SIR—There are many anecdotal reports and brief case studies concerning the positive impact of doll therapy on the lives of elderly people with dementia [1–6]. Despite increasing support, there is a paucity of literature examining what the goals of doll therapy are, how it is best implemented and how it affects patients. This pilot project, the first systematic study in the area, examined the use of dolls in two Elderly Mentally Ill (EMI) homes.

Methodology

Participants

Fourteen dolls were introduced into two homes. All residents (n = 37) were given the opportunity to choose one of the dolls. Once a resident selected a doll, his/her interaction was monitored by staff over a 3- to 6-week period. Twelve women and two men used a doll. See profiles in Table 1.

Table 1.

Summary of the impact of the use of dolls on the activity and affective states of residents as assessed by resident’s key worker (n = 14)

      1 = much less; 2 = little less; 3 = no change; 4 = little more; 5 = much more
 
     
ID Sex Age Diagnosis Brief description of frequent behaviours before the use of doll Doll perceived to be a baby? Y/N Activity/liveliness Interacting with staff Interacting with other residents Happier/ content Agitation Amenable to personal care 
91 NFD Rocked and shouted. Sometimes disruptive, would pull at others 
2 F 75 ALZ Withdrawn and uncommunicative Varies 5 5 5 5 1 5 
83 ALZ Agitated, wandered and hoarded 
4 F 83 VAS/ALZ Distressed and angry, wanting to go home Varies 5 5 5 5 1 5 
75 ALZ Wandered, as if looking for someone 
6 F 87 VAS Picked at wallpaper. Frequently scratched own arma Y 1 5 3 5 1 4 
77 VAS Argumentative and pinched staff/residents 
8 81 ALZ Agitated, banged on door and paced Y 4 5 3 5 2 3 
83 VAS Agitated and paced 
10 F 85 LBD Aggressive and wandered Y 4 4 3 4 2 3 
11 91 VAS Wandered 
12 M 83 KORS Agitated and paced Y 3 4 3 4 2 4 
13 94 ALZ Quiet and withdrawn 
14 88 VAS Aggressive, agitated and wandered 
      1 = much less; 2 = little less; 3 = no change; 4 = little more; 5 = much more
 
     
ID Sex Age Diagnosis Brief description of frequent behaviours before the use of doll Doll perceived to be a baby? Y/N Activity/liveliness Interacting with staff Interacting with other residents Happier/ content Agitation Amenable to personal care 
91 NFD Rocked and shouted. Sometimes disruptive, would pull at others 
2 F 75 ALZ Withdrawn and uncommunicative Varies 5 5 5 5 1 5 
83 ALZ Agitated, wandered and hoarded 
4 F 83 VAS/ALZ Distressed and angry, wanting to go home Varies 5 5 5 5 1 5 
75 ALZ Wandered, as if looking for someone 
6 F 87 VAS Picked at wallpaper. Frequently scratched own arma Y 1 5 3 5 1 4 
77 VAS Argumentative and pinched staff/residents 
8 81 ALZ Agitated, banged on door and paced Y 4 5 3 5 2 3 
83 VAS Agitated and paced 
10 F 85 LBD Aggressive and wandered Y 4 4 3 4 2 3 
11 91 VAS Wandered 
12 M 83 KORS Agitated and paced Y 3 4 3 4 2 4 
13 94 ALZ Quiet and withdrawn 
14 88 VAS Aggressive, agitated and wandered 

ALZ, Alzheimer’s; KORS, Korsakoff’s dementia; LBD, dementia with Lewy Body; NFD, no formal diagnosis; VAS, vascular dementia.

a

Case 6: since the introduction of the doll, she was calmer and her psoriasis had improved and she no longer scratched.

All staff in the homes were invited to participate; the response rate was 96% in home 1 and 79% in home 2 (total n = 46 staff). The homes were registered as EMI social care, and neither home employed qualified staff.

Design

Before the introduction of the dolls, an RMN (L.M., first author) visited each home and discussed the use of dolls with the manager and the staff and left an article on the approach [6] at the home. Assent was obtained from at least one family member. The dolls were introduced into the homes by placing them on a table in the lounge area. Residents were free to ‘pick them up’ from the table. After a minimum period of 3 weeks, L.M. returned to the home to administer questionnaires to the staff. A five-item questionnaire, completed by all 46 staff, contained general questions about the approach (e.g. overall impression of the use of dolls and general benefits). A 14-item questionnaire, an extended version of the five-item questionnaire, composed of both quantitative and qualitative questions, was completed by the key workers (n = 14) of residents using a doll. The additional questions asked the key workers to identify the impact on a specific resident (e.g. levels of activity, agitation and interactions with others, e.g. To what extent is the resident interacting with staff? 1–5 Likert scale, much less–much more). Furthermore, they were required to hypothesise on the mechanisms of change occurring via the use of dolls (e.g. whether the doll promoted communication between fellow residents and/or staff) and provide details of their overall impression of doll use (e.g. What is your overall impression of using dolls with residents?).

Results

Care staff’s (n = 46) perceptions of the use of dolls

The overall impression of care staff concerning the use of dolls was positive. All staff, apart from one, felt that there were clear benefits of using the dolls. Sixteen carers (35%) reported that there had been some problems using the dolls: arguments between residents over ownership of dolls, residents trying to feed their dolls and dolls being mislaid.

A question concerning the carers’ ‘initial impression of the use of dolls when they first heard about them’ had intended to capture staff’s misgivings. Three staff reported major concerns, six had minor concerns, 16 were neutral, six were mildly positive and 15 were very positive from the outset. However, the answers obtained were contaminated by the information (article and discussion) provided by the RMN before the introduction of the dolls. Nevertheless, as outlined above, 13% of carers recorded that they had misgivings—carer quotes included: ‘Thought it was babyish’; ‘. . . totally demeaning’; ‘. . . patronising’; ‘inappropriate . . ., thought it would confuse residents further, but having seen the way residents react when using the doll opinion has changed’.

In response to a global question concerning whether the residents’ lives were affected following the introduction of the dolls, 14 carers felt that residents’ lives were a little better, and 32 felt that their lives were much better.

In summary, despite initial concerns, all care staff reported that there were clear benefits of introducing dolls, and residents’ lives improved as a result.

Key workers’ (n = 14) perceptions of the impact of the dolls on residents

As presented in Table 1, the impact on the residents was generally positive across the six domains examined (quantitative scores on the right side of the table). Residents tended to be more active, showed greater levels of interaction with staff and fellow residents, appeared happier, less agitated and more amenable to personal-care activities. It is relevant to note, however, that the individual profiles differed greatly. For example, Case 4 improved markedly on all the domains, whereas in Cases 5 and 7, the changes appeared solely in the affective areas (i.e. levels of ‘happiness’ and ‘agitation’).

In Case 6, the use of the doll actually made the person less active and lively. However, this was perceived positively by the key worker, as previously the resident ‘. . . stood picking wallpaper all day’.

Thirteen (93%) key workers thought that the dolls helped with communicating with the residents. Four key workers reported that their view of the resident had changed. For example, one key worker reported that she ‘found out more about her and her family history’. Another staff member commented that the resident is ‘much calmer, more approachable’.

Care staff’s (n = 46) perceptions of the nature of the impact

Table 2 summarises the main types of interactions observed by care staff; the number of staff who thought the dolls had a calming effect was particularly striking. Many of those expressing the latter opinion suggested that the resident had now been given a sense of purpose or focus.

Table 2.

Staff’s (n = 46) qualitative responses concerning the perceived benefits categorised by interactions, functional impact and emotional status

Nature of interaction n Emotional status n Functional impact n 
Talks to doll Calmer 18 Purpose 
Talks to others via doll Happier Focus 
Uses doll to interact with staff Comforted Loved object 
Uses doll to interact with residents Relaxed Structure 
Smiles at doll Content Keeps occupied 
Cradles and walks with it Less agitated Role 
Specifics included kissing, dressing, cuddling, singing to, patting, putting socks on, showing off to others etc.  Settled Company 
  Quieter Topic to talk about 
  Less bored Helps them remember 
Nature of interaction n Emotional status n Functional impact n 
Talks to doll Calmer 18 Purpose 
Talks to others via doll Happier Focus 
Uses doll to interact with staff Comforted Loved object 
Uses doll to interact with residents Relaxed Structure 
Smiles at doll Content Keeps occupied 
Cradles and walks with it Less agitated Role 
Specifics included kissing, dressing, cuddling, singing to, patting, putting socks on, showing off to others etc.  Settled Company 
  Quieter Topic to talk about 
  Less bored Helps them remember 

Other perceived benefits included a reduction in wandering (n = 3), improvement in intimate-care interactions (bathing etc.) (n = 2) and an improvement in speech (n = 1). It is also worth noting that the benefits generalised because once again there was evidence of an improved attitude towards residents. For example, one key worker said, ‘He’s a different man with a doll in his hand. I found out more about him—the tender side’.

Discussion

The data presented clearly illustrate that carers thought that the introduction of dolls had beneficial effects on the well-being of people with dementia across a wide range of domains. Despite the positive effects, there were problems associated with using the dolls. In one home, arguments occurred between residents over ownership of the dolls. There were also criticisms of the use of the dolls by fellow residents. One carer noted that some relatives were critical, as they saw the use of dolls as demeaning.

It is important to note that the approach presents several ethical and practical problems which have already been debated in the literature. For example, Cayton [7] and Boas [8] criticised the use of dolls on the grounds that it is infantilising. Infantilisation refers to the societal treatment of old age as a second childhood, with little or no recognition of a lifetime of experiences that separate the elderly from children [9].

In practical terms, there was evidence in our study that residents could become over-invested in caring for their dolls. It seemed, at times, the doll’s interests were being put before the resident’s own well-being. Also, on occasions, the dolls may have over-stimulated some residents, causing them to become excessively tired.

This study clearly has many methodological weaknesses. For example, there were potential biases with respect to the staff’s perspectives, as they were not blind to which residents had received dolls nor to the rationale underpinning the questions. Also, the behaviours being rated (interactions with staff/residents, activity, happiness, etc.) were worded in positive terms, which may have influenced the key workers’ perceptions. Furthermore, the failure to use well-validated measures may have introduced additional confounds with respect to the findings. This study should, therefore, be regarded as an opportunistic audit of a clinical intervention. Such a perspective would also help account for the rather post hoc type of methodology employed. It should be noted, however, that the methodological flaws outlined are due, in part, to the fact that the decision to introduce the dolls was a clinical one. Originally, there were no plans to monitor the impact empirically. Future work in this area clearly requires more rigorous designs and the use of well-validated measures for assessing the impact of the intervention in terms of the residents, staff and families.

Key points

  • Care staff’s positive impressions of the impact of the use of dolls on residents’ well-being.

  • Use of a cost-effective non-pharmacological intervention for people with dementia in care homes.

  • Survey of a novel approach that previously has only been supported by anecdotal work.

Project registered as Service Improvement/Evaluation Project with R&D Department of Newcastle, North Tyneside and Northumberland Mental Health NHS Trust.

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