Effect of doll therapy in managing challenging behaviours in people with dementia: a systematic review protocol

Abstract

Review question/objective What is the effect of doll therapy on challenging behaviors (including agitation and verbal or physical aggression) in patients with dementia? Background It is estimated by the year 2050 that 115.6 million people1 globally will have dementia, the majority of whom will be from developing countries. Dementia, often referred to as a disease, is a process of transition from a healthy, active state to a dependent state with progressive loss of memory, functional skills and independence.2 Classic symptoms range from loss of ability to express the right words or understand what others are saying, personality changes and mood swings to decline in performing activities of daily living.3 It has been suggested that over 50% of patients with dementia will experience behavioral and psychological symptoms of dementia (BSPD).4 Symptoms can include agitation, wandering, altered sleeping patterns, disinhibited behavior which may include inappropriate sexual behavior and harmful behaviors such as aggression.5,6 It has been postulated that people with dementia exhibiting BPSD have some universal emotional needs that are often not fulfilled. These needs include: (1) being needed and feeling useful, (2) to be able to care for others, (3) having an increased sense of self-worth, (4) to love and be loved, and (5) to be able to convey their emotions without inhibition.7 In clinical practice, BPSD is frequently treated with pharmacological interventions with antipsychotic medications being the treatment of choice.8,9 Concerns with the use of these medications include the risk of mortality,10 their side effects and their effectiveness in relieving BPSD.1,11,12 Extra pyramidal symptoms, falls, gait disturbances, sedation, tardive dyskinesia and cerebrovascular incidents have been widely reported in literature associated with the use of antipsychotics for people with BPSD.13 Evidence-based guidelines have therefore been developed to advise on prescribing requirements for these drugs.14,15 Living with dementia is not only distressing for the patient when they experience BSPD, it also has a negative impact on the quality of life of their carers.16 Non-pharmacological management of BPSD in patients with dementia Given the adverse effects associated with pharmacological management, various non-pharmacological approaches have been implemented to address the emotional needs that cause the inappropriate behaviors.17 These include doll therapy,18 physical activity programs,19 music therapy,3 aromatherapy,20 massage and touch,21 and art therapy.22 Systematic reviews of literature published in the Cochrane Library have demonstrated reductions in BPSD following the use of physical activity, music therapy,3 aromatherapy,20 massage and touch,21 and art therapy.22 However there has been no review undertaken to investigate the effects of doll therapy in managing people with BPSD. Doll therapy Doll therapy has been used for patients with dementia for over 20 years and is based on the principles of attachment theory.23 Although the conceptual work on attachment focussed on children, the impact of attachment experiences is evident from childhood through adult life.24 For people with dementia, attachment behavior can be observed at various stages of dementia, and parent fixation or searching for deceased relatives has been reported when attachment needs were not being met.25 The use of dolls for therapeutic purposes involves giving a doll to a person with dementia to care for and is purported to assist in overcoming some of the attachment needs.26 For example, cuddling and caring behaviors towards the doll are said to be an expression of being needed, feeling useful and being able to care for others.27 In addition, hugging a transitional object such as a doll is represents security during a period of uncertainty. Doll therapy has been reported to reduce agitation, aggression and behaviors of concern in people with BPSD.28,29 In contrast, doll therapy has been reported by staff and family members to be childish, demeaning and patronising.30 Doll therapy as a strategy in managing challenging behaviors in people with dementia has not yet been quantified in a manner to enable clinicians to make an informed decision about its benefits. Therefore the aim of this review is to present the best available evidence relating to the effect of doll therapy in managing challenging behaviors in people with dementia. Definition of terms For the purpose of this review dementia will be defined as a chronic or persistent disorder of mental processes caused by brain disease or injury and characterized by symptoms that include f memory loss, mood changes, and problems with communication and reasoning.