clinical research

Dog visitation therapy in dementia care: a literature review

Abstract This article considers the effectiveness of dog visitation therapy in dementia care and considers implications for practice. The literature indicates that visits by animals to care settings can bring various benefits to patients and residents, including relaxation, less apathy, agitation and aggression, and lower blood pressure. Much of the evidence is, however, anecdotal. If animals are to be introduced to care settings, careful multidisciplinary planning is required to ensure that stringent protocols and procedures are in place to protect the health and safety of all involved.

Alamy

Canine comfort?

Elizabeth Williams RMN, RGN, PGCert (Ed), RNT, BN, PGCert Social Research Methods, MPhil, is a senior lecturer mental health nursing, University of Glamorgan Rhiannon Jenkins RMN, is ward manager, Abertawe Bro Morgannwg University NHS Trust

Key words  Dementia Elderly: services Pet therapy These key words are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review.

The prevalence of dementia in the UK is set to increase (Bayer and Reban 2004). This means that service providers are seeking alternative ways of providing therapeutic, stimulating environments that do not focus merely on physical problems (Kitwood 1997) but on helping people to reach their potential. Attempts to enhance the quality of life of people with dementia have become more apparent over the past decade (Claudia and Kayser-Jones 2004), with approaches ranging from music therapy to reminiscence therapy. Some institutions have also considered introducing animals to the clinical care environment for the benefit of residents (Shaw 2007). Animals have long been seen as having positive effects on people with diverse health conditions (Laun 2003) and a number of hospitals across the country permit visits by animals (Society for Companion Animal Studies (SCAS) (2005). The National Institute for Health and Clinical Excellence (NICE) (2006) recommends the use of animal-assisted therapy in dementia care, where available, seeing this as another way of providing stimulation: Dementia of all types should be given opportunity to participate in a structured group cognitive stimulation programme (NICE 2006). By reviewing the literature, this article examines critically the effectiveness of dog visitation therapy for patients with dementia and considers implications for practice.

The idea of using animals to enhance well-being is not new. The earliest documented therapeutic relationship between humans and domesticated animals is said to date back to the late 1700s (Ormerod 2005, Velde et al 2005). In Britain, the York Retreat, in its attempts to improve the psychiatric institutional environment, instigated a human-animal therapy in which patients cared for animals, as well as tending the gardens. Such activity, described later as the Eden alternative (Laun 2003), was believed strongly to promote the healing process. Human-animal bond therapy has since been extended to America and continental Europe (Dono 2005). Animals have been used to ease human problems such as loneliness, lack of physical exercise and restricted vision (Brodie and Biley 1999), with the animals used ranging from cats and rabbits to fish, although dogs are the most commonly used pet in institutional settings. The aim of using a pet is usually to reduce stress and improve an individuals health outcomes (Stanley-Hermanns and Miller 2002). Gradually, however, it has been realised that animals offer more than just companionship but whether animals contribute to a persons bio-psychosocial wellbeing is a question that has not been well researched, prompting Parshall (2003) to comment on the paucity of empirical studies. It is thought, however, that a number of healthcare institutions across the UK allow ani-

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mal visitation for example on childrens wards, rehabilitation wards, hospices and nursing homes (SCAS 2005) and animals, including cats, rabbits and dogs, have been brought in to interact with older people, in most cases where the person has no regular visitors. Soosayraj (2003) argues that the recipients of animal visits become more responsive and active, but provides no evidence to back this assertion. In most cases, providing that official policy allows animals to be brought into the hospital, staff approach organisations that cater for animals (Owen 2001). The SCAS claims to have backed a number of projects using animals as therapy in institutions and has devised criteria governing the suitability of animals for intervention. It has also produced a code of good practice to ensure hygiene standards, protection of residents and the welfare of the animal. For example, the animal should have a calm temperament, and be mature and free from disease (Beck 2000). Crucially, participating institutions should adhere to health and safety protocols and procedures. How the animal is used to develop a therapeutic environment differs, with some establishments having a resident dog (McCabe et al 2002), while in others the handler takes the dog to particular residents for them to pat and touch (Dono 2005). Some allow the dog to wander freely among clients.

Different terminology
There appears to be a wide range of terminologies and definitions used to describe this kind of therapy (Edwards and Beck 2003), giving rise to misunderstanding. The literature uses different forms to describe animal therapy: a resident dog (McCabe et al 2002); assisted animal therapy; animal visitation; pet therapy (Velde et al 2005); assisted animal activities (Dono 2005); and human-animal bond therapy (Ormerod 2005). Some of these describe owning an animal as a pet (Prosser et al 2008), while others involve establishments that promote the introduction of animal-assisted therapy (Soosayraj 2003). There is no clear distinction between these terms but what is important is that the animal or pet is actively engaged in a therapeutic context for a purpose. In this article, the focus is on dog visitation therapy, which clearly identifies the animal or pet used. In all cases, the animal or pet is used therapeutically and the therapy follows a structured programme that ultimately serves to stimulate residents interest (Fick 1993, Dono 2005), adhering to certain protocols and to promote health.

Bio-psychosocial benefits
Pet therapy has been shown to have some effect on people with dementia (Walsh et al 1995, Velde

et al 2005, Morrison 2007) and on hypertension (Walsh et al 1995, Baun et al 2002), with evidence still being sought to establish whether pets contribute to a persons wellbeing (Hubbard and Tester 2003). A proliferation of studies has concentrated on animal-assisted interactions in nursing homes and psychiatric institutions (Fick 1993, Jorgenson 1997, Barker and Dawson 1998, Kaisler et al 2002, Wenborn 2004, Filan and Llewellyn-Jones 2006), although a majority of the studies are anecdotal. The literature asserts that the introduction of dog therapy in a care setting may stimulate the social environment, with patients becoming more responsive and interactive. However, criticisms have been levelled at studies for their lack of scientific rigour. In an effort to rectify this weakness, some experimental studies have been undertaken. While using an experimental design to measure the effects of the presence of a dog on patients with dementia in a psychiatric ward in comparison with a matched control group, Walsh et al (1995) found that the presence of the dog invoked generalised palliative effects. These included reduced incidents of yelling, screaming and abusive behaviour towards nursing staff, with consequent reduction in noise levels and a significant reduction in patients heart rates. Walsh et al (1995) used a range of rating scales that measured mental disorganisation/confusion, physical disability, socially irritating behaviour and disengagement, although it may be difficult to decipher what exactly is being measured in these broad categories. Additionally, a behaviour scale was used to assess the daily functioning of people with dementia, but the findings showed no statistically significant differences between experimental groups and the control. Because the study did not provide detailed information on how these scales were used, it is difficult to draw firm conclusions. A study by Elliot and Milner (1991) found that visits from a dog can increase older peoples interaction, with nurses noting an improvement in both the quality and quantity of patients interactions. The studys aim was to evaluate what changes followed the visits of a companion dog to one ward for older people with dementia and another for people with depression, with the dogs absence used to provide control data. But the findings need to be treated with caution as other variables, such as the presence of the dogs owner, could have influenced the findings, resulting in a Hawthorne effect (Parahoo 2006): where a subjects change of behaviour is due to being observed rather than as a result of intervention; in this case, the presence of the dog owner rather than rather than the dog intervention therapy. Barker and Dawson (1998) found no statistically

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significant differences in anxiety rating scales using the same sample population of psychiatric patients before and after the introduction of a pet into a single session in comparison with involvement in recreational group activity. A possible explanation for this is that in both treatments human presence, rather than the dogs, may have influenced patients responses. Another study reported a significant reduction in noise levels and increased social interaction following the animals introduction (Richeson 2003). These findings are comparable with those of Fick (1993) who, in an effort to determine the effects of the presence and absence of a dog, showed clearly that a significant difference in verbal interaction among residents occurred when the dog was present. Using a range of measurement tools before and after therapy for example, a behaviour problem rating scale McCabe et al (2002) attempted to evaluate the effect of a dog on problem behaviour in a sample population of 22 people in a special care dementia unit. The dog was with the residents in the mornings and evenings, except at meal times, and the frequency with which medication was administered to control problem behaviour was noted. The findings suggest that there was a sustained positive effect on the behavioural disturbances measured aggression, irritability, poor sleep, and inappropriate and annoying behaviour over a four-week period. Behavioural mean scores during evening shifts were lower than day shift scores. Although the study does not provide a rationale, it could be that patients are less active and more tired in the evenings, hence the low scores. Motomura et al (2004) investigated the impact of animal-assisted therapy on eight female nursing home residents with dementia using a number of mental state examination assessment tools. The findings suggest no significant difference in irritability and depression pre- and post-therapy but a greater improvement was noted in the apathy dimension. Although there were no significant differences in all the sub-scales, the authors report that 63 per cent of the residents indicated that they liked the dogs and would like the activity repeated. The authors recommended further research on animalassisted therapy. Hall and Malpus (2000) examined the social effects of pet therapy on ten patients with chronic psychiatric illness using a quasi-experimental design. They found a noticeable increase in verbal and nonverbal social behaviours during twice-weekly visits by a dog, but the exact timeframe of the dogs visits is unclear, therefore drawing firm conclusions is problematic. A number of studies have demonstrated how pet therapy can be beneficial. A six-month study of a sample population of 60 residents interacting with a dog revealed a positive behavioural change (Ormerod 2005), while other studies noted a reduction in blood pressure, and the promotion of healing processes and relaxation (Colombo et al 2006). According to the literature, a number of residential homes either possess a resident animal or have an animal visitation programme, which could be integral to their psychosocial recreational programmes (Beck and Katcher 1996). There is evidence to show that the presence of a dog can noticeably improve social behaviours including smiles and laughs when the animal is present (Batson et al 1997). Few disadvantages have been reported in the use of pet therapy. One criticism levelled at some studies into animal-assisted therapy is that there are often no goals or that the evaluation of the goal is unclear (Beck 2000). Zisselman et al (1996), who evaluated pet therapy in patients with dementia, reported no significant effects, but noted that women who received either pet therapy or exercise intervention had improved irritable behaviour scores after treatment. This seems to suggest that any diversionary tactic can instil therapeutic effects in subjects, as evidenced also by Kaisler et al (2002), who concluded that a visit to nursing home residents from a happy person may be just as beneficial as a dog visitor. Six residents were visited by a happy person and by a dog. They were equally likely to smile at and move closer to both visitors. It is not clear whether these residents were diagnosed with dementia. Caution needs to be exercised when interpreting the results on account of the small sample size, which makes generalisation difficult. The authors recommend further research on animal-assisted interventions. Animals offer humans physical contact, something that can be missing in older people and which can revive pleasant memories. Summing up the physical benefits of pet therapy, Reiman (2002) states: Residents can stroke their visitors, ably assisting socialisation and encouraging physical movement. The attachment between an animal and a resident is also said to be unconditional and less complicated than human relationships. Attachment is one of the psychological needs vital for the maintenance of wellbeing in dementia (Kitwood 1997) and can be gained through different relationships including those with animals, which have the ability to generate a response in clients who may not respond to other forms of therapy (Velde et al 2005). To summarise, the literature reports a range of benefits stemming from pet therapy including

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non-verbal and tactile outcomes (Fick 1993), social interaction and pleasurable activity (Beck 2000, Kaisler et al 2002, Motomura et al 2004, Morrison 2007), play, laughter, comfort, and enjoyment from touching and watching the animal (Hall and Malpus 2000). Psychosocial function, life satisfaction, social competence and psychological wellbeing may all be improved and depression reduced (Walsh et al 1995, Edwards and Beck 2003).

Discussion
Although pet therapy has been around for a long time, it appears not to be used routinely as part of a complete care programme (McColgan and Schofield 2007). Morrison (2007) notes that it is not widely incorporated into mainstream healthcare delivery. There may be some contraindications to pet therapy. Notably, patients may be uninterested in or even afraid of the animal or allergic to it. In addition, they may have medical conditions that could be aggravated by the presence of an animal (Morrison 2007). It is crucial to recognise that not all older people like dogs or other animals and do not welcome their presence (McColgan and Schofield 2007). But evidence shows that pet therapy has a significant influence on the psychosocial wellbeing of older adults living in the community or in institutions. As a companion for an older adult, a pet may reduce loneliness and owning a dog negates feelings of isolation (Prosser et al 2008). In some instances the presence of the animal offers the person meaningful and stimulating activity (Velde et al 2005). A number of studies have described the psychological and social benefits associated with animal-assisted therapy for people experiencing dementia. The use of animals can improve older peoples motivation and incentive to participate in an activity that staff have described repeatedly as enjoyable (Hubbard and Tester 2003). And visits by dogs may help combat some of the negative aspects of long-term hospitalisation. Reviewing the literature, it appears that there is a dearth of empirical research pertaining to pet therapy, with a number of studies recommending further investigations be carried out to find a direct link between pet therapy and outcomes (Kaisler et al 2002, Prosser et al 2008). Methodologically, there is a variation in the designs of these studies, and the fact that a majority are anecdotal has been a major criticism. However, a small number have attempted to address such criticism by using experimental designs, albeit, in most instances, single case studies (Walsh et al 1995, Hall and Malpus 2000, McCabe et al 2002).

In none of the studies is it clearly documented what protocols were followed to avoid risk to patients. Furthermore, it is not clear how ethical approval was sought to protect the subjects, particularly those with dementia who may have been unable to give consent to the research. Also missing from the literature is relatives perspectives on dog visitation therapy. It is vitally important to ensure that dogs used in this kind of therapy are screened for their suitability. A risk assessment should also be undertaken to make sure that patients are not exposed to something detrimental to their health. Most of the studies cited tend to be quantitative in nature, with very little qualitative data. Even so, there is limited evidence to demonstrate the effectiveness of animal-assisted therapy. And yet, although the studies may not be considered to provide an evidence base according to the hierarchy of evidence (Ryrie and Norman 2004), nevertheless, they show repeatedly that the use of animals provides some positive outcomes, including stimulation in patients with dementia. What is noticeable, however, is that the therapeutic responses tended to be transient, occurring only in the presence of the animal, although Hall and Malpus (2000) suggest that the effects last for longer, exceeding the period they term the factor of novelty. A number of the studies have been small in scale or had some methodological inadequacies, or both, so the results should be interpreted with caution. One basic problem is finding suitable outcome measures. Some researchers have used standardised instruments that measure cognitive functional state while others have looked for improvements in problem behaviour and social interaction both during and following a therapeutic activity. A further difficulty that all researchers in the dementia field appear to encounter is that it is often impossible to ask older people experiencing severe dementia for their subjective reaction to activities with animals or to ask them to fill in standardised questionnaires, so alternative ways of collecting data have to be found. None of the studies reviewed attempted to use dementia care mapping (DCM), specially designed to assess the complete wellbeing profile of patients. Over the past ten years, DCM has been used extensively in the UK and internationally (Brooker 2005), and is believed to have the potential to improve wellbeing in patients. Used as a research tool (Younger and Martin 2000, Beavis et al 2002, Claudia and KayserJones 2004), it has been checked for reliability and validity and found to stand up to academic scrutiny (Brooker 2005). Fossey et al (2002) concluded that DCM is a useful tool for longitudinal and interven-

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tion studies among people with cognitive impairment residing in care facilities. as some staff may be opposed to the idea and there may be no official policy on how or when animals can be introduced to a care facility. SCAS advocates the use of dog visits as long as there are stringent policies and protocols to safeguard the health and safety of patients. The intervention has to be fully supported by the multidisciplinary team, including patients or residents carers. Weekly dog visits can contribute to a structured routine but there should be constant monitoring and evaluation of the effectiveness of the therapy by reference to wellbeing indicators, with outcomes documented in care plans n

Implications for practice

NICE guidelines (2006) have highlighted the importance of using pet therapy, where available, in dementia care. Many of the studies reviewed clearly support the use of pet therapy despite showing little scientific and methodological rigour. There appears to be a general agreement that whatever form of pet therapy is in place it is advantageous to clients, particularly those who are institutionalised. It is not always easy to introduce animals

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