Age and Ageing Advance Access originally published online on April 25, 2006
Age and Ageing 2006 35(4):441-444; doi:10.1093/ageing/afl007
Research Letter |
A pilot study on the use of dolls for people with dementia
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 |
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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.
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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?).
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Results |
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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.
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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’.
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Discussion |
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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.
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Key points |
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- 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.
1 Centre for the Health of the Elderly, Newcastle General Hospital, Westgate Rd, Newcastle upon Tyne NE4 6BE, UK Tel: (+44) 191 273 6666 ext: 22551 Fax: (+44) 191 219 5040 Email: ianjamesncht{at}yahoo.com
2 University of Newcastle upon Tyne, Newcastle upon Tyne, UK
* To whom correspondence should be addressed
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Notes |
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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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References |
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- Godfrey S. Doll therapy. Aust J Ageing 1994; 13: 46.
- Mayers KS. Play therapy for individuals with dementia. In: Schaefer CE, ed. Play Therapy with Adults. New York: John Wiley & Sons, 2003.
- Ehrenfeld M. Using therapeutic dolls with psychogeriatric patients. In: Schaefer CE, ed. Play Therapy with Adults. New York: John Wiley & Sons, 2003.
- Libin A, Cohen-Mansfield J. Therapeutic robocat for nursing home residents with dementia: preliminary inquiry. Am J Alzheimers Dis Other Demen 2004; 19: 111–6.
[Abstract/Free Full Text] - Ehrenfeld M, Bergman R. The therapeutic use of dolls. Perspect Psychiatr Care 1995; 31: 21–2.[Medline]
- Moore D. It’s like a gold medal and its mine—dolls in dementia care. J Dementia Care 2001; 9: 20–3.
- Cayton H. From childhood to childhood? Autonomy, dignity and dependence through the ages of life. In: 15th Alzheimer’s Disease International Conference, Christchurch, New Zealand, 2001.
- Boas I. Why do we have to give the name ‘therapy’ to companionship and activities that are, or should be, a part of normal relationships? J Dement Care 1998; 6: 13.
- Salari SM. Intergenerational partnerships in adult day centers: importance of age-appropriate environments and behaviors. Gerontologist 2002; 42: 321–33.
[Abstract/Free Full Text]
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