Critical Appraisal of Doll Therapy for Dementia in Long-Term Care

This report provides a critical appraisal of a research article focusing on the use of lifelike baby dolls to reduce anxiety, agitation, and aggression in elderly dementia patients within long-term care facilities. The study, published in Aging & Mental Health, employs a mixed-methods approach, combining randomized controlled trials and staff interviews to assess the effectiveness of doll therapy compared to usual care. The appraisal evaluates the article's title, abstract, research design, sampling methods, data collection techniques, and data analysis. While the study found no significant reduction in anxiety, agitation, or aggression, it did observe increased displays of pleasure and a perception among staff that doll therapy provides emotional comfort and purposeful activity. The report concludes by discussing the implications for clinical nursing practice, emphasizing the importance of evidence-based practice and person-centered care when considering doll therapy for dementia patients, highlighting the need for further research to tailor the intervention to individual needs and preferences.

Introduction
This article is about the use of lifelike baby dolls to reduce anxiety, agitation,
and aggression in people with dementia in long-term care (LTC). The population was
patients aged over 65 years-old with dementia in long-term care. The authors
compared the results to patients receiving usual care. The primary outcome was the
reduction of anxiety, aggression, and agitation at week three, and the secondary
outcome was the reduction of anxiety, aggression, and agitation at week one.
The UK journal, Aging & Mental Health published the study, a prominent
international forum discussing the relationship between mental health and the aging
process (Taylor & Francis, n.d.). The journal has an impact factor of 2.956, boasts
readers from more than 30 countries, and widely used indexing systems have accepted
it for coverage. Impact factors reflect the average amount of times that an article
within the journal is cited, this is used to judge the quality of journals (Bornmann &
Marx, 2016).
The authors consisted of members of the Menzies Health Institute, the School
of Nursing and Midwifery at Griffith University and The Queensland University of
Technology, the School of Psychiatry at The University of New South Wales, and the
School of Applied Psychology at Griffith University. This information is identified in
the article and shows that the authors hold qualifications relevant to the field of
research. There is no concern of a language barrier as the article is published in
English by Australian authors.
Title and Abstract
A good journal article title should be specific, summarising the main idea of
the study in as few words as possible (Villar, 2017). The title should aim to capture
the attention of the reader and highlight the research problem (Babbie, 2018). From

the title, the reader should know; the purpose of the research, the scope, the narrative
tone, and the methods used (Babbie, 2018). Following these parameters, the article
does have a good title and is consistent with the text. The study aims to compare a
lifelike baby doll intervention for reducing anxiety, agitation, and aggression in older
people with dementia in long-term care, with usual facility care; and explore the
perceptions of care staff about doll therapy (Moyle et al., 2019).
An abstract is a brief outline of the research article that should include; the aim
of the study, the research problem investigated, study design, significant findings, and
a brief conclusion (Babbie, 2018). The abstract should tell the whole story of the
study and helps readers decide if they want to read more (Babbie, 2018). The article
successful summarises the critical components within the provided abstract.
The article cites relevant and comprehensive literature, with 13 references
discussing the use of doll therapy for dementia patients. The literature cited is current,
supported by seminal work, allowing the potential for future research. The author's
previous research was also cited to support the literature further and the need for the
study (Moyle et al., 2017).
Research Design
The research design used is a mixed-method study, using randomised control
trials (RCT) and interviews to gather data. The RCTs were used to assess the
effectiveness of the intervention and compare it to the control group. The interviews
were used to assess the staffs’ perception of doll therapy and its use for dementia
patients in long term care. These staff members are looking after the patients all the
time so they can notice more subtle changes that could be missed by the researchers.
This is an example of methodological triangulation and adds credibility and validity to
research results (Noble & Heale, 2019).

The research question is not so prominent but can be extracted using the
hypothesis and article title. The researchers are questioning whether or not lifelike
baby dolls reduce symptoms of anxiety, agitation, or aggression for people with
dementia in long-term care. Pharmacological treatments have long been the preferred
choice for alleviating the symptoms that people with dementia face, recent studies
have now found that a psychosocial approach to treatment can better meet the needs
of dementia patients, and reduce the adverse side effects of conventional medications
(Oyebode & Parveen, 2019). Due to the lack of evidence surrounding doll therapy,
this study was needed to develop a basis for further research and begin to explore the
risks and benefits of this treatment (Moyle et al., 2019).
The Sample
The inclusion criteria for the study required the participants to be; 65 years old
or above, diagnosed with dementia and had a documented history of anxiety,
agitation, or aggression in the past four weeks. If they were already using doll therapy
as part of their usual care, then participants were excluded. The study was conducted
between August 2016 and October 2016, and set over five different long term care
centres within Brisbane. The eligible participants were identified by the LTC facility
managers, who then made initial contact with the residents and their families in
regards to the research. The study was approved by the Griffith University Human
Ethics Committee, as well as being registered with the Australian New Zealand
Clinical Trials Registry. Participants (or next-of-kin, as appropriate) provided written
informed consent, and verbal consent was given before each intervention session.
This all aims to protect patient’s rights and privacy. As the trial is working with

patients with dementia, it is beneficial that they are regaining consent before each
intervention session to ensure the consent is valid.
Data Collection
The study clearly states that the primary outcome for the RCT were; changes
in the participants’ agitation, anxiety, and aggression from baseline to week three,
with the short-term effects at week one being the secondary outcome. These results
were all measured by coded video observations data that implanted the use of the
Observed Emotion Rating Scale and a modified version of the Cohen-Mansfield
Agitation Inventory-Short Form. A trained research assistant coded all of the data
which was then reviewed for accuracy by a member of the research team. The use of
video observations allows the researchers to be able to replay the footage as many
times as necessary, this increases the quality of the data and ensures the validity of the
results (Jones et al., 2015). This leads to greater confidence in the findings, again
using triangulation methods (Noble & Heale, 2019). The interviews were semi-
structured and conducted by the Project Manager after the study. The interviews
consisted of nine questions exploring the staffs’ views on the intervention. They were
conducted via telephone, recorded, and professionally transcribed.
The study did identify potential risks for bias within the study, highlighting the
fact that it was the LTC facility managers that selected eligible participants. This leads
to the possibility of selection bias, where the facility managers may select and recruit
residents whom they feel may benefit most from the interventions. Selection bias can
be avoided by blinding the recruiters, using simple randomisation, or using outside
sources to select eligible participants (Kahan et al., 2015).
Data Analysis

The data results from the RCT are presented in a table that identifies the
results at baseline, week one, and week three of the intervention therapy and usual
care, and compares this with the primary (changes at week three) and secondary
(changes at week one) outcomes. The table is easy to follow, with a general
understanding of statistics required to understand the results. The qualitative findings
were used to support the quantitative results by, again, using triangulation methods to
increase validity and credibility to the results and allow a secondary perspective to the
results (Noble & Heale, 2019).
Results
The results obtained from the collected data did not show a significant
reduction in the outcome measures when compared to usual care at week three or
week one. Although, there was a significant increase in displays of pleasure within the
intervention group at week three. The staff interviews showed the perception that the
doll therapy provided emotional comfort, purposeful activity, and producing a
calming effect. The researchers highlighted that the results might have been limited
by the fact that the residents may care for the dolls at the expense of their health, and
it may only be suitable for some individuals. The different components of the study
do effectively answer the research the questions, as it was found that they do not
reduce anxiety, agitation, and aggression in dementia patients. However, it did lead to
the discovery that it produces a calming effect, emotional comfort, and provides a
purposeful activity for residents. The authors did make suggestions for further
research, identifying the need to alter the study design to allow a more person-centred
approach that is individualised and needs-driven. It also highlighted the benefiting of
using outcome measures that are more sensitive to change, such as engagement and

meaningful activity. This study only focused on female participants; the authors
suggested further studies recruiting men to explore their interest in doll therapy.
The authors also made suggestions for implications in clinical practice. From
their findings, they recommended the use of doll-therapy on an as-needed basis, and
use in a person-centred way. It is also suggested that staff monitor the residents’ level
of interaction in order to avoid them prioritising the dolls care at the expense of their
own health needs.
Conclusion
In conclusion, this pilot study shows that doll therapy can provide some
dementia patients with purposeful engagement and enjoyment. The need for further
research is evident, with a focus on developing an understanding of the individual
circumstances and characteristics in which the participants would benefit most.
Relevance to clinical nursing practice
The fact that the best available evidence should inform clinical care provided
to people is widely acknowledged (Curtis et al., 2017). Clinical practice should be
driven by the knowledge and evidence that is derived from scholarly research to
improve how care is delivered (Curtis et al., 2017). This pilot study has allowed a
starting point for further research, as well as providing evidence that can improve
practice. The ability to translate research evidence to clinical practice is essential in
order for effective and efficient healthcare provisions to meet the expectations of
society (Curtis et al., 2017). Evidence-based practice (EBP) underpins the basis in
which we practice as nurses (Curtis et al., 2017). EBP should be considered in a triad
approach; patient values, clinical expertise, and available evidence (Greenhalgh et al.,
2019). When it comes to finding the best possible research evidence to implement in
practice, the higher the level of research, the better the evidence is (Greenhalgh et al.,

2019). RCTs are considered to be a middle ground in regards to levels of evidence,
with systematic reviews ranking at the top level (Greenhalgh et al., 2019). When done
correctly, RCTs are considered the gold standard for studying the effectiveness for
new interventions or treatments (Hariton & Locascio, 2018). Clinical expertise is also
essential to consider when evaluating research to implement into practice. The authors
should be considered to asses if they are experts in their field and are knowledgeable
in regards to the topic discussed (Greenhalgh et al., 2019). The article's authors have
previously published work in the same field and have shown great interest and
dedication to the topic of psychosocial interventions for dementia patients.
Considering the patient's values should be at the forefront of decision making when
implementing EBP. The article highlights the importance of person-centred care and
outlines how the intervention can align with patients values and elicit a positive
response. Therefore, this article is relevant to the clinical nursing setting as it adds to
clinical knowledge and assists nurses in providing evidence-based care when dealing
with dementia patients in LTC facilities. The research method is of a high level of
evidence, the authors are experts in their field, and the study is centred around
patient's values.

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