Taking a group of residents with dementia to a real store might prove overstimulating, he said, and people couldn’t simply leave when they’d had enough. But an only-sort-of-real store or nursery “gives them those life experiences which are familiar, which are comfortable, which are empowering and negate the feeling that they don’t have control over their lives.”
It’s a strategy with advocates — and some critics.
A few decades ago, those caring for people with dementia, whether at home or in facilities, took a very different approach.
They tried “reality orientation,” reminding patients that today is Tuesday, not Thursday. That they couldn’t “go home” because their house had been sold. That their spouses weren’t visiting because they had died years ago (causing fresh shock and grief with every repetition).
“It didn’t work,” said Steven Zarit, emeritus professor at Penn State and a longtime researcher on caregiving and dementia. “It didn’t help people’s memories, it didn’t help their adjustment, it wasn’t useful.”
Instead, caregivers have largely adopted a strategy, sometimes called “therapeutic lying,” that gently deflects painful questions. Where is a (deceased) loved one? “I’m sure he’ll be here soon. You know how traffic is. Let’s go for a walk while we wait.”
The introduction of robotic pets that purred and woofed, and baby dolls to care for, extended that approach. Especially when the pandemic restricted other kinds of interactions, some people with dementia seemed to enjoy such inanimate companions.
Creating whole environments, which may evoke the past or may simply allow people to feel they’re participating in the present, appears to be the next step.
In 2018, the nonprofit Glenner Alzheimer’s Family Centers developed the Town Square adult day program, replicating a small-town Main Street of the 1950s within a large warehouse in Chula Vista, Calif.
It features a retro diner for meals, a library displaying Ike’s portrait, a space mimicking a vintage movie theater and atmospheric touches like a 1959 Thunderbird and an old-fashioned phone booth. Franchisees have opened nine similar Town Squares in seven states, with more in development.
Day programs have demonstrated benefits for cognitively impaired participants and their caregivers, but “this environment allows us to go deeper into reminiscence therapy,” said Lisa Tyburski, chief marketing officer for Glenner, referring to the use of prompts and objects to encourage memories and communication.
For participants, “it brings so much peace to be able to have a conversation about something they recall,” Ms. Tyburski said. “We see them laughing and smiling, forming friendships.”
There’s scant evidence that such environments, including dementia villages in Europe that create entire residential neighborhoods (but don’t mimic the past), provide clinical benefits or reliably improve quality of life.
Yet “environment is really important, and it can be enabling or disabling,” said Andrew Clark, co-editor of the book “Dementia and Place” and a professor at the University of Greenwich in England.
“We need to find ways for people to connect, to maintain routines and everyday activities,” he said. Such environments may encourage those with dementia “to engage with people, to get out and about, to not be shut away.”
Some experts express ambivalence and ethical concerns. Dr. Clark supports the shift from reality orientation. “In dementia, there are all sorts of situations where not telling the truth could be better for people’s well-being,” he said.
But the ethics get “murky,” he added, if well-intentioned caregivers treat people with dementia like children. To Dr. Zarit, for instance, distributing baby dolls “feels infantilizing.”
Throwback Main Streets “test the limits of how much is this creativity versus deception,” said Dr. Jason Karlawish, a geriatrician and co-director of the Penn Memory Center. “It starts to become problematic if it ‘others’ people,” he said, creating distance between those with cognitive impairment and everyone else.
“I think we could find more creative ways to engage in meaningful activities,” he added.
Indeed, dementia programs around the country increasingly have offerings like interactive theatrical experiences, opportunities to make art and explore music, efforts to connect through church congregations, intergenerational gatherings with real children, and pet therapy with live animals. Hundreds of Memory Cafes meet regularly.
Nancy Berlinger, an ethicist and researcher at the Hastings Center, points to another concern about dementia-focused environments: “So much of this comes down to what you can afford.”
At franchised Town Squares, participants pay an average of $150 a day. (Medicaid, Veterans Affairs and state and local agencies sometimes subsidize day care costs.) At RiverSpring, which already offers a full schedule of interactive programs, memory care costs $15,000 a month.
(In New York City, for comparison, assisted living averaged $6,500 a month and nursing home care about twice that in 2023, according to Genworth’s annual survey.)
With dementia villages and environments, “the worry is that they become enclaves for the wealthy,” Dr. Clark said.
Or that they become substitutes for adequate staffing. Creating RiverSpring’s nursery and store was inexpensive, Mr. Pomeranz said. But staffing isn’t, and to function as intended, the environments require employees engaging in extended conversations.
Many nursing homes and assisted living facilities, perennially short-staffed, struggle to respond to basic needs like escorting residents to the bathroom, let alone facilitating shopping at a twice-weekly store. Instead of hiring and training enough people, administrators may be tempted to simply pass around dolls and robo-pets.
Nevertheless, the continuing search for ways to make life more stimulating and sustaining for elders with dementia, a growing proportion of the population, wins applause all around.
“The choice to restore their brains to an undamaged state does not exist,” Dr. Berlinger said.
But caregivers can “try to meet people where they are and say: ‘What gives comfort? What reduces stress? What brings pleasure?’” she said. “We should be thinking about this all the time.”