Inconclusive, but promising evidence for the efficacy of functional analysis interventions for challenging behaviour in dementia

The management of challenging behaviour, such as aggression and agitation in dementia has been dominated by drug therapies such as the antipsychotics, despite their modest efficacy, side effects and potential detriment to quality of life. Functional analysis (FA) is a behavioural intervention that is described by international guidelines as the first line alternative to drug therapy for challenging behaviour. FA typically requires the therapist to develop an understanding of the function or meaning behind the person’s distressed behaviour. It uses this understanding to develop individually tailored strategies aimed at both the person with dementia and the caregivers, to relieve the distress caused by the behaviour. FA can be applied in home settings where the family or informal caregiver is offered support from a therapist, or in care homes, hospitals or assisted living settings, where training in FA and specialist support to deliver interventions is provided for staff. 

In this review we analysed the effectiveness of functional analysis-based interventions for challenging behaviour in dementia. We found eighteen randomised controlled trials suitable for analysis in all four types of care settings. The majority were in family care settings and there were surprisingly few care home based studies. Most evaluated broad programmes of care, where FA was just one component of a wide range of other interventions. This made it hard to determine the real effect of FA for the management of challenging behaviour in dementia. 

However, positive results were noted in the frequency of the person’s reported problem behaviours and the caregiver’s reaction to them. No significant effects were found for incidence or severity of mood and other problem behaviours. Similarly, no significant effects were found for caregiver mood or burden.

Whilst it is too early to reach a firm conclusion on the evidence for FA in the management of challenging behaviour in dementia, we note emerging beneficial effects on challenging behaviour where multi-component psychosocial interventions have used FA as part of the programme of care.

Authors' conclusions: 

The delivery of FA has been incorporated within wide ranging multi-component programmes and study designs have varied according to setting - i.e. family care, care homes and hospital, with surprisingly few studies located in care homes. Our findings suggest potential beneficial effects of multi-component interventions, which utilise FA. Whilst functional analysis for challenging behaviour in dementia care shows promise, it is too early to draw conclusions about its efficacy.

Read the full abstract...

Functional analysis (FA) for the management of challenging behaviour is a promising behavioural intervention that involves exploring the meaning or purpose of an individual’s behaviour. It extends the ‘ABC’ approach of behavioural analysis, to overcome the restriction of having to derive a single explanatory hypothesis for the person’s behaviour. It is seen as a first line alternative to traditional pharmacological management for agitation and aggression. FA typically requires the therapist to develop and evaluate hypotheses-driven strategies that aid family and staff caregivers to reduce or resolve a person’s distress and its associated behavioural manifestations.


To assess the effects of functional analysis-based interventions for people with dementia (and their caregivers) living in their own home or in other settings.

Search strategy: 

We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group’s Specialized Register on 3 March 2011 using the terms: FA, behaviour (intervention, management, modification), BPSD, psychosocial and Dementia.

Selection criteria: 

Randomised controlled trials (RCTs) with reported behavioural outcomes that could be associated with functional analysis for the management of challenging behaviour in dementia.

Data collection and analysis: 

Four reviewers selected trials for inclusion. Two reviewers worked independently to extract data and assess trial quality, including bias. Meta-analyses for reported incidence, frequency, severity of care recipient challenging behaviour and mood (primary outcomes) and caregiver reaction, burden and mood were performed. Details of adverse effects were noted.

Main results: 

Eighteen trials are included in the review. The majority were in family care settings. For fourteen studies, FA was just one aspect of a broad multi-component programme of care. Assessing the effect of FA was compromised by ill-defined protocols for the duration of component parts of these programmes (i.e. frequency of the intervention or actual time spent). Therefore, establishing the real effect of the FA component was not possible.

Overall, positive effects were noted at post-intervention for the frequency of reported challenging behaviour (but not for incidence or severity) and for caregiver reaction (but not burden or depression). These effects were not seen at follow-up.