Current Controversies in Dementia Care

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Juliet Holt Klinger

Juliet Holt Klinger
Senior Director of Dementia Care
Brookdale Senior Living

If you are trying to keep up with what’s new in dementia care these days you’re probably as busy as I am. There is a lot going on. It seems every day I am presented with a new idea, technology, or concept that challenges all that I have known to be true for the 35 years I’ve been serving elders with dementia and their families.

Recently I presented a deep-dive session at the Environments for Aging (EFA) Conference entitled; “Current Controversies in Dementia Care Design” where we spent over two hours reviewing what my co-presenter, Laura Busalacchi, head of Brookdale’s interior services and I believe to be some of the most controversial elements of creating environments that support people living with dementia. Specifically we engaged the audience (standing room only by the way—lots of interest in this topic!) in discussions of the following elements; hidden / camouflaged exits and murals to reduce elopement risk, use of fake items or motifs, hospitality aesthetic vs. functional dementia-friendly design and the biggest controversy of them all, segregated vs. inclusive designs for dementia. We examined each element and discussed as a group whether we believed the item / design element supported well-being and person centered values or whether it contributed to one of Tom Kitwood’s identified malignancies; such as treachery, outpacing, banishment, infantilization, labeling, invalidation, etc. (Kitwood, Dementia Reconsidered, 1997). Some of these items prompted rigorous debate and some we all agreed were a little more muddy in terms of a clear right or wrong answer.

Reconsidered: The Person Comes First.
Open University Press, Buckingham

Should we or shouldn’t we? It’s the question that has been at the root of the advancement of dementia care for as long as I can remember. I have seen much progress in best practices over the years and frankly most were no-brainers. Un-tie people? Yes! Reduce the overuse of antipsychotics and benzodiazepines? Yes! Create spaces where people living with dementia can interact in a natural environment with each other and friends and family, kitchens, tools, yards, pets, plants, music, and alcohol? Yes! We have debated them all and peeled back the regulations, while standing up to the concerns of well-meaning folks who only see the down side of risk. It has been the calling for many of us veterans in the field.

But it strikes me today after I read yet another LinkedIn post debating the use of robotic pets, that it is possible that we have reached the minutia stage with this debate—we are literally debating whether a solidly evidence-based object of affection is a good or bad thing for people with dementia. Seriously. Yes, it is not a real cat, true, but honestly I just don’t see the harm (or a malignancy) here. We have many of these robotic pets in service in our communities and I would say that most of our residents do not in fact, believe the pet is real—nor do we ever tell them that it is. We are also not substituting a fake experience for a real one. The robots do not, and will never, replace real pets…we still have those in abundance, including two or three communities with chicken coops. But I will say the fake cat will always sit on a resident’s lap much longer than the real ones do, it also tolerates being combed, kissed, and squeezed a little too tight.

The issue I have with fake components in dementia care environments is when the malignancy is at the genesis of the idea. E.g. “We will put a fake bookcase mural on this exit door and then the residents will be tricked into not knowing the way out.” That is pure treachery and in my opinion causes a very harmful lack of trust in the environment that can corrode the very relationship that is central to our care partnership.

But that is just my opinion, one opinion in what is now happily a sea of opinions. This field has grown so much and expanded so wide it now includes many different models, different sets of values, and vastly different answers to the question…should we or shouldn’t we? And that can only be a good thing.




10 comments on “Current Controversies in Dementia Care

  1. Laura on

    I think we all agree we want to go on the Journey with them Does that mean dolls and fake animals. Hell ya…bring them to me when I am 85 and need comfort. Does it mean camouflaging doors. If it simplifies my living g with dementia then bring it on. We dont use these things to harm anyone. We use them to make life more comfortable. Always keeping 8n mind they are just one of the many”tools” in the toolbox of care. Of couse we want each resident to have meaning and purpose in their lives, that is everyone’s goal. If a cuddle of a pretend cat helps me settle down in the meantime..give me the cat please!

  2. Kim Warchol on

    I echo this sentiment and want to compliment the quality of the blog post-well done Juliet. I intend to post a photo on my linkedin page that exemplifies the value of baby dolls (and robotic pets) to quality of life. In my career I have also observed many individuals who are living with dementia gain comfort and purpose from baby dolls and robotic or stuff animal pets. I think we can agree that is our job to learn and assimilate evidence into practice, while also always observing the outcomes of our interventions. Our collective goal is to give a person a reason to get up in the morning, providing quality to their life in every way possible. We can debate all we want, and I personally believe debate is helpful, but at the end of the day we must be guided by the pro or con impact of the intervention. We must recognize that at times we can make decisions with a broad brush stroke and at other times the decision will require complete awareness of the individual’s history, preferences, habits, and routines. Dementia care is challenging but with passionate leaders such as Juliet, care quality will continue to improve because the “person in care” and what they require for well-being, will and always should come first.

  3. AJC on

    Juliet, love this! Thank you for sharing so clearly what is often muddied. Appreciate you and your efforts in this field!

  4. Kathryn Anderson on

    Thank you for sharing these thoughts, Juliet. I’d like to add that using fake animals and babies might be malignant if they are offered to a person with dementia without an individualized assessment of the person’s goals, wants, and needs. When we just “try something” to respond to expressions of distress, we can get lucky if it “works”, but this doesn’t respect an individual’s dignity or our obligation to know and respond to each person.
    Does it matter if the person believes the baby is real or knows it is not? One of our residents is thriving providing care to 3 “babies”, and at times declares they are real, and other times says “it’s not a real baby, you know”. Does it matter? If the goal is resident happiness, the answer is obvious.

    • Juliet Holt Klinger on

      Kathryn, yes I agree. Almost any aspect of dementia care can contribute to a malignancy if not approached with the person’s own needs, wants, and goals in mind and if not provided within the context of an authentic partnership. I think you are also absolutely correct that the approaches and the experiences we offer our residents, especially any that are offered in response to distress, should be not one-size -fits all. The real work of dementia care is knowing them so well that we know in advance what to provide that works for them. Thanks for your comments.

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