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Using dolls to alter behaviour in patients with dementia

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VOL: 103, ISSUE: 5, PAGE NO: 36-37

Jenny Ellingford, BSc, is assistant psychologist; Ian James, PhD, MSc, BSc, C.Psychol is clinical psychologist; Lorna Mackenzie, RMN, is challenging behaviour nurse specialist, Centre for the Health of the Elderly; all at Newcastle General Hospital Northumberland, Tyne and Wear Trust. Lisa Marsland, BSc, MSc, is trainee clinical psychologist, Doctorate Course in Clinical Psychology, Newcastle University.

Ellingford, J. et al (2007) Using dolls to alter behaviour in patients with dementia. 

ABSTRACT: Ellingford, J. et al (2007) Using dolls to alter behaviour in patients with dementia.

AIM:This study examined the impact of doll therapy by conducting a retrospective analysis of the case notes of nursing home residents with dementia three months before and after introduction of the dolls, to determine whether there were changes in incidences of problematic behaviours.

METHOD Sixty-six residents’ case notes were examined (34 doll users and 32 non-doll users). Comparisons involved auditing three key variables: residents’ (i) positive and (ii) negative behaviour, recorded by staff in their daily communication records; and (iii) incidences of aggressive behaviour (both physical and verbal) and (iv) neuroleptic use.

RESULTS: The findings supported the hypotheses that doll therapy can increase positive behaviours in doll users and can help to decrease negative behaviours and incidences of aggression. Significant effects were not found for use of neuroleptics.

CONCLUSION This study provides support for previous attitudinal studies that have suggested doll therapy is a promising and effective approach to use in the care of older adults with dementia.

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The most widely used form of treatment for challenging behaviour in dementia is neuroleptic medication. It is estimated that more than 40% of people with dementia in care homes are currently prescribed such medication (Dempsey and Moore, 2005). Recent evidence from major studies suggests that neuroleptics are of limited benefit (Sink et al, 2005) and may even increase the rate of the dementing process. This has led for calls in the US and UK to develop effective non-pharmacological treatments for people with dementia (Jackson, 2005; Elon and Pawlson, 1992). A number of potential psychological strategies have been developed to treat residents displaying challenging behaviours (James et al, 2004):

- Behavioural therapy;

- Reality orientation;

- Validation therapy;

- Reminiscence therapy;

- Art and music therapy;

- Activity therapy;

- Aromatherapy.

Using dolls in dementia care settings is a promising recent development. The ethics and impact of using dolls has been systematically investigated by the Newcastle Challenging Behaviour Service (NCBS) at Newcastle GeneralHospital in the past three years (Mackenzie et al, 2006a; 2006b; James et al, 2005). Investigations have involved the introduction of doll therapy into the care homes following a standard format (Mackenzie et al, in press). Information and guidelines on the use of dolls in care settings are given to staff (Mackenzie, et al 2006b).

The findings of the investigations (James et al, 2006a; Mackenzie et al, 2006a; 2006b) have been favourable for both residents and staff. Following the introduction of dolls into two elderly mentally ill homes in the north-east of England, Mackenzie et al (2006a) found that 69% of care staff reported that they thought that residents’ lives were much better. Care staff noted improvements in residents’:

- Interaction with staff;

- Interaction with other residents;

- Level of activity;

- Happiness/contentment;

- Amenability to care interventions and agitation.

Despite these positive findings, there had been some problems using the dolls, such as arguments between residents over ownership of dolls, residents trying to feed their dolls, and dolls being mislaid leading to distress. In addition, some staff working in homes felt that the dolls may be infantilising residents. All of these issues are currently being addressed by psychoeducational training sessions before the introduction of dolls. The sessions include information about the psychological benefits for people with dementia of using dolls, behavioural and environmental strategies for minimising problems, and de-escalation techniques when problems arise (for additional information see Mackenzie et al (in press)).

This study examined the impact of the dolls by retrospective analysis of the case notes of residents before and after the introduction of the dolls, to determine whether there were changes in incidences of problematic behaviours.



This was a retrospective audit of residents’ case notes, examining data over a six-month period (three months pre- and three months post-doll introduction). A mixed design was used to compare the impact of the dolls on doll-users before and after introduction of the dolls and to compare those who used dolls and those who did not.

The comparisons involved auditing three objective features:

- Neuroleptic dosages (standardised in the form of ‘chlorpromazine-equivalent’ units) over the period specified;

- Residents’ positive and negative behaviour recorded by staff in their daily communication records;

- Number of incidences of aggressive behaviours (both physical and verbal) recorded by staff in their daily communication records.

Therefore the following hypotheses were examined:

After the introduction of the dolls, those residents using dolls will have been prescribed less neuroleptic medication (including as-required doses (PRN)), displayed less negative behaviours and displayed more positive behaviours compared with pre-doll usage and with those not using dolls.

Recruitment process

All residents living in four care homes in the Newcastle area where dolls had previously been introduced were asked to participate. The homes were approximately equal in size and registered as elderly mentally ill facilities. All residents were required to give consent, or where necessary assent was obtained from residents’ families or the home manager.

The dolls were introduced to the residents indirectly, being placed on chairs or small tables in communal areas. This method allowed all residents to observe the dolls and, if they were so inclined, they could select a doll to use. Thus, in terms of the present study, the doll users were a self-selecting group based on their own desire to use a doll.

The dolls used in the study were all plastic with a soft torso; they were approximately 16-20 inches in length; had eyes that opened and closed; and did not have any additional auditory or kinetic functions, such as crying or breathing. The dolls had different faces and clothes to avoid potential disputes over ownership. For a rationale of the above information see Mackenzie et al (in press).


Sixty-six participants (mean age = 84.41; SD = 8.16) met the criteria and were recruited (34 doll users and 32 non-doll users).


A keyword data sheet was used to record information on residents’ positive and negative behaviours reported by staff in their daily records during the six months. Behaviours were recorded using a ‘keyword’ data entry system. This involved reading the notes and each time a predetermined ‘key’ word was identified, a point was awarded to the relevant category. The categories were:

i. Positive behaviour- There were four subcategories:

Action/activity (including, engagement in an art or craft, socialising or exercising);

positive verbalisations (including, positive feedback statements and reminiscence);

positive mood state (including, being happy, joyful, content or pleased);

and positive physical appearance (including, bright, tidy and groomed).

ii. Negative behaviour- There were four subcategories:

Action/activity (including, physical aggression towards people and objects, wandering, non-compliance and self-isolation);

negative verbalisations (including, verbal aggression, swearing, shouting and screaming);

negative mood state (including, depressed, low, upset, anxious, and agitated);

and negative physical appearance (including, poorly presented and poor hygiene).

iii. Aggression- It was decided that a sub-analysis would be carried out to examine aggression as a separate variable. Incidences of verbal aggression and physical aggression were combined from the subcategories of action/activity and negative verbalisations.

To ensure consistency and inter-rater reliability, a list of relevant keywords were developed and agreed between the researcher and an independent rater (assistant psychologist). Inter-rater reliability checks, using percentage agreement calculations, were conducted on 3% of the sample (five residents) selected randomly. There was 79% agreement. This level of agreement was deemed to be acceptable (Sturmey, 1996).

iv. Neuroleptic use: Medical Administration Records (MAR) were used to record both the neuroleptic drugs and doses residents received.


Data collection

After obtaining consent and assent, the case notes of the residents were examined in the four homes where dolls were routinely used. The researcher and an assistant psychologist extracted information pertaining to medication, and residents’ behaviours from daily communication sheets. Ethical approval was given by the local mental health trust and identities of participants were kept confidential and anonymous.

Data analysis

The data was not normally distributed and both parametric and non-parametric statistics were required. Wilcoxon signed-rank non-parametric test were used to examine doll users’ and non-doll users’ scores on the dependent variables before and after introduction of the dolls. Mann Whitney tests were used to compare doll users’ scores against non-doll users’ scores at baseline and following doll introduction. ANOVAs (analysis of variance) were used to examine interactions between the two groups over time (pre/post). Examination of the data set revealed that very few changes were made to neuroleptic use (two cases; 1% of the group). As such, further analyses were not undertaken with respect to this variable.


The descriptive statistics for participants’ characteristics can be found in Table 1. There were significant differences between doll users and non-doll users in terms of gender (92% and 66% female respectively) and diagnosis (97% and 56% with dementia respectively). All other comparisons were non-significant.

Table 1. Descriptive statistics for participant characteristics

    Doll-users Non-doll users
Age Mean SD 85.3 7.9 83.4 8.3
Neuroleptic use Mean SD 0.3 0.4 0.2 0.4
Gender * % Female 92% 66%
Diagnosis * %Vascular Dementia 59% 44%
  % Alzheimer’s 32% 12%
  % Lewy-body Dementia 6% 0%
  % No Dementia 3% 44%
Marital status % Married 91% 84%
Parental status % Have children 79% 66%
  % No children 21% 34%

* Significantly different


Table 2 shows all descriptive statistics, comparisons and interactions for the two groups over time.

Table 2. I: Means, medians and standard deviation for doll users and non-doll users on behavioural measures pre- and post-doll introduction, and II: differences between groups and interaction effects

I. Positive Negative Aggressive
Doll user Mean Median SD Mean Median SD Mean Median SD
Pre 6.32 6.00 4.13 13.71 10.50 13.41 1.29 0.00 2.11
Post 14.21 13.00 9.86 8.03 4.50 9.85 0.32 0.00 0.77
Wilcoxon sign test (pre v post) z= -4.36, p< 0.005 * z= -3.47, p<0.005* z= -2.82, p<0.005*
Non -doll user Mean Median SD Mean Median SD Mean Median SD
Pre 7.31 6.00 5.63 8.97 5.00 12.75 0.50 0.00 1.16
Post 7.19 4.00 8.13 8.50 3.00 12.97 0.72 0.00 1.53
Wilcoxon sign test (pre v post) z= -0.856, p=0.39 z= -0.83, p= 0.40 z= -1.82, p= 0.07
II. Differences between doll user and non-doll users Positive Negative Aggressive
Mann Whitney (pre/baseline) U= 524.0, p= 0.79 U= 404.5, p= 0.07 U= 441.0, p= 0.10
Mann Whitney (post) U= 297.5, p= <0.005* U= 497.5, p=0.59 U= 507.5, p= 0.52
Interaction effect doll use x time (ANOVA) 22.2 (1, 64) <0.001* 8.09 (1, 64) <0.01* 14.3 (I, 64) <0.001*

* Significantly different

Doll users and non-doll users

There was an increase in doll users’ positive behaviour following introduction of the dolls and a reduction in negative behaviours and aggression. There were no significant differences for non-doll users on all four of the behaviour measures (see Table 2). Hence, doll therapy can help to reduce doll users’ negative behaviours and levels of aggression and can increase positive behaviours.

Comparison of doll and non-doll users

There were no significant differences between doll users and non-doll users on all four of the behaviour measures at baseline (pre-doll introduction). Following introduction the two groups were significantly different on scores of positive behaviour. However, there were no significant differences between the two groups on scores of negative behaviour and aggression (see Table 2).


There were significant interaction effects of group (user/non-user) and time (pre/post) on the three behavioural variables (see Table 2). This means that after the introduction of the dolls, all those who used a doll improved significantly more on all of the behavioural measures compared with those who did not use a doll. Overall, these results indicate that the introduction of the dolls had a significant impact on these behavioural variables.


The aim of this study was to examine the impact of the dolls by auditing residents’ case notes to determine whether there were beneficial impacts in terms of both positive and problematic behaviours. The results clearly suggest that doll use is effective for those people who choose to use them. Before discussing the results in detail, it is worth acknowledging that the significant differences between doll users and non-doll user, in terms of gender and diagnosis, are consistent with the recent findings that being female and having a diagnosis of a dementia are associated with choosing a doll (James et al, 2006a). Our findings in relation to medication are also consistent with the emerging literature on neuroleptic prescribing in this area. This literature demonstrates that there is a general reluctance to stop using such drugs despite concerns about the use of neuroleptic medication in this population (James, et al 2006b; Dempsey and Moore, 2005). Hence, the results obtained in this study may reflect current pharmacological treatment practices. However, Jackson (2005) also suggests that the continuing use of medication may be due to circumstances in the care homes; more specifically, low staffing and staffing training levels, and management as opposed to therapeutic cultures.

The results of the study provide support for the hypotheses that after the introduction of dolls, doll-users showed an increase in positive behaviour and a decrease in negative behaviour and incidents of aggression compared with before the dolls were introduced. These results support previous attitudinal studies, which have reported doll therapy to be an effective approach in reducing negative and challenging behaviours, and promoting more positive behaviours and mood (James et al, 2006a; Mackenzie et al, 2006b). The results (Table 2) also provide support for three of the hypotheses, that there would be significant interaction effects of group and time on: positive behaviour, negative behaviour and incidents of aggression, over time.

The main limitation of the study was its naturalistic design. Variables which could not be controlled for in the study included: the size of the homes, the number of residents choosing dolls, missing data, staff attitudes and staff procedures for recording information (for example, not all homes record incidents of problematic behaviours in the same way). Also, the care homes used in the study were selected on a voluntary basis, which may have resulted in a positive bias when compared with other dementia care settings.

Clinical implications

Doll therapy is still seen as a controversial intervention. However, this study provides further evidence that the approach brings positive effects to the residents who choose to use the dolls. Given these findings, it would be beneficial for future research to explore the impact of dolls for patients with dementia who reside on inpatient wards or in their own homes. Our work may also have implications for practices in long-term care settings, for example learning disabilities. In relation to the finding that neuroleptic drugs use did not change, despite the fact that challenging behaviours have subsided, indicates a need to review current pharmacological treatment strategies for challenging behaviour in dementia (James et al, 2006b). This is particularly poignant as guidelines recommend that discontinuing pharmacological treatments should occur after symptoms have been absent or are minimal for three months (Howard et al, 2001).

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