The holiday season can be very challenging for a person with dementia and their family. Of course, engaging in the mitzvot of the holiday and the getting together with family members and the congregation can uplift the family – and the dementia patient – bringing them joy and strength each year, and granting them the power to continue to deal with the trials of everyday life. Yet it can also present challenges, both big and small. The very fact that there is a deviation from routine can be tremendously burdensome for a person with dementia and the anticipation of an uplifting and joyous caretaking environment can be replaced with bitter disappointment from the exhausting daily maintenance. Is a person with dementia obligated to hear the shofar? Should and for how long should they stay in shul? How should Yom Kippur be run? Are they obligated to sit in the sukkah? How should they fulfill the mitzvah of joy on the holiday? And what is the obligation of a community towards a person with dementia and their family?
As will be explained, a person with dementia is not obligated in mitzvot like other people. Worrying about their wellbeing must be centrally focused on what is best for them and their needs, together with preservation of the holiday atmosphere and fulfilling mitzvot and customs that correlate with their level of obligation. Special attention towards a person with dementia and those who take care of them must occur from the congregation’s perspective – in topics such as the person’s place in shul and their and their family’s joy over the holiday.
2. Guiding Principles
As we have already discussed at length elsewhere1, our guidelines and recommendations enclosed here are based on three principles:
1. The level of consciousness of a person with dementia continuously declines with advancement of the disease, and a dementia patient’s obligation in mitzvot is dependent on their consciousness and the context of the specific mitzvah. When he is aware that today is Rosh Hashanah, Yom Kippur, or Sukkot and is generally aware of halachot and customs – he is obligated in them; and when he is not aware of this and is unable to fulfill these obligations independently – he is not obligated in them2.
2. Even when a person with dementia is obligated in a mitzvah, if fulfilling this mitzvah involves a great amount of effort or suffering – he is exempt from it. A person with dementia requires a fixed and organized daily schedule and having steady habits is important for their daily functioning. Therefore, if the mitzvot and customs could potentially disrupt the status quo in a way that will negatively impact them – they are exempt from them3. Spending extended periods in shul on Rosh Hashanah and Yom Kippur and going out into the sukkah on Sukkot are fundamentally changes to one’s daily routine and can be incredibly burdensome for dementia patients.
3. Those around the patient are not only required to instruct the person of their halachic obligations. Fulfilling mitzvot and belonging to a congregation that keeps them is a privilege, and a person with dementia has the right to be part of the congregation and their family and not isolated from them. At times, exposure to familiar mitzvot and customs can benefit them. One should, however, evaluate each case independently, and if fulfilling the halachot and customs would benefit them, one should assist them in fulfilling them.
3. Rosh Hashanah
1. A person with dementia who is not aware of the mitzvah of blowing the shofar, even if they are reminded, is not obligated in the mitzvah. If bringing the person to shul for blowing the shofar damages their health or mental well-being, and it is a great burden to bring someone to blow the shofar in their home, they are exempt from hearing the shofar as well4. However, we do not know how hearing the shofar can impact the mind, what memories it could awaken and what benefit participating in tefillah can have on a person. Therefore, it is proper, if possible, to direct a person with dementia to come to shul during the shofar blowing and listen to at least 30 blasts or to arrange for someone to blow the shofar for them at home.
2. When blowing a shofar for a person with advanced dementia, it is proper that a second person should listen to the blasts with them who has not fulfilled the mitzvah, yet if necessary one can blow a shofar for a person with advanced dementia alone5.
3. The prayer service for Rosh Hashanah is long, and there are a variety of different levels of obligation for different parts of davening. It is proper to plan ahead – together with the dementia patient, if possible – how long they will spend in davening, and according to this determine at what stage of davening it is best to arrive. Addition information can be found in the footnote6.
4. In line with this, we recommend that a dementia patient who wants to go to shul should arrive shortly before the shofar blasts before mussaf and participate in the prayer service as much as possible, before or after this. If there is no kiddush in shul, it is recommended that the person pray Shacharit at home, make kiddush, and eat – and afterwards head to shul7.
5. If a person with dementia requests to pray in shul but acts in a manner that embarrasses themselves and their family and could potentially disrupt other daveners, the congregation has an obligation to find an appropriate way to integrate them into the prayer service with the congregation. If the disruption is significant, it is better that they do not attend shul8.
6. Regarding a person with dementia that used to blow the shofar for the congregation in shul, who is still of sound mind and requests to blow the shofar, yet there is a reasonable concern that they will make a mistake, it is proper to avoid having them blow the shofar. If this brings him great suffering, and it would be minimally burdensome for the congregation, it is fitting to allow him to blow at the very least a portion of the shofar blasts9.
7. A person taking care of a person with dementia who is only able to go to one prayer on Rosh Hashanah should go to the Mussaf service in order to hear the shofar10.
8. A person with dementia who stays at home on Rosh Hashanah and Yom Kippur can sense the difference compared to normal days; for example, that they do not go to the clinic, that family is not visiting (or the opposite, that there are more guests than normal); no television, music, or phones, etc. It is proper to organize an appropriate experience and accompany them during these days – and not leave them confused or lonely.
4. The Month of Elul and the Ten Days of Repentance
1. It has been the Jewish custom to say selichot on the days before Rosh Hashanah (from the beginning of the month or from the Saturday night before Rosh Hashanah) andduring the Ten Days of Repentance, as well as the custom to blow the shofar during the month of Elul at the end of Shacharit11.Since these are customs and not total obligations, a person with dementia is not required to go out of their way in order to fulfill these in a way that is beyond their normal effort for tefillah. If they are interested in saying Selichot or hearing the shofar, they should join an appropriate minyan based on their schedule12
5. Yom Kippur13
a. A person who is in the early stages of dementia is not defined as exempt from mitzvot and it is a right for them to be part of the congregation of fasters. Therefore, if they forget the fast day and wish to eat, it is the responsibility of those around them to remind them that it is a fast day – in a way that will not cause them embarrassment.
b. In the intermediate stages, where the person is still not in a state where they do not understand the concept but already lack the capability to be responsible for their own eating or fasting – if they request to be fed, one should feed them. If there is a way to feed them shiurim (in small increments), and this would not have a significant toll on the patient or caretaker, it is preferrable to feed them in this manner14.
c. A person with dementia who is disconnected from their environment – is not obligated to fast at all. It is permitted even to feed them as necessary and it is permitted to feed them directly.
d. The precise definition of the mental and physical condition of a person with dementia is complex and dynamic and the boundaries between the cases in the previous subarticles are not obvious. Therefore, it is recommended to consult with medical professionals and a rabbi before the fast, in order to define what is permitted and forbidden.
e. The obligations in the rest of the Yom Kippur afflictions, such as the prohibition of bathing or wearing leather shoes, are more lenient than the obligation to fast. When it is sufficient to remind a person with dementia of the situation, one must remind them and prevent them from transgressing prohibitions. However, when observing these prohibitions becomes burdensome or confuses him, and definitely if they are not aware of the prohibition, one should allow them to act as they can and wish.
f. A person who eats on Yom Kippur is not obligated in kiddush, even on Shabbat, and is not obligated in lechem mishneh. If they eat bread, they should perform netilat yedayim as usual, despite the prohibition of washing. They should make a bracha before eating, and if they eat or drink beyond the minimum measurement, they should make an afterbracha. In birkat hamazon they should add “ya’aleh veyavo”; on Shabbat they should add “retzei”; and in the bracha me’ein shalosh they should add “vezachreinu letova beyom hakippurim hazeh”. In both brachot, if they forget to add this, they should not go back and recite it over.
a. A person with dementia who regularly takes medication, including sedatives, should take them on Yom Kippur just like on a weekday.
b. If they require water in order to swallow the pill, they should drink less than a shiur, or should use bitter water that is unfit for drinking or mix the medication into the water. If they have difficulty drinking in this manner and there is a genuine need for the medication, they should swallow the pill with water as intended.
c. If the medical guidelines dictate that one must take a medication with food and a person is in a condition where they are obligated to fast – they should eat less than a shiur, or should juxtapose several incidences of eating less than a shiur, as explained earlier. If one cannot eat in this fashion, the decision as to whether they are permitted to eat and take the medication is dependent on the importance of the medication, and one should consult a rabbi and physician.
a. The prayer service for Yom Kippur is long, and there are a variety of different levels of obligation for different parts of davening, as detailed in the footnote. It is proper to plan ahead – together with the dementia patient, if possible – how long they will spend in davening, and according to this determine when – and at what stage of davening – it is best to arrive15.
b. Following the order of importance detailed in the footnote, we propose that a person with dementia who wishes to go to shul should arrive in the morning at “Barchu” and stay as long as they are able (or wish to). One can offer them to daven Minchah at home and return to shul for the Neilah service.
c. A person taking care of a person with dementia who is only able to go to one prayer on Yom Kippur should go to the Maariv service at the beginning of Yom Kippur16.
1. A person with dementia who is unaware of the mitzvah to sit in the sukkah is not obligated in it at all17. Even if they are aware of the mitzvah, they are exempt from it, as all sick people are exempt from sitting in the sukkah18. However, it is possible that sitting in the sukkah will benefit them and they will enjoy spending time with the family, potentially even awakening memories from past years. Therefore, one should consider the importance of sitting in the sukkah even if they are exempt from the mitzvah.
2. One taking care of a person with dementia who is dining outside of the sukkah – is also exempt from the mitzvah of sitting in the sukkah19.
3. A person with dementia is exempt from sleeping in the sukkah20.
4. “And you should be joyous on your holidays” – a person is obligated to be joyous on holidays and to bring joy to their household. A person with dementia is part of the family, and one is obligated to bring them happiness, more so than during the rest of the year21.
5. Included within the mitzvah of being happy on the holidays is worrying about the happiness of those who it is difficult to uplift, even if they are not family members. Therefore, it is the obligation of friends, neighbors, and the community to pay attention to the needs of sick people, as well as the family members who are busy all year and the holiday season taking care of their relatives – and bring joy to them22.
6. It is customary to wear more holiday appropriate attire during chol hamoed. It is proper to encourage this for a person with dementia as well, if it does not burden them23.
7. A person with dementia’s obligation in the arbaat haminim (four species) is like all other mitzvot: if they are unaware of the mitzvah, they are not obligated in it; and if fulfilling it involves a large burden for them, they are exempt from it.
You are not alone! Caretakers and family members who are debating how to act are welcome to refer to Tzohar Ad 120’s call center for answers to their questions. The rabbis and social workers at the center are at your service and will assist you in bearing the burden of taking care of family members.
- See the article ‘Obligations of a Dementia Patient on Fast Days and in Mourning Rites of the Three Weeks’, https://bit.ly/3Y2lE9q, (We have also dealt with this on our page with guidelines for Yom Kippur, cited later on).
- For more discussion see ibid., footnote 3. Our conclusion there is that for a person with dementia, if they understand the mitzvah – they are obligated in the same way as a mentally competent individual; if they do not understand the mitzvah or are not aware of it – they are exempt. The precise definition is dependent on different factors, especially the condition of the person and their level of awareness, as well as the consciousness and capability required to fulfill the specific mitzvah.
- For more discussion see ibid, footnote 4. Our conclusion there is that a person with dementia who is able to fulfill the mitzvah is obligated in it and its fulfillment could even benefit him. However, if they are confused, have difficulty connecting to it, or if it involves great difficulty – they are exempt from the mitzvah. We also explain there that there is no special value to being strict beyond the letter of the law when the desire to be stringent is from the caretaker and not from the person themselves.
- In our essay there (see the previous note), we bring, amongst others, the opinion of Rav Moshe Feinstein (Igrot Moshe Responsa, Orach Chaim, volume 1, article 172), who exempts a psychiatric patient from leaving the hospital to hear shofar, since preserving one’s health is more important than all of their assets – and a person is not obligated to spend more than a fifth of their assets in order to fulfill a positive commandment.
- The Rema (Shulchan Aruch, Orach Chaim, 596:1) rules that one should not blow the shofar unnecessarily since the act is prohibited on Yom Tov and is only permitted for the sake of the mitzvah. On this Rav Zilberstein writes in the name of Rabbi Yosef Shalom Elyashiv (Shiurei Torah for Physician’s, volume 3, article 208, page 481) that one should not blow the shofar for someone with no mental competence; this is also written by Rabbi Yonatan Rosensweig and S. Harris, I Ask For My Soul: Halachot of Mental Health, Jerusalem 5782, page 144. However, the Taz (ibid. subarticle 2) disagrees with the Rema and is lenient. Rabbi Ovadiah Yosef also writes in Kuntrus He’arot that we do not see people who are concerned for this violation and one should not stop those who observe this halacha (Yalkut Yosef, Holidays, The Rosh Hashanah Mussaf Service, footnote 8). As we have written above, it is possible that it is beneficial for a person with dementia to hear the shofar even if they are not obligated in it, and therefore our opinion is that one can rely on those who are lenient and blow the shofar for them.
- The piyyutim are a significant portion of the prayer service. From a halachic perspective, they are of lower importance, but on the other hand specifically through piyyutim is a unique experience expressed which can raise the spirit of a dementia patient. The core obligating part of the prayer service is the recitation of Shema and the Shemoneh Esrei, and the Chazzan’s repetition with the recitation of Kedushah (without piyyutim). The shofar blasts can be heard during the prayer service, or separately not during the prayer service. This is the order of importance for the sections of Shacharit and Mussaf: 1) the Shacharit Shemoneh Esrei (without Chazzan’s repetition); 2) from “Barchu” until Shemoneh Esrei; 3) the Mussaf Shemoneh Esrei (without Chazzan’s repetition); 4) The shofar blasts before Mussaf; 5) the Chazzan’s repetition of Mussaf; 6) the Chazzan’s repetition of Shacharit; 7) the Torah reading; 8) Pesukei DeZimra; 9) the rest of tefillah.
- The poskim allow kiddush and eating a small amount before hearing the shofar (see Tzitz Eliezer Responsa, volume 6, article 7), and for a sick person one can surely be lenient.
- Shulchan Aruch, Orach Chaim, 90:9 rules: “A person should make an effort to pray in a shul with the public”. Two ideas are mentioned in this halacha – praying in a shul and praying with the public – and both are lofty values with tremendous importance, even if they are not definitively required. Therefore, the starting point should be that one should enable any Jew to pray with the congregation in shul. Yet one should also consider the congregation who arrive at shul to fulfill the same obligation (a similar dilemma is found in a question discussed by the poskim regarding whether to allow a blind person to enter a synagogue with a seeing-eye dog). Rav Moshe Feinstein [Igrot Moshe Responsa, Orach Chaim, volume 1, article 45] permits this because of the distress of the blind person, despite the impairment to the other daveners – yet there are those who disagree with him. See Chelkat Yaakov Responsa, Orach Chaim, article 34; Yalkut Yosef, Hilchot Kriyat HaTorah U’Beit HaKnesset, article 151:25, and the footnote there in the name of his father Rav Ovadiah Yosef. Rabbi Yitzchok Zilberstein (Shiurei Torah for Physicians, volume 3, article 218) rules – after writing that one should be careful not to embarrass the patient – that when the presence of the patient in shul impacts the congregation negatively, one must remove him, even if it is painful and embarrasses him. Rav Zilberstein relies on the responsum of the Chatam Sofer (Yoreh Deah, article 7) yet the Chatam Sofer writes only that it is best for him to pray in a room near the shul and does not write that one should remove him. An additional consideration brought by Rav Zilberstein is that it will bring shame to the patient and his family, and if he was mentally competent, he would have agreed that he should be removed. However, in the Chatam Sofer Responsa, Orach Chaim, volume 1, article 83, the Chatam Sofer writes that a mentally incompetent person does not have the capacity for embarrassment. See also, I Ask For My Soul: Halachot of Mental Health, chapter 4, article 13, pages 76-77 and footnotes 16-17; Aside from everything stated here, the authorities have emphasized the moral obligation of the congregation to support disabled people and the fact (which has been scientifically proven) that integration of dementia patients into society, to whatever extent, helps slow the deterioration of their condition. Therefore, it seems to us that one should find a way to enable a person with dementia to be in shul, and this is a person’s right and the congregation’s obligation – aside from cases where there is significant disturbance to the congregation.
- Just like in the previous footnote, here too we are dealing with the ruling between honoring the wishes of an individual and preserving their dignity and the congregation. The issue of a dementia patient’s human dignity is two-fold – honoring their wishes to be a shofar blower on one hand and preventing them from experiencing potential disorientation and confusion on the other hand. Yet the discussion here is different from the discussion in the previous footnote in two aspects. First, the right to pray in a synagogue is the right of each individual and therefore our starting point is that he should go to shul, yet not every congregant can be a shofar blower, and one who does not blow the shofar does not lose a basic right. Secondly, during shofar blowing, the congregation’s obligation to hear proper shofar blasts trumps the need for an individual, and burden on the congregation is prioritized as well. Therefore, if it is possible to politely convince them not to be the shofar blower, it is best; otherwise, if one cannot convince them and it is disruptive to the congregation, the honor of the congregation and their obligation to fulfill the mitzvah comes before the honor of the individual. Depending on the circumstances, it may be possible to allow them to blow some of the shofar blasts and thereby fulfill both the individual’s and the congregation’s needs.
- The Radbaz (Radbaz Responsa, volume 4, article 13) discusses the issue of a person who is in prison and can leave for one day to pray with a minyan in a shul: Should they wait until Yom Kippur or Purim because of publicizing the miracle? His response is that according to the principle ‘we do not pass over mitzvot’, a person should not wait and should leave for the first mitzvah that they would be unable to fulfill in prison. The Chayei Adam (volume 1, principle 68:1 and the Nishmat Adam, ibid., subarticle 1) disagrees on a number of points, and according to him one should opt for the more important mitzvah. The Mishneh Brura (article 90:28) brings both opinions and does not rule either way. In practice, regarding Rosh Hashanah even the Radbaz agrees that if a person is unable to hear the shofar at home, they should go out to hear the shofar which is a biblical commandment, and not the Arvit service which he may pray independently at home. On the other hand, on Yom Kippur, where the goal of going out is to participate in the congregation’s prayers and no person’s prayers are more important than another, it is proper to act in accordance with the Radbaz and leave for the first prayer.
- Shulchan Aruch, Orach Chaim 581, and the Rema ibid.
- Since a person with dementia is exempt from saying Selichot, we have not expanded here on the issue of the time to say Selichot. According to Rav Moshe Feinstein (Igrot Moshe Responsa, Orach Chaim, volume 2, article 105), when necessary one can say Selichot even before midnight, yet according to Rav Ovadiah Yosef (Yechave Da’at Responsa, volume 1, article 46) it is better not to say Selichot than to say them before midnight.
- See the essay ‘Yom Kippur – A Sick Person and a Dementia Patient’ [link]; there we deal with a sick person in general and specifically a dementia patient, see an expanded discussion there in the footnotes which have been abridged here.
- When a person with dementia has difficulty eating shiurim or it causes them tremendous discomfort, they can eat normally. Eating shiurim is eating less that the amount of food qualified as “eating” in one sitting, taking breaks between each meal. The amount of “eating” is around 30 cm3. The amount of drinking shiurim is less than a cheekful (melo logmav). This measurement is different from person to person and since it is difficult to evaluate this for a person with dementia, the amount of liquid should be less than 40 cm3. The break between each meal or between each drink should ideally be 9 minutes, and if necessary, can be shortened to 4 minutes; for drinking one may even shorten this to a minute. It is preferrable, if they are capable, to subsist just on sugar water and abstain from eating. When this is properly prepared for, one can drink shiurim in a manner which allows for a significant amount of liquid which will satisfy the needs of the patient.
- This is the order of importance of the parts of Shacharit and Mussaf (compare to footnote 6 earlier): 1) the Shemoneh Esrei of Shacharit (without the Chazzan’s repetition); 2) from “Barchu” until the Shemoneh Esrei; 3) the Shemoneh Esrei of Mussaf (without the Chazzan’s repetition); 4) Vidui during the Chazzan’s repetition of Shacharit; 5) Vidui during the Chazzan’s repetition of Mussaf; 6) Chazzan’s repetition of Shacharit; 7) Chazzan’s repetition of Mussaf; 8) Torah reading; 9) Pesukei DeZimra; 10) the rest of tefillah.
- See earlier footnote 10.
- See earlier footnote 2, as well as Rabbi Yitzchok Zilberstein (Shiurei Torah for Physicians, volume 3, article 208, page 480) who adds that it is possible that one must have the intent to sit in the sukkah in order to fulfill the mitzvah (see Biur Halacha, article 60, ד”ה ואין, and the Mishneh Brura, article 621:1) – and therefore one who has no mental competence is lacking a vital component of the mitzvah.
- “Sick people and those caring for them are exempt from [the mitzvah of] sukkah” (Shulchan Aruch, Orach Chaim, 240:3). Additionally, anyone who is suffering from sitting in the sukkah is exempt from it (ibid., article 4) since the mitzvah is “You should sit – in the same manner that you dwell”. This halacha is the foundation of the argument and discussion regarding the exemption of mitzvot in situations of sickness or excessive burden (see earlier footnote 3), yet no one disagrees regarding the sukkah itself. The definition of sickness, according to the Shulchan Aruch, is “even if one has a headache or discomfort in their eye”, i.e. one who finds sitting in the sukkah difficult because of their condition (Mishneh Brura, ibid., subarticle 9). Regarding a person with dementia, at the stage where sitting in the sukkah begins to be difficult for them, they are exempt from sukkah. Regarding eating a kezayit on the first night, the Rema (ibid., article 4) writes that even one who suffers is obligated in eating a kezayit in the sukkah on this night, yet this is an argument between the Rishonim and the Shulchan Aruch (here, and in article 639:5) did not qualify his wording and did not differentiate between cases – and according to him one who experiences discomfort is exempt even on the first night. Rabbi Ovadiah Yosef (Chazon Ovadiah, page 122) writes that the core principle follows the Shulchan Aruch and the Mishneh Brura (article 639:35) writes that even though one should be stringent and eat a kezayit, one should also be concerned for those who exempt and not make the bracha of “leisheiv basukkah”. For the sake of a sick person, even those following the Rema can rely on the lenient opinions and exempt them from eating a kezayit (even on the first night).
- Shulchan Aruch, Orach Chaim, 640, 3-4 (see also the previous note) writes that those who are sick and their caretakers are exempt from the sukkah, yet those who are taking care of one who is experiencing discomfort are obligated. One taking care of a sick person is busy with a mitzvah, and therefore is exempt from the mitzvah of sukkah, yet when they are free, or when there is more than one caretaker, they are obligated (Mishneh Brura, ibid., subarticle 10). In the previous footnote we brought the opinion of the Rema, who qualifies that the caretaker is obligated in the first night of sitting in the sukkah, yet there are those who disagree with him. A couple who lives alone, where the wife has dementia and the husband wishes to be stringent on himself and eat in the sukkah – should consider the circumstances and determine if dining separately would affect the mitzvah of having a joyous holiday (see Shaarei Teshuvah, article 639:13, and Mishneh Brura, ibid., subarticle 35).
- Many are lenient with the obligation to sleep in the sukkah even for a healthy individual (see Rema, Shulchan Aruch, Orach Chaim, 639:2). A person with dementia requires a fixed routine. Sleeping in an unfamiliar place will inevitably be burdensome for them, and one should not add additional distress to their already existing difficulties. Therefore, a person with dementia who does not explicitly request to sleep in the sukkah should sleep in their home; even if they do request, it is best to convince them to sleep more comfortably in their bed or their normal location.
- “A person is obligated to be joyous and happy on the holiday, him and his wife and children and all those accompanying him” (Shulchan Aruch, Orach Chaim, 529:2). The mitzvah is during the entire holiday and also on Chol HaMoed (Mishneh Brura, ibid., subarticle 16).
- The Rambam (Mishneh Torah, Hilchot Yom Tov, chapter 6, halacha 18) emphasizes the obligation to feed the convert, orphan, and widow, as the verse instructs (Devarim 16:14), together with the rest of the poor and downtrodden, and writes that one who cares only for themselves – “this is not joy of fulfilling a mitzvah but joy of [filling] their stomach”. Therefore, there is a unique obligation on the holidays to encourage feelings of happiness amongst those who need assistance.
- Mishneh Brura, article 530, subarticle 1 writes: “one is obligated to honor Chol Hamoed through food, drink, and clean clothing”, and the Shaar Tzion (ibid., subarticle 1) explains that the obligation on Chol Hamoed is not like the obligation of Yom Tov itself but just to honor it more than a weekday. For a person with dementia, it is recommended to dress them in comfortable and appropriate clothing as one does during the year, but it is fitting to make sure that on holidays and Chol Hamoed they are wearing more respectful attire if it does not burden them. If they insist on wearing a specific article of clothing, it is proper to allow them to wear it.