Tiffany Robinson (00:03.726)
Today, we're joined by someone who has shaped the field of dementia care for more than 35 years. David Troxell is internationally known for working with Virginia Bell to develop the Best Friends approach, a model built on empathy, deep connection, and truly knowing the person you're supporting. His work encourages caregivers to move away from the task-oriented routines and towards meaningful relationship-centered care. We'll talk about why social history matters.

how to spark engagement at home and what caregivers can do to create therapeutic, joyful moments every day. David, welcome to the podcast.

David Troxel (00:42.824)
Thank you Tiffany, it's great to be with you.

Tiffany Robinson (00:45.558)
Now, before we dive in, can you share a little about your journey and what led you to focus your life's work on dementia care?

David Troxel (00:54.004)
Well, it has been a life's work, Tiffany. Thanks for that question. I actually began my career, it seems so long ago and yet not that long ago, in 1986 when I was recruited to join the University of Kentucky Alzheimer's Disease Research Center at the College of Medicine. And back then, that was only one of 10 federally funded Alzheimer's Disease Research Centers in the whole country. So it was a fantastic time to get in the field.

just almost, was sort of a wild, wild west of exploration, trying to understand more about the disease. That's where I met my best friend, Virginia Bell, who became my writing partner for over 40 years. But I have to say, Tiffany, it was kind of an accident. I did a degree in public health at Rutgers Medical School through friends of friends. I got offered this job, not even knowing what Alzheimer's disease was, but you kind of learn as you experience things. And I spent

thousands of hours with people with dementia, with their care partners, teaching, learning. We started one of the first adult day programs in the country in Lexington, still going strong. So I often say to younger people, you you can't always plan your career. It was very serendipitous, but on day one, I knew I'd found my calling.

Tiffany Robinson (02:10.164)
see that you've said many times, if you've met one person with dementia, you've met one person with dementia. So let's start right there. Can you share a little bit about what that means?

David Troxel (02:20.5)
Tiffany, I'm smiling right now because that was in our very first book that came out in 1995. Virginia and I, we were always struck how it seems like Alzheimer's doesn't strike every brain the same way. This was an insight we had more through behavioral observation back then. We didn't have all the PET scans and biomarkers and things we have nowadays.

There's lots of reasons why this is an important concept. I'm going to keep it very practical and say one reason I think it's so important to recognize that if you've met one person with dementia, you've met one person with dementia, is I've always been a fan of strength-based care planning. You look at each person with cognitive loss as an individual. What can they still do? What are their unique personality traits? What are their strengths? And so I want to make sure that if someone's been an artist, we're encouraging them to do art.

If someone's always been a very productive nurse, that we give them a clipboard and encourage them to be helpful. But basically, we know that Alzheimer's disease now with much more sophistication than back in the 80s when I began, we know that there are different impacts of areas of the brain that impact behavior, our frontal temporal lobes involved. We know there's biological, in effect, environmental, and even personality issues that sort of shape someone's experience with the journey of dementia.

Bottom line, I've never been a fan, Tiffany, where you say everybody with dementia has this, everybody with dementia does this. My own mother had Alzheimer's disease. Very pleasantly confused. A really beautiful journey where she still remembered me and my father until almost the very end. My late mother-in-law had Alzheimer's, had a very contentious, difficult journey with lots of delusions and paranoia and anger.

So you just have to recognize that it's important to learn all you can and take every day one day at a time and build on strengths.

Tiffany Robinson (04:20.002)
You're so right, everyone has their own journey and it's going to affect them in different ways. And so it's important to look at each person as their own person. You also teach that friendship skills are caregiving skills. What does that look like in practice?

David Troxel (04:37.428)
Well, again, from my early days, Tiffany, when Virginia Bell, who passed away a couple years ago at almost 102, worked until just a few weeks before she died, we wrote seven books together. Her last book came out on her 100th birthday, so quite a life. Virginia started one of the first adult day programs in the country and we called our volunteers back then best friends. We don't even remember really quite where that came from.

Tiffany Robinson (04:52.431)
my goodness.

David Troxel (05:01.896)
But we noticed that when the person with cognitive loss came to the day program, not always knowing quite where they were, what was going on, that when the volunteer who we assigned one-on-one to sit with their best friend throughout the morning or afternoon, that when they talked about, you know, so good to be with you, and when they knew their social histories, and when they introduced themselves as a good friend, that the person with dementia kind of breathed that in almost like oxygen. And so from those early days where we realized

Back then, Tiffany, and I'm sure you've seen this in your work, families were bringing people into the day program saying, nothing's working, my mother fights me all day long, I'm in a terrible, terrible situation. Mother would come to the day program and have this delightful day and cooperate and do all these different things with us because we had empathetic, loving, friendly volunteers. We had music, art, exercise, we had good food, we had entertainment, we created an interesting day, we did purposeful chores.

And that was sort of our light bulb moment, Tiffany, that the environment and the approach matter. We, of course, now know that to be very true, that we can do a lot to create this therapeutic healing environment. And when you're a friend to somebody, you know, you're empathetic, you do things together, you communicate, you're patient, you say positive words. And this all boils down to this concept we write about in our books called the knack of good caregiving. And knack is the art of doing difficult things with ease. If mom says,

President Clinton's doing a great job. You don't say now, Mom, he's not the president. You say, gosh, Mom, I'm glad you liked him. I know that you always liked the fact that he played the saxophone or something like that. You kind of go with them in that moment.

Tiffany Robinson (06:44.558)
You mentioned Virginia and I actually took a screenshot on my phone of a quote from her the other day, just because I thought it was so, I just thought it was so great when we're talking about working with people with dementia. says, it was amazing how friendship melts the angry feelings of people. If we can create this, we have them at their best instead of their worst. And I just think that that...

David Troxel (07:08.008)
That's beautiful, Tiffany. And I don't even remember that quote, but it's a beautiful quote. Yes. Virginia was a remarkable person. I love it. Yeah. Yeah. The day program she founded, I came in about six or eight months after it started and we grew it together. It is still going strong in Lexington, Kentucky called the Best Friends Program. They have, think, over a hundred active volunteers, a very rich program. I encourage anyone to make a

Tiffany Robinson (07:12.334)
She was talking about her adult program.

David Troxel (07:37.214)
call and visit if you're in the area. But it really does defy stereotypes. Probably the most remarkable thing happened to Virginia and me in our early days, Tiffany, that we've written about in our books. The head of the University of Kentucky Alzheimer's Research Center was a man named Dr. Bill Marksberry. Even now, he's considered one of the top dementia researchers ever. He was really a very important figure. He brought in millions of dollars in grant money to the university.

a tremendous person, he came to visit our day program. We worked for him. You we were part of the Center on Aging and he walked in and said, you know, David and Virginia, I only have 15 minutes because he was, you know, booked like, like almost like a, you know, a U S Senator or something. He stayed Tiffany for over two and a half hours of the day center. He danced the hokey pokey with Elna. He served ice cream. He walked, you know, this famous neurologist and what was so stunning to him in the eighties when he went in.

Many of these people were his own patients. We recruited from the memory disorder clinic at the University of Kentucky. He was seeing his own patients defy his stereotypes of what it was like to live with dementia, having this good day. When he walked out the door, Tiffany, he said to Virginia and me, you know this program, this is the treatment for Alzheimer's disease. And I think that's still true today, Tiffany. You've been in the field a long time. You know, I remain

hopeful about the medicines. We know there's something like a hundred and eighty five hundred ninety clinical trials under underway right now with like a hundred and thirty five different, different approaches. My numbers are rough, but you know, we still don't really have, from my point of view, effective medicine for dementia. These newer drugs can be helpful for some people with very early stage dementia. I think the treatment for you for dementia is really you and me. It's about

you know, the caregivers at Comfort Care or the workers and senior living, the workers and day centers, all learning to kind of pivot and learn how to be a little less task-oriented, a little bit more person-centered. When you put the person before the task, when you practice this best friends approach, not only is it more effective, you actually save time because if, you know, for your in-home caregivers, if the person likes them and trusts them, everything goes better. So, you know, we want to do

David Troxel (09:56.68)
This approach not only out of kindness, but it's also an effective strategy for getting things done, whether you're a family member or a staff member working in this field.

Tiffany Robinson (10:07.15)
Can you talk about the social history or the life story card and why every caregiver should have one and how we should be using it?

David Troxel (10:17.022)
Great question, Tiffany. I'm very proud, Virginia and I think are some of the first people to write about the importance of social histories and life stories in dementia care, because the person with Alzheimer's disease or another type of dementia, they're gradually losing their memories. And so I think it's important for us to kind of become their biographers and keep their stories alive. But where this comes down to in very practical care is when you know

the person well that you're caring for, or if you're a family member, making sure that other people around know, you see you can cue them. You can respect preferences. If you have someone who's getting a home care and maybe they grew up in New Orleans, Louisiana, now they're living in Milwaukee, well, maybe they love hot and spicy food. Well, perhaps a well-meaning caregiver comes to the house and makes the omelet and the person has a bite or two and pushes it away.

They make the meatloaf, the person eats a bite or two and pushes it away. Because we've missed the fact that they like their Tabasco sauce or hot sauce. You see now when your caregiver knows that, they can say, hey George, good morning. Here's your omelet and look what I have for you my friend. A little bit of Tabasco sauce. Here we go. Pop a few bits on the omelet, let the good times roll. And you see you've made a connection.

when the person with dementia feels like you know them and they know you, I think it's very comforting for most people and helps them feel known and safe, secure and valued. So one tip I have for your listeners, Tiffany, is do a little top 10 card, a little mini memoir if your mom is living in senior living memory care or has to go to the emergency room. And you say, even though my mother's name is Catherine, she goes by Kitty. My mother loves chocolate, she loves animals.

My mother was the mayor of Spokane, Washington. Call her Madam Mayor. know, my mother won, she's always been proud that she won an eighth grade spelling bee. Have some fun spelling words with her. And you have this little, little list that I think can be a quick guide or quick cue for many of your professional staff working with people with dementia.

Tiffany Robinson (12:35.672)
I think that's great. I also saw that in the best friends approach, you guys have said social histories aren't paperwork, they're invitations to connect. And I think sometimes we take the information or we might even get the social history and then we forget, what do I do with it? How do I apply this? How do I share this with my staff to make sure that we are bringing in all of these things that make that person that person to help them connect with us? I think that's just so important.

David Troxel (13:00.018)
Okay.

David Troxel (13:07.424)
You're right, Tiffany. We just published a new book, the last book Virginia finished before she passed away, called The Best Friends Staff Learning to Deliver Exceptional Dementia Care. And one of the points we make in the book is that you collect these pieces of information, but are we teaching the staff how to use them? So it might say, David Troxell used to own an antique store on Main Street, and he loves antiques. Okay, well, that's interesting.

But what if you instead also had some instructions for team members? He loves to watch that old TV show, Antiques Roadshow on streaming services. Go through antique magazines, bring in some fun things from your house and have a little mini appraisal session. Look at the scrapbook he has from the various auctions he's attended around the world. He enjoys looking at that together.

So again, this idea that we don't just simply make a fact, like she won a prize for her pumpkin cheesecake, instead encourage staff, you know, pull out the cookbooks and pick out recipes with her or ask her to teach you how to make this cheesecake. And all of this again, kind of builds that nice connection. And I think sometimes we miss that little step within the senior living and senior care industry.

Tiffany Robinson (14:27.316)
we definitely do an example that I have is we were lucky enough to have a local Comfort Care in the same city that my grandma lived in and we were able to utilize them for providing care to her. And something about her is that she liked putting her best foot forward. She liked being dressed up. She liked getting her nails done every week. And over time as we were

you know, she was living with dementia, a lot of those things had not taken place and her caregiver decided to do a nail salon right in the kitchen table, right? She set it up and she's having her, you know, soak her nails in a bowl and now we're gonna paint the nails and we're filing them. And she lit up because this is something that was important to her and we're using that in a meaningful way to keep her engaged. And I think it's just so important. What are some other go-to activities

that you like for home caregivers.

David Troxel (15:23.06)
Well, I'll just mention a few from my mom that I did that I think were really fun and then a few that I've heard. But a couple of things that I enjoyed. I love Tiffany activities that are purposeful, that have some kind of community involvement. So I've done things like make dog biscuits with my mother or with a person with dementia at home. Very easy to make. Doesn't hurt them if they eat them. Very simple ingredients.

but make dog biscuits for the local animal shelter. Okay. And then go deliver them. I also had a lot of fun wrapping presents. I bring a book into my mom's house with my dad and say, gosh, mom, my secretary is having her birthday next week. You're so good at this. Would you help me wrap the present? Now, do you like the blue paper, the green paper, this paper, this ribbon, and do it all together? And at the end you say, mom, thank you so much. What would I do without you?

I'm also a fan, Tiffany, of asking opinions. So, you know, if I ask you, Tiffany, hey Tiffany, I'm wearing this blue shirt for the podcast. You do think it's gonna look good if you take a picture? And you might say, oh, how about switching to the red? You see, when I ask somebody their opinion, it means you value them. So I would bring in shirts and neckties on hangers and say, mom, you know, I've got a busy week at work. Would you help me match my shirts and ties? So things like that can be very, very lovely.

I'll put a plugin for music. I'm a big fan. One of my heroes was the late physician, Oliver Sacks, you this famous neurologist who did a lot of writing about, you know, the human brain. He wrote a beautiful book on music called Music Ophelia. And he points out, as others have, that song lyrics and music actually live in a different part of the brain than words and language. And so I think music is amazing. Many of them, even after they've lost a lot of words and language, people with dementia,

can sing those old songs, can enjoy rhythm, play simple instruments. So I think music is very, very good. And Tiffany, maybe you've done a podcast on this, but more and more, what I'm excited about, even there was this big study, the US Pointer study that came out of July of this year, July, 2025. And we now know that socialization is not only good for the body, but good for the brain. Eating well, exercising, music.

David Troxel (17:48.798)
you know, activity, engagement, all of these things can be neuroprotective and not only maybe help us if we're going to maybe have the bad luck to get Alzheimer's when we're 82, you live a certain lifestyle, maybe you won't get Alzheimer's till you're 88. Similarly, if you have Alzheimer's or one of the other dementias, we more and more think that these kinds of, you know, lifestyle interventions might slow it down or delay the onset.

Tiffany Robinson (18:20.162)
have to tell you with music, you really got me where I'm saying yes, yes, because at Comfort Care and at your side, we really love the idea of connecting with our clients through music. And so ways that we've done that is we actually have a special program called Joyful Memories. And what we do with that is we can either one-on-one with a client or even in a community setting with a whole group, we will do sing-alongs.

And I have to tell you, I'm not a person who is musically inclined or has played an instrument. And so when I went to the first one, I kind of didn't know what to expect. And my mind was blown because I saw individuals who were withdrawn, not responding. And then I saw the music come on and it was, know, patriotic songs or songs from their childhood. And I saw individuals who were lighting up, who were now engaged, they're moving around now.

And I mean, it's just so powerful to see that. And it's something that we really try to use with our clients to keep them moving, engage with us, but also the music comes on, we see them now moving a little bit. We're getting some exercise and movement in. mean, music is just such a huge way that we can connect with people.

David Troxel (19:39.754)
I totally agree. And I've actually written a couple of books on activities. I don't mean to be plugging my own work here, but it's just so timely. One of the things that I suggest with my colleagues in these activity books is to make more of it. So let's say you're a home caregiver and you know the person loves the Beatles. Well, enjoy the Beatles music, but use your tablet to begin sharing some history about the Beatles and maybe doing like a little mini class on

Tiffany Robinson (19:45.996)
I love it.

David Troxel (20:09.332)
Paul McCartney and George Harrison and Ringo Starr. Maybe start a little playlist where you actually keep a little notepad somewhere where you start listening to a different Beatles song every day and ask AI or Wikipedia, what is the origins of this song and the history and when was it written? And even keep a little notepad of all the classes you've taken. So maybe six or seven months in, you can say to your in-home client and the family,

Would you believe that we've listened to 85 Beatles songs so far this year and we voted and here is your mother's top 10 list for her playlist. And not only that, did you ever know that, you know, I'm making this up, but you know, the famous song, Hey Jude was written for, you know, Jude Smith, who was the mayor of Manchester or whatever. know, again, I'm totally making that up because I don't know the origin. But the idea of teaching a little class, having a conversation of learning.

I love Tiffany teaching classes to people with dementia, even inspired by their life story. Maybe someone grew up in San Francisco and we do trivia and reading about San Francisco. And teaching a class, I think is so good for the brain. And even if an hour or two later, they've forgotten that you've ever done a class on San Francisco, in the moment, they enjoy the experience of learning. And I think getting these, connecting these moments together is really what quality dementia cares about.

Tiffany Robinson (21:38.474)
I really like all of your examples and especially how we are personalizing it to each and every person. That part is so important. Now, the physical and emotional environment also shapes the caregiving experience. Let's talk about how caregivers can set the stage for trust. What does setting the stage for trust look like?

David Troxel (22:02.482)
Wow, very, very good question. So let me kind of say it this way. One of the strategies I often think about, Tiffany, is I kind of embrace a very contemporary view that in many ways, people with dementia are just like the rest of us. They have the same needs, emotions, feelings. They have a disease that's robbing them of cognition, personality change. But kind of what works for most of us works for them.

I would attack that question without being too wonky here, Tiffany. Like, what builds trust in any of us? Positive body language, smiles, curiosity, knowing the person, being honest or staying in integrity, having the person feel that you have their goodwill, not arguing, not correcting, kind of understanding the experience of dementia.

So I think that broadly speaking, I like to think about, how do we build trust with any of our friendships? I think with dementia, I'll just see if I can be very specific here, know and use the life story. Be aware that as communication breaks down, that you're paying attention to your nonverbal communication. I think that can be very, very powerful. Doing things, being active, being present, I think all of those things can be very, very powerful.

I think your folks can Google it, but Virginia and I wrote an early article on what we call the Alzheimer's disease bill of rights, or David Troxell Alzheimer's bill of rights, where we lay out a number of things that, know, everything from telling the person their diagnosis and keeping them engaged in the community that I think can really build this sense of trust. One quote that I've used, Tiffany, and I'm kind of guessing you've used this too, having met you and learning about your passion for dementia care, but.

I love Maya Angelou's quote that people will forget what you said, people will forget what you did, but they'll never forget how you made them feel. And she did not write that, Maya did not write that about dementia, but it is so perfect. And so I think that to me is very powerful. I hope, and I believe that I'm sure many of you are in-home workers, have this kind of love of elders and integrity and being present. And that does build trust.

David Troxel (24:19.3)
Even when someone has dementia, Tiffany, if you're being wildly dishonest, if you're not being present, if you're not being authentic, I think they can sense that and the relationship will go down, not up, will go downwards or deteriorate and not improve.

Tiffany Robinson (24:36.32)
I agree with you. You teach caregivers to pause before tasks. Why is that moment so powerful?

David Troxel (24:44.648)
You know, boy, you're asking some great questions today. I think a couple of things. One is, know, loneliness and isolation is a huge challenge in our life today. And I've seen studies of people living in skilled nursing, for example, where you take away the time that staff spend passing meds, changing a wet brief, feeding somebody, and somebody in skilled nursing might only get two.

to three minutes a day of individualized attention. So loneliness can be a huge issue. But in terms of your very specific question, I believe that even 30 seconds or a minute can make a difference. That there are lots of activities you can do in a minute, giving a hand massage, smiling, looking out the window, those add up. But if you take that minute or two before the shower, for example, Tiffany, to

Talk to them about their life. Talk to them about being the mayor of Milwaukee or about their life as an artist or an antique dealer. Admiring something in their room. Gosh, I see this beautiful painting you painted. It's so lovely. Would you teach me to paint sometime? Smiling, maybe have a bit of music. Doing a little fun dance to a fun song. You take that minute or two just to be, again, a little less task-oriented, a little bit more person-centered. You take that two or three minutes sometimes. You might save.

20 minutes, 40 minutes an hour, because again, if that person likes you, trusts you, everything will go better. So I do think we don't do a good enough job reminding our team members and staff, and even our families to some extent, that even small gestures make a difference. Small matters make a difference. My late mother, Dorothy, her parents were English and she was Canadian. She was a lifetime afternoon tea person. Her favorite tea was Earl Grey tea with milk.

And I have to say, Tiffany, when the caregivers, when she was living in senior living, we had an in-home helper for a while too before that. When she was having a bad day or having a little agitation, if they said, Dorothy, how about I pour you this lovely cup of Earl Grey tea with milk, just the way you like it? heaven, she was almost 100 % of time in a much better space. Definitely, you know, we want to avoid psychotropic meds wherever possible. And this kind of,

David Troxel (27:04.185)
a non-pharmacological approach, remembering my mother's favorite tea, what was terrific.

Tiffany Robinson (27:11.436)
those small moments really matter and they can make a huge difference in the day to day. So I love the examples that you've shared. Now, David, before we wrap up, I would love to talk about some of the resources that you have created for caregivers over the years. I know you've written several influential books. Can you walk us through which ones are best for families and which ones are geared towards professional caregivers?

David Troxel (27:37.14)
Well, thank you, Tiffany. I'm gonna hire you to be my publicist because I always need all the help I can get. Well, I'll start off with my family book. Many of my books are oriented toward professionals, although families buy them too, but we've written a book called A Dignified Life, The Best Friend's Approach to Alzheimer's Care with Virginia Bell and David Troxell. It's widely available on Amazon as all my books are. think it's, you know, sometimes it's 15 bucks, sometimes it's even 10 bucks on Amazon.

So again, A Dignified Life, The Best Friends Approach to Alzheimer's Care, all about this best friends philosophy and approach. We have a number of other professional books. I mentioned we had two activity books called The Best Friends Books of Alzheimer's Activities, and those books probably have three or 400 activities each. Again, we're trying to, with activities, Tiffany, make more of what's already happening and touch on spirituality, on music, art, exercise.

cognitive stimulation. So I think the activities are ambitious but very doable. We have a book called the best friends approach to dementia care for the professional community and our latest book is on dementia education. So my publisher you can Google their website health professions press. Also, just simply you're welcome to join my Facebook community Facebook. I think you go forward slash best friends approach or David Troxell on LinkedIn. I'm always happy to

Tiffany to answer emails from families having challenges. I've been there for so many family members. People are always welcome to email me simply at davidtroxel at gmail.com. But thanks for that question. We're very, very delighted. Our first book came out something like 30 years ago and is still in print. I think we're in eight different languages now. So it's an honor. I've loved every moment of being in this field. As I mentioned to you before, I think we got started.

One thing that puts our books, I think, apart from other books is we only tell real stories where we've gotten permission. So we might say Tiffany Robinson cared for her Aunt Sophie in Walla Walla, Washington, and we tell real stories where people have given us permission to use their names. We tell professional anecdotes, stories about best practices and day centers, in-home situations, senior living, memory care. And I think that storytelling also sets us apart because

David Troxel (30:04.072)
I don't know about you, Tiffany, but I learned from anecdotes and stories when people tell me an example or a case study, I find those very, very powerful. So again, thank you for inviting me to be part of this stimulating conversation.

Tiffany Robinson (30:12.341)
Absolutely.

Tiffany Robinson (30:17.688)
Definitely, we will make sure that we include information on how to access your books in our show notes. And as we close, what is one piece of encouragement you'd like every caregiver to hear, especially those who are feeling overwhelmed or unsure?

David Troxel (30:34.916)
gosh, okay, where are we? So let me just say this. I am very encouraged about where we are with our research in the field of Alzheimer's and dementia care. I think that our field of knowledge is constantly expanding. We will have new and better medications in the near future. So I wanna just say, stay hopeful, particularly for any of you listening who might be people living with dementia, with early stage dementia or for care partners. So I think there's...

great sense of optimism in the field. And I guess I would say one more thing, Tiffany, you probably get to know me by now, but when you say David, just, can you have one more thing? I've got to go with two or three, but I'll just say one more thing, which is don't wait and wait to use services. You know, I mean, we have so many great organizations for for-profits who do a good job at dementia here, lots of nonprofits, of course, the Alzheimer's Association or your local Alzheimer's society.

I'm a big fan of a group called Alzheimer's Disease International in London that has a very informative website and publishes an annual World Alzheimer's Report. But when you feel like you can do it all by yourself, maybe you can, I think in a way you're forgetting that the person with dementia benefits from socialization, from stimulation. So find out if there's a local day program with you, try to find an in-home worker who's lively and engaging.

If you think you might end up having to make a placement, look early, pick a place. Again, don't wait and wait to make a decision until a crisis happens. Dementia tends to be like a slow and lazy river, as my mother's neurologist, Dr. Harbaugh, in Santa Barbara said. So we do have time to get our legal and financial affairs in order, make a game plan, and travel this journey with your, hopefully your best friend, your family member, or your client with dementia.

Tiffany Robinson (32:26.843)
Great advice, and David, thank you so much for being with us today.

David Troxel (32:30.856)
You're welcome.