Using biophysical and social analysis methods, this paper evaluated agricultural practices under changing climate in the Koshi Basin and assessed adaptation options. Agricultural trend analysis showed that in the recent three to four decades, the total cultivated area had declined in all parts of the basin except in the Nepal Mountain Region. Household survey results also confirmed such decline and further revealed shifts towards non-agricultural activities. Climate trend analysis showed changes in the frequency of wet and dry days in study districts, implying an increasing chance of flood and drought events. Household surveys further revealed that, in general, people perceived a decline in agricultural water availability and an increase in drought and flood events. The direct impacts of these changes were reduced crop yield, increased fallow lands, displacement of people from settlement areas, sedimentation of cultivable land and damage to properties. Household surveys showed that despite the perceived impacts on agriculture and livelihoods, only limited adaptation options are currently practised. Adaptation efforts are constrained by several factors, including: finance; technical knowledge; lack of awareness about adaptation options; lack of collective action; unclear property rights; and ineffective role of state agencies.