Can lifelike baby dolls reduce symptoms of anxiety, agitation, or aggression for people with dementia in long-term care? Findings from a pilot randomised controlled trial

Therapeutic Doll Interventions for People Living with Dementia in Care Homes: A Scoping Review

Doll therapy is a psychosocial intervention that has been commonly used within dementia care for many decades. The practice of doll therapy involves supporting people with dementia to engage with a therapeutic doll and this has been associated with positive changes in a person's wellbeing and behavior. While there have been several systematic reviews that have focused on behavioral outcomes, limited reviews have explored the broader psychosocial outcomes associated with doll therapy in care home settings. A scoping review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR). Four electronic databases were searched systematically (CINAHL Plus, Medline, PsycINFO, and PubMed). Twelve primary research studies from the past ten years (2013-2023) were included in this review. Primary data were synthesized using a narrative synthesis methodology. The three main themes from this review relate to a reduction in levels of behavioral and psychological symptoms of dementia (BPSD), increased communication skills, and a reduction in caregiver distress. Doll therapy has the potential to be an effective person-centered intervention that can enhance quality of life for people living with dementia in care home settings.

Therapeutic use of the humanoid robot, Telenoid, with older adults: A critical interpretive synthesis review

This review sought to critically evaluate the use of the teleoperated humanoid robotic communications device, Telenoid, for therapeutic purposes with older adults, and identify and highlight key considerations for future research and clinical practice within gerontechnology. A critical interpretive synthesis was conducted, with nine electronic databases and online sources searched using the keyword "Telenoid." Studies were included in the review if they were: written in English; reported primary research; employed a qualitative, quantitative, or mixed-method design; and described or measured effects, experiences, or perceptions of using Telenoid for therapeutic purposes with older adults. Critical engagement with the studies identified key themes, as well as opportunities to advance future research. Ten studies involving Telenoid were identified, with eight focused on older adults living with dementia. Study findings centered around two themes: effects (including positive effects and negative reactions), and challenges and considerations (including technical issues, operator training, acceptability, and dosage). Although several issues currently challenge the use of Telenoid, available studies show some therapeutic potential of using Telenoid with older adults, including those living with dementia, particularly for communication and mood. Higher-quality studies are required to advance understanding, and considerations for the field are outlined to aid development.

Clinical effectiveness of pharmacological and non-pharmacological treatments for the management of anxiety in community dwelling people living with dementia: A systematic review and meta-analysis

People living with dementia commonly experience anxiety, which is often challenging to manage. We investigated the effectiveness of treatments for the management of anxiety in this population. We conducted a systematic review and meta-analysis of randomised controlled trials, and searched EMBASE, CINAHL, MEDLINE and PsycInfo. We estimated standardised mean differences at follow-up between treatments relative to control groups and pooled these across studies using random-effects models where feasible. Thirty-one studies were identified. Meta-analysis demonstrated non-pharmacological interventions were effective in reducing anxiety in people living with dementia, compared to care as usual or active controls. Specifically, music therapy (SMD-1.92(CI:-2.58,-1.25)), muscular approaches (SMD-0.65(CI:-1.02,-0.28)) and stimulating cognitive and physical activities (SMD-0.31(CI:-0.53,-0.09)). Pharmacological interventions with evidence of potential effectiveness included Ginkgo biloba, probiotics, olanzapine, loxapine and citalopram compared to placebo, olanzapine compared to bromazepam and buspirone and risperidone compared to haloperidol. Meta-analyses were not performed for pharmacological interventions due to studies' heterogeneity. This has practice implications when promoting the use of more non-pharmacological interventions to help reduce anxiety among people living with dementia.

Doll therapy for improving behavior, psychology and cognition among older nursing home residents with dementia: A systematic review and meta-analysis

OBJECTIVE

To explore the effectiveness of doll therapy (DT) on behavior, psychology and cognition among older nursing home residents with dementia.

METHODS

A systematic review and meta-analysis was conducted. Subgroup analyses were performed to determine whether the intervention characteristics influenced effect sizes.

RESULTS

Ten studies met the inclusion criteria and were selected for qualitative and quantitative synthesis. The overall methodological quality was relatively high. DT significantly improved all behaviors [SMD=-0.42, P=0.01], including agitation [SMD=-0.94, P<0.001], apathy, irritability and wandering, and psychological states (i.e., pleasure, anxiety and depression). However, there was no significant difference in the improvement of cognition. Subgroup analyses revealed that the DT process employing empathy dolls and coordinating with caregivers was more beneficial for improving all behaviors (P=0.01; P=0.02).

CONCLUSION

DT significantly reduced behavioral and psychological disturbances among older nursing home residents with dementia. Specifically, administering empathy dolls and coordinating with caregivers may be the most appropriate and effective option.

[Quality of life in institutionalized older adults with moderate to severe major neurocognitive disorder: Effect of Doll therapy]

BACKGROUND AND OBJECTIVES

Major neurocognitive disorder is characterized by progressive cognitive impairment, a decrease in the person's ability to perform activities of daily living and the appearance of psychological and behavioral symptoms that lead to a deterioration in the quality of life and progression towards institutionalization. The most common management of major neurocognitive disorder is pharmacological therapy that mitigates or slow progressive deterioration and symptom control. The objective of this study was to establish the effect of a nursing intervention based on Doll therapy, compared to conventional care on the quality of life of older adults with moderate to severe major neurocognitive disorder institutionalized in nursing homes in the city of Medellín, Colombia.

METHODS

Pilot experimental study with two groups and pretest post-test measurement. The sample consisted of 26 institutionalized elderly adults with advanced-stage major neurocognitive disorder, randomly assigned to each group. The experimental group received Doll therapy, based nursing therapy, while the comparison group continued to receive conventional therapy according to the institution's protocol. The QUALID instrument was used, which was evaluated by professionals external to the care centers.

RESULTS

The comparison of the groups, before and after the intervention, indicates that the experimental group showed a positive effect on quality of life, supported by the statistical significance of the data, with a moderate effect.

CONCLUSIONS

The Doll therapy as a non-pharmacological therapy has a positive effect on the quality of life of patients with moderate to severe major neurocognitive disorder, which constitutes a contribution to strengthen the knowledge associated with the effects or this intervention.

Network meta-analysis of comparative efficacy of animal-assisted therapy vs. pet-robot therapy in the management of dementia

Objective

This network meta-analysis aimed to compare and rank the efficacy of animal-assisted therapy (AAT) and pet-robotic therapy (PRT) in the management of dementia.

Methods

Relevant studies were identified by searching PubMed, EMBASE, the Cochrane Library, SCOPUS, and Web of Science (WoS) until October 13, 2022. Traditional meta-analysis was first conducted based on the random-effects model, then random network meta-analysis was conducted to determine the relative efficacy and rank probability of AAT and PRT.

Results

Nineteen randomized controlled trials (RCTs) were included in this network meta-analysis. Network meta-analysis revealed that PRT marginally benefited agitation alleviation compared with control (standard mean difference [SMD]: -0.37, 95% confidence interval [95%CI]: -0.72 to -0.01) although both AAT and PRT did not improve cognitive function, reduce depression, and improve Quality of Life (QoL). The SUCRA probabilities indicated that PRT ranked better than AAT in agitation, cognitive function, and QoL, although there were no differences between the two therapies.

Conclusion

The present network meta-analysis reveals that PRT may help alleviate agitated behaviors in people with dementia. However, future studies are warranted to establish evidence of the effectiveness of PRT and further evaluate the differences between different robot types in managing dementia.

[Les effets de l'environnement de soins sur les comportements réactifs des personnes ayant des troubles neurocognitifs vivant en centre d'hébergement : Une revue de la portée]

Les personnes âgées atteintes de troubles neurocognitifs (démences) vivant en centre d'hébergement adoptent fréquemment des comportements réactifs qui limitent leur engagement dans des occupations. La présente étude vise à identifier des moyens d'intervention centrés sur l'engagement des personnes âgées ayant un trouble neurocognitif avec l'environnement humain et non humain en centre d'hébergement afin de diminuer leurs comportements réactifs, en particulier les comportements d'errance, d'apathie et d'agitation. Cette revue de la portée est basée sur la méthode proposée par Levac et ses collaborateurs (2010). Parmi les 21 études retenues, la plupart s'intéressent à des interventions ciblant l'environnement non humain (n=9) ou ciblant simultanément l'environnement humain et non humain (n=9). Plusieurs de ces interventions sont efficaces pour diminuer les comportements réactifs et permettent aux personnes âgées de s'engager avec leur environnement. Le support de l'environnement humain semble toutefois nécessaire à l'utilisation optimale de plusieurs interventions.

Doll Therapy Intervention Reduces Challenging Behaviours of Women with Dementia Living in Nursing Homes: Results from a Randomized Single-Blind Controlled Trial

Background: Doll therapy (DT) is a non-pharmacological intervention for the treatment of the behavioural and psychological symptoms of dementia (BPSD). We designed a single-blind randomized controlled trial of the 30-day efficacy of DT in reducing the BPSD, professional caregivers’ distress and patients’ biomarkers of stress, and in improving the exploration and caregiving behaviours. Methods: We randomly assigned 134 women with moderate-to-severe dementia living in nursing homes (NHs) to a DT intervention (DTI, 67) or a sham intervention with a cube (SI, 67). Results: From the first to the 30th session, the DTI group showed a significant decrease in the Neuropsychiatric Inventory-NH (NPI-NH) total score and in the NPI-NH-Distress score compared to the SI group (both p < 0.001). We observed a greater interest in the doll than in the cube, a greater acceptance of a separation from the nurse among DTI participants, and caregiving and exploratory behaviours towards the doll. There were no differences between the groups in the stress biomarkers. Conclusions: Consistent with attachment theory, our findings support the 30-day efficacy of DT, as this non-pharmacological intervention promotes perceptions of security by creating a situation in which patients feel confident and engaged in a caregiving relationship with the doll and reduces the challenging behaviours that are stressful for professional caregivers.

Effect of Doll Therapy in Behavioral and Psychological Symptoms of Dementia: A Systematic Review

(1) Background: Behavioral and psychological symptoms of dementia (BPSD) are a threat for people with dementia and their caregivers. Doll therapy is a non-pharmacological person-centered therapy to promote attachment, company, and usefulness with the aim of minimizing challenging behaviors. However, the results are not clear. (2) Objective: To know the effectiveness of doll therapy in reducing behavioral and psychological symptoms of people with dementia at a moderate-severe phase. (3) Methodology: The systematic review was informed according to the criteria established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Searches were conducted in eight databases: Cochrane, PubMed, Web of Science, Cinahl, Embase, Lilacs, PeDro, and Scopus before October 2021. Studies were selected when they accomplished the simple majority of Consolidated Standards of Reporting Trials (CONSORT). The risk of bias was appraised with the Cochrane Collaboration Risk of Bias Tool. The review protocol was recorded in Inplasy:1539. (4) Results: The initial search strategy showed 226 relevant studies, 7 of which met the eligibility criteria. In the included studies, a total number of 295 participants (79% female) with a mean age of 85 years were enrolled. There was found to be a reduction in challenging and aggressive behaviors, the participants were less rough and irritable, and their communication skills and emotional state were also improved. (5) Conclusion: Our findings suggest that doll therapy improves the emotional state of people with dementia, diminishes disruptive behaviors, and promotes communication. However, randomized studies with a larger sample size and higher methodological rigor are needed, as well as follow-up protocols in order to reaffirm these results.

The doll therapy as a first line treatment for behavioral and psychologic symptoms of dementia in nursing homes residents: a randomized, controlled study

Background

Patients living with dementia are severely affected by the development of behavioral and psychologic symptoms (BPSD) which represent a burden for patients and caregivers. The use of psychotropic drugs in the control of BPSD is widely diffused, however the use of a first line non-pharmacologic approach is highly recommended.

Here we evaluate the effect of doll therapy (DT) in the management of BPSD, on the reduction of caregiver burden and delirium incidence in nursing home residents by a randomized controlled trial.

Methods

We enrolled fifty-two nursing homes residents living with dementia and BPSD. Subjects were randomized to DT (26) or standard treatment (ST, 26), we measured BPSD, caregiver burden and delirium with standard clinical scales at baseline, after 45 and 90 days.

In order to evaluate the presence of BPSD we used Neuropsychiatric Inventory (NPI) scale and the A.Di.CO scale, the caregiver burden was measured by the Greutzner scale and delirium by the Confusion Assessment Method (CAM) scale.

Results

DT was more effective in reducing agitation and aggressiveness as respect to ST. Moreover DT globally reduced the presence of BPSD as dysphoria, wandering and apathy. We observed a significant reduction of the professional caregiver burden and the incidence of delirium was significantly reduced in subjects treated with DT.

Conclusions

We show that DT is more effective that ST in the control of BSPD in patients affected by moderate to severe dementia. Moreover we suggest that DT may effective in reducing the incidence of delirium.

Trial registration

Retrospectively registered in ClinicalTrials.gov the 10th June 2, 2021 trial registration number NCT04920591.

Effectiveness of robot therapy in the management of behavioural and psychological symptoms for individuals with dementia: A systematic review and meta-analysis

Robot therapy presents a promising alternative in dementia care. However, its effectiveness has not been verified comprehensively. This systematic review and meta-analysis aim at evaluating the effectiveness of robot therapy in the management of behavioural and psychological symptoms for individuals with dementia. Studies assessing the effectiveness of robot therapy were identified using 10 academic research databases: CENTRAL, CINAHL, CNKI, The Cochrane Library, Embase, IEEE Xplore, MEDLINE, PubMed, Scopus, and ProQuest Dissertations & Theses. Additional references were identified from the reference lists of included studies and relevant reviews. Data extraction and risk of bias assessment were conducted independently by two review authors. Meta-analyses and subgroup analyses were performed and the heterogeneity of studies was examined. 18 published articles from 14 studies involving a total of 1256 participants were included. Participants with robot therapy had a significant decrease in agitation (SMD -0.38, 95% CI -0.66, -0.09; p = 0.01) and a significant increase in social interaction (SMD 0.49, 95% CI 0.01, 0.97; p = 0.04) while effects for depression, anxiety, cognitive status, and quality of life were not statistically significant. Results from this review show that robot therapy can effectively reduce agitation and increase social interactions for individuals with dementia. Future clinical practice should consider the potential of robot therapy as an option to be implemented into current dementia programmes. Further large-scale trials are required for the thorough investigation of different intervention formats and robot types, while considering potential confounding factors.

Rationale, Design, and Methodology of a Prospective Cohort Study for Coping with Behavioral and Psychological Symptoms of Dementia: The RECage Project

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are quite challenging problems during the dementia course. Special Care Units for people with dementia (PwD) and BPSD (SCU-B) are residential medical structures, where BPSD patients are temporarily admitted, in case of unmanageable behavioral disturbances at home.

OBJECTIVE

RECage (REspectful Caring for AGitated Elderly) aspires to assess the short and long-term effectiveness of SCU-Bs toward alleviating BPSD and improving the quality of life (QoL) of PwD and their caregivers.

METHODS

RECage is a three-year, prospective study enrolling 500 PwD. Particularly, 250 community-dwelling PwDs presenting with severe BPSD will be recruited by five clinical centers across Europe, endowed with a SCU-B, for a short period of time; a second similar group of 250 PwD will be followed by six other no-SCU-B centers solely via outpatient visits. RECage's endpoints include short and long-term SCU-B clinical efficacy, QoL of patients and caregivers, cost-effectiveness of the SCU-B, psychotropic drug consumption, caregivers' attitude toward dementia, and time to nursing home placement.

RESULTS

PwD admitted in SCU-Bs are expected to have diminished rates of BPSD and better QoL and their caregivers are also expected to have better QoL and improved attitude towards dementia, compared to those followed in no-SCU-Bs. Also, the cost of care and the psychotropic drug consumption are expected to be lower. Finally, PwD followed in no-SCU-Bs are expected to have earlier admission to nursing homes.

CONCLUSION

The cohort study results will refine the SCU-B model, issuing recommendations for implementation of SCU-Bs in the countries where they are scarce or non-existent.

Agitation and Dementia: Prevention and Treatment Strategies in Acute and Chronic Conditions

Agitation is a behavioral syndrome characterized by increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress. According to several observations, agitation prevalence ranges from 30 to 50% in Alzheimer's disease, 30% in dementia with Lewy bodies, 40% in frontotemporal dementia, and 40% in vascular dementia (VaD). With an overall prevalence of about 30%, agitation is the third most common neuropsychiatric symptoms (NPS) in dementia, after apathy and depression, and it is even more frequent (80%) in residents of nursing homes. The pathophysiological mechanism underlying agitation is represented by a frontal lobe dysfunction, mostly involving the anterior cingulate cortex (ACC) and the orbitofrontal cortex (OFC), respectively, meaningful in selecting the salient stimuli and subsequent decision-making and behavioral reactions. Furthermore, increased sensitivity to noradrenergic signaling has been observed, possibly due to a frontal lobe up-regulation of adrenergic receptors, as a reaction to the depletion of noradrenergic neurons within the locus coeruleus (LC). Indeed, LC neurons mainly project toward the OFC and ACC. These observations may explain the abnormal reactivity to weak stimuli and the global arousal found in many patients who have dementia. Furthermore, agitation can be precipitated by several factors, e.g., the sunset or low lighted environments as in the sundown syndrome, hospitalization, the admission to nursing residencies, or changes in pharmacological regimens. In recent days, the global pandemic has increased agitation incidence among dementia patients and generated higher distress levels in patients and caregivers. Hence, given the increasing presence of this condition and its related burden on society and the health system, the present point of view aims at providing an extensive guide to facilitate the identification, prevention, and management of acute and chronic agitation in dementia patients.

The Perceptions of People with Dementia and Key Stakeholders Regarding the Use and Impact of the Social Robot MARIO

People with dementia often experience loneliness and social isolation. This can result in increased cognitive decline which, in turn, has a negative impact on quality of life. This paper explores the use of the social robot, MARIO, with older people living with dementia as a way of addressing these issues. A descriptive qualitative study was conducted to explore the perceptions and experiences of the use and impact of MARIO. The research took place in the UK, Italy and Ireland. Semi-structured interviews were held in each location with people with dementia (n = 38), relatives/carers (n = 28), formal carers (n = 28) and managers (n = 13). The data was analyzed using qualitative content analysis. The findings revealed that despite challenges in relation to voice recognition and the practicalities of conducting research involving robots in real-life settings, most participants were positive about MARIO. Through the robot's user-led design and personalized applications, MARIO provided a point of interest, social activities, and cognitive engagement increased. However, some formal carers and managers voiced concern that robots might replace care staff.

Systematic Review of Randomized Controlled Trials in Australian Nursing Homes from 2000 to 2018

BACKGROUND/OBJECTIVES

High-quality research provides an evidence base for optimal practice care in clinical settings, yet, little is known about the nature and extent of randomized control trials (RCTs) conducted in Australian nursing homes (NHs). Research from other settings and other countries is not necessarily transferable to the Australian NH sector. We sought to identify and describe RCTs conducted in Australia which investigated interventions targeted at improving care for NH residents.

DESIGN

The design of this study comprised a systematic literature search with a narrative review. Studies were included if they were RCTs published after 2000, conducted in an Australian NH, and evaluated a health intervention which may have directly or indirectly benefitted the NH resident.

SETTING

Australian NHs.

PARTICIPANTS

Nursing home residents.

MEASUREMENTS

Jurisdiction (state or territory where the study was conducted), number of NHs recruited in each trial, number of residents included in each trial, intervention characteristics, comparator characteristics, and characteristics of outcome.

RESULTS

Only 43 articles reporting on 39 RCTs were identified. In contrast, 30 Australian musculoskeletal RCTs were published in just 2 years (2011-2012). Most of the RCTs identified were conducted in New South Wales (n = 14), Queensland (n = 10), and Victoria (n = 9). The mean number of NHs included in each trial was 22.4 (standard deviation (SD) = 27.0), with a median of 14.5 (interquartile range (IQR) = 27.8), while the mean number of residents included was 412.4 (SD = 921) with a median of 187 (IQR = 341.0). The most common interventions targeted: managing dementia (n = 20), prevention of falls (n = 7), and addressing mental health issues (n = 6).

CONCLUSION

This review provides evidence of the paucity of high-quality research in the form of RCTs, in the Australian NH setting and demonstrates the need for Australia to improve its research capability in the NH sector.

Effects of a Humanoid Companion Robot on Dementia Symptoms and Caregiver Distress for Residents in Long-Term Care

OBJECTIVES

To test the effects of deploying a humanoid companion robot (Kabochan) in comparison with usual care for long-term care facilities' residents with dementia.

DESIGN

A 2-arm, randomized controlled trial with ABAB withdrawal design, lasting 32 weeks. After an 8-week baseline period, Kabochan was introduced in a nonfacilitated, individual approach with experimental-group participants (n = 52) for 8 weeks, then removed for 8 weeks, and then reintroduced for another 8 weeks. The control group (n = 51) received the usual standardized care.

SETTING AND PARTICIPANTS

Seven long-term care facilities in Hong Kong. 103 residents (76% women, 87.2 ± 7.4 years) with a clinical diagnosis of dementia.

MEASURES

Outcome assessments occurred at 5 time points: baseline (week 1) and the end of each phase (weeks 8, 16, 24, and 32). Primary outcomes were assessed with the Neuropsychiatric Inventory Questionnaire (symptom severity and caregiver distress subscales) and the Geriatric Depression Scale; secondary outcomes were measured by the Hong Kong Montreal Cognitive Assessment 5-minute Protocol, the Modified Barthel Index for Activities of Daily Living, and the Quality of Life-Alzheimer's disease scale.

RESULTS

A multivariate analysis of variance indicated a statistically significant group × time interaction for neuropsychiatric-related caregiver distress at week 16 (F = 6.72, P = .011), with a moderate effect size (η_p² = 0.06). When Kabochan was removed in the withdrawal phase (weeks 17-24), the neuropsychiatric symptoms became more severe at week 24 for the intervention group (F = 4.68, P = .003), although the effect size was small to moderate (η_p² = 0.04). No statistical between-group differences were found in other health outcomes.

CONCLUSIONS AND IMPLICATIONS

The Kabochan was potentially effective at reducing short-term neuropsychiatric symptoms and relevant caregiver distress for residents with dementia. An individualized care plan with continuous monitoring is required to integrate the humanoid robot into routine dementia care.

Effects of non-facilitated meaningful activities for people with dementia in long-term care facilities: A systematic review

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Most activity interventions for people with dementia in long-term care are facilitated.

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Non-facilitated meaningful activities included music/stimulated family presence, animal-like social robot, lifelike dolls.

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Some beneficial effects for agitation, emotional wellbeing, feelings of pleasure, engagement and sleep quality.

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Future research into the potential benefits of non-facilitated meaningful activities is needed in rigorously designed RCTs.

This systematic review sought to evaluate the effectiveness of non-facilitated meaningful activities for older people with dementia in long-term care facilities. Searches were conducted in PubMed; CINAHL; EMBASE; Web of science; PsycINFO; Cochrane; ProQuest; and ClinicalTrials.gov to identify articles published between January 2004 and October 2019. A total of six studies were included. Results implied that current randomised controlled trials or controlled trials about non-facilitated meaningful activities for people with living dementia in long-term care facilitates are limited, but those included in this review were of adequate methodological quality. Meaningful non-facilitated activities, such as music, stimulated family presence, animal-like social robot PARO/plush toy and lifelike dolls, may have beneficial effects on agitation, emotional well-being, feelings of pleasure, engagement, and sleep quality. However, there remains a lack of conclusive and robust evidence to support these psychological and physiological effects of non-facilitated meaningful activities for older people with dementia living in long-term care facilities by care staff.