaviour may be associated with frontal lobe damage (Grigsby, Kaye, & Robbins, 1995; Miller, Darby, Benson, Cummings, & Miller, 1997), lan- guage impairment (Welsh, Corrigan, & Scott, 1996) or decreased levels of serotonin (Palmer, Stratmann, Copyright  2003 John Wiley & Sons, Ltd. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.370