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An Evaluation of Dog-Assisted Therapy for Residents of Aged Care Facilities with Dementia

Taylor & Francis
Anthrozoös
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Although some research suggests that dog-assisted therapy may be beneficial for people with dementia living in residential aged care facilities, the intervention has not been adequately investigated. To address this shortcoming, we conducted a randomized controlled trial of dog-assisted therapy versus a human-therapist-only intervention for this population. Fifty-five residents with mild to moderate dementia living in three Australian residential aged care facilities completed an 11-week trial of the interventions. Allocation to the intervention was random and participants completed validated measures of mood, psychosocial functioning, and quality of life (QOL), both prior to and following the intervention. No adverse events were associated with the dog-assisted intervention, and following it participants who had worse baseline depression scores demonstrated significantly improved depression scores relative to participants in the human-therapist-only intervention. Participants in the dog-assisted intervention also showed significant improvements on a measure of QOL in one facility compared with those in the human-therapist-only group (although worse in another facility that had been affected by an outbreak of gastroenteritis). This study provides some evidence that dog-assisted therapy may be beneficial for some residents of aged care facilities with dementia.
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An Evaluation of Dog-
Assisted Therapy for
Residents of Aged Care
Facilities with Dementia
Catherine Travers*, Jacqueline Perkins, Jacqui
Rand, Helen Bartlett§and John Morton**
*Centre for Research in Geriatric Medicine, The University of
Queensland, Woolloongabba, Queensland, Australia
PO Box 118, Bribie Island, Queensland, Australia
Centre for Companion Animal Health, School of Veterinary Science,
The University of Queensland, St. Lucia, Queensland, Australia
§Monash University—Gippsland Campus, Churchill, Victoria, Australia
**PPO Box 2277, Geelong, Victoria, Australia
ABSTRACT Although some research suggests that dog-assisted ther-
apy may be beneficial for people with dementia living in residential aged
care facilities, the intervention has not been adequately investigated. To
address this shortcoming, we conducted a randomized controlled trial of
dog-assisted therapy versus a human-therapist-only intervention for this
population. Fifty-five residents with mild to moderate dementia living in
three Australian residential aged care facilities completed an 11-week trial
of the interventions. Allocation to the intervention was random and partic-
ipants completed validated measures of mood, psychosocial functioning,
and quality of life (QOL), both prior to and following the intervention. No
adverse events were associated with the dog-assisted intervention, and
following it participants who had worse baseline depression scores
demonstrated significantly improved depression scores relative to partic-
ipants in the human-therapist-only intervention. Participants in the dog-
assisted intervention also showed significant improvements on a measure
of QOL in one facility compared with those in the human-therapist-only
group (although worse in another facility that had been affected by an
outbreak of gastroenteritis). This study provides some evidence that
dog-assisted therapy may be beneficial for some residents of aged care
facilities with dementia.
Keywords: behavior therapy, dementia, dogs, residential facilities, social
behavior
213 Anthrozoös DOI:
ANTHROZOÖS VOLUME 26, ISSUE 2 REPRINTS AVAILABLE PHOTOCOPYING © ISAZ 2013
PP. 213–225 DIRECTLY FROM PERMITTED PRINTED IN THE UK
THE PUBLISHERS BY LICENSE ONLY
Address for correspondence:
Dr Catherine Travers,
The University of Queens-
land, Centre for Research in
Geriatric Medicine,
Level 2, Building 33,
The Princess Alexandra
Hospital,
Ipswich Rd, Woolloongabba,
Queensland 4102, Australia.
E-mail:
catherine.travers@qut.edu.au
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Dementia is a leading cause of disability in later life (The World Health Organization
and The World Bank 1996) and often precipitates institutional placement in developed
countries (Knapp and Prince 2007). Frequently, behavioral and psychological symp-
toms such as wandering, agitation, aggression, disinhibition, and apathy accompany dementia
and have been reported in as many as 86% of patients with dementia living in residential care
settings (Ballard et al. 2001). These symptoms not only cause distress to the individual con-
cerned but negatively impact upon the quality of life of carers and co-residents, and lead to
considerable stress and burn-out in care staff (Gilley et al. 1991; Astrom et al. 2004).
Although a need for effective treatments for behavioral and psychological symptoms in pa-
tients with dementia is clearly evident, few such treatments have been identified. Pharmacolog-
ical approaches are mainly of benefit in the short-term and pose safety concerns in these patients
(Schneider, Dagerman and Insel 2005), and although a number of non-pharmacological
approaches have been trialed, the effects are modest, at best. Of the non-pharmacological
a p proaches that have been investigated, dog-assisted therapy has demonstrated some promise
in ameliorating these symptoms in people with dementia, with increases in pro-social behavior
and decreases in agitated behavior reported (Perkins et al. 2008). It has been suggested that
dog-assisted therapy addresses the “unmet needs” of patients with dementia that underlie the
behavioral and psychological symptoms (Cohen-Mansfield and Werner 1997; Richeson 2003),
by introducing activities that provide meaningful activity, stimulation, pleasurable social interaction,
and comfort through physical contact.
However, evidence regarding the effects of dog-assisted therapy for patients with dementia
is limited and only nine such studies were identified for inclusion in a recent review (Perkins et
al. 2008). The studies, however, involved relatively small numbers of participants, ranging from
four to 28, and varied in a number of dimensions including the outcome measures used (phys-
iological versus observational versus questionnaire), the setting in which the intervention was
delivered (residential care versus psychiatric day hospital), the severity of dementia of the par-
ticipants (mild to moderate to severe), the duration and frequency of the intervention (from one
10-minute session to 24 3-hour sessions over 12 weeks) and the mode of the intervention
(resident dog versus visiting dog, delivered individually or in a group setting) (Kongable, Buck-
walter and Stolley 1989; Walsh et al. 1995; Batson et al. 1998; Churchill et al. 1999; Kanamori
et al. 2001; McCabe et al. 2002; Richeson 2003; Motomura, Yagi and Ohyama 2004; Sellers
2005). Seven of the studies involved a test-retest design with only two being randomized con-
trolled trials (RCTs) (Walsh et al. 1995; Kanamori et al. 2001). So for most of these studies, it
is not possible to assess the extent to which the outcomes were due to the dog or whether
they might also have occurred without the dog (human-therapist-only therapy).
Thus, the aim of the present study was to conduct a RCT of dog-assisted therapy for people
with dementia living in aged care facilities using validated instruments of mood, quality of life, and
psychosocial functioning, and controlling for potentially confounding variables. It was hypothesized
that dog-assisted therapy would result in improvements in mood, quality of life and psychosocial
functioning in residents with dementia compared with a human-therapist-only intervention.
Methods
A multicenter RCT was conducted, with participants randomly allocated to either the dog- assisted
or the human-therapist-only interventions within three aged care facilities. The University of
Queensland Human Research Ethics Committee approved the study, and informed, written con-
sent was obtained from each participant or their legal guardian, prior to commencing the study.
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Sample Size
Based on logistic and resource constraints, it was estimated that approximately 20 participants
in each of three facilities could be managed in the therapy sessions, 10 in each intervention
group. Accordingly, as these constraints determined sample size, no a priori sample size/power
calculations were performed.
Participants
Residents from three residential aged care facilities located in and around Brisbane (population
1.85 million; Australian Bureau of Statistics 2008), Australia, were invited to participate in the
study. The facilities ranged in size from 90 to 130 beds, and each facility catered for residents
with low- and high-care needs. No facility had a current or prior pet therapy program and none
had a resident dog, although all facilities had caged parakeets. Residents were eligible for inclu-
sion in the study if a probable diagnosis of mild to moderate dementia of any kind was recorded
in the resident’s medical record. Residents with severe dementia were excluded, as participants
were required to be cognitively able to complete the baseline and follow-up measures. Initially,
77 residents were deemed potentially eligible for the trial by the study psychologist, in collabo-
ration with each facility’s senior recreational therapist. Of those, 10 were ineligible or did not par-
ticipate. Sixty-seven were enrolled in the study and randomized to a treatment group; 55
completed the study. Reasons for non-participation and withdrawal are presented in Figure 1.
Procedure
Following consenting procedures, within each facility, participants were randomly assigned
(names were drawn from a hat) to either a dog-assisted therapy group or a human-therapist-
only group (control), with approximately 10 participants in each group. Prior to commencement
of the study, basic demographic details were obtained from each participant (or their chart) in-
cluding the length of time the participant had resided in the facility, psychotropic medications
regularly taken (including antidepressants, benzodiazepines, cholinesterase inhibitors, an-
tipsychotics and mood stabilizers), and whether they had owned a dog prior to entering the
facility. Reasons for not owning a dog were also sought; no participant identified dog allergies
Figure 1. Study flowchart.
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as a problem. The Modified Mini-Mental State Exam (MSE-3MS) (Teng and Chui 1987) was
used to assess cognitive capacity and is a valid and reliable measure in patients with demen-
tia (Bravo and He´bert 1997). MSE-3MS scores range from 0 to 100, and a cut-off score of
77 has been shown to have a sensitivity of 92% for differentiating impaired cognition (lower
scores) and intact cognition (Tombaugh et al. 1996).
Questionnaire measures of quality of life, mood, and psychosocial functioning were also ad-
ministered by the study psychologist one week before the study started and in the week fol-
lowing its completion. The psychologist was blinded regarding the intervention received by
each resident. Records of participants’ attendance at each therapy session were also main-
tained by the therapist to assess treatment fidelity.
Interventions
All therapy sessions were conducted by a therapist who was a veterinarian (JP) and who was
also a registered psychiatric nurse with previous experience working with people with demen-
tia and in conducting small group therapy sessions. Prior to implementing the interventions,
the therapist received four days training in recreational therapy theory and techniques from a
consultant recreational therapist experienced in conducting dog-assisted therapy for people
with dementia living in residential aged care. To structure and standardize interventions, semi-
structured session protocols were developed and implemented. Each therapy session involved
an introductory activity, general discussion, the opportunity for each participant to individually
interact with the dog through play, petting and/or feeding it, and concluded by reading a short
story to the group (see Table 1 for details). The human-therapist-only intervention adopted the
same format but instead of a dog, an article was brought into each therapy session to stimulate
discussion (e.g., an unusual insect in a bottle, a plant cutting).
The interventions were conducted sequentially over an 18-month period. Although each
intervention lasted only 11 weeks, additional time was required to establish relationships
with each facility, to negotiate with them regarding the implementation of the interventions,
and recruit and consent participants. Sessions were conducted three times a week in Fa-
cility A (the first facility in which the intervention was conducted). However, based on advice
from staff in that facility that the time commitment with three sessions a week was too great
for both residents and facility staff, the intervention consisted of two sessions per week in
Facilities B and C.
Sessions were conducted on two non-consecutive days for 11 consecutive weeks, with
each session lasting 40 to 50 minutes. Each facility provided a room in which to conduct the
sessions, and while the control group therapy session was conducted, the therapy dog was
housed in a covered crate in an adjoining secure area; control group participants did not have
any contact with the dog.
Therapy Dogs
Three dogs (Miniature Poodle, Staffordshire Terrier, German Shepherd) owned by the thera-
pist were used, and were either Delta Society (Australia) accredited (two dogs) or accredited
by the consultant therapist. All dogs were fully vaccinated and in good physical health. Only
one dog was present at a therapy session, and the dogs were used in a rotating order to min-
imize stress to the dogs. The dogs were kept on a lead for the duration of the dog-assisted
therapy session, with the lead occasionally held by participants instead of the therapist, but al-
ways under the supervision of the therapist. Participants were advised to wear long sleeves
and trousers to minimize the possibility of skin tears or bruising from dog contact.
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Outcome Measures
Participants’ quality of life (QOL) was assessed using the Quality of Life-Alzheimer’s Disease
(QOL-AD)(Logsdon et al. 1999), a brief, psychometrically sound, 13-item measure developed
for use with individuals with dementia that can be reliably completed by individuals with a
MMSE score of more than 10 (Logsdon et al. 2002). Issues assessed include relationships with
Travers et al.
217 Anthrozoös
Table 1. Example of a session plan: dog-assisted therapy and human-therapist-only interven-
tions.*
Dog-Assisted Therapy Session Plan:
Seat each participant and apply name tag,
Greet each participant by name, introduce myself (JP) and the dog,
Address the group and briefly state why I (JP) am here and they are helping me learn,
Take dog to each participant, and allow participant to offer small supplied food treat and pet and talk to dog,
Dog can remain either sitting with, or on lap of, a participant throughout the remainder of the session (rotate),
depending on willingness of participants and dog,
Draw attention to the dog’s name, mention how the dog got its name, and ask participant to name as many
other dog names beginning with the same letter as they can,
Pass an item around e.g., gloves, scarf, hat. Ask “what is this item, tell me about one you had, and why is it
useful?” Discuss,
Volunteer participants to dress-up dog with supplied outfit (e.g., super dog outfit, fur-lined small coat, jumper,
scarf),
Dog’s history/news e.g., pound dog, recent dog sporting competitions,
Display relevant dog breed from dog encyclopedia and briefly discuss breed attributes,
Read short story from “Chicken Soup for the Dog Lover’s Soul” or poetry about dog(s) or human–animal
relationships,
Writing poetry: for three participants, construct poem about their dog prompted by my lines e.g., “Golly (one
of the therapy dog’s names) is furry, (human therapist name) loves Golly, Golly likes to play ball ... what was
your dog’s name?” (any animal subject will suffice, or if no prior pet ownership, construct the participant’s
poem around a person they were close to),
Thank each participant by name for attending and remind them of the day and time of the next session,
Human-Therapist-Only Session Plan:
Seat each participant and apply name tag,
Greet each participant by name, introduce myself (JP) individually to each participant and touch them gently
on the lower arm, if appropriate,
Address the group and briefly state why I (JP) am here and they are helping me learn,
Draw attention to my name, mention a nick-name, and ask participants to name as many other names be-
ginning with the letter “J” as they can, and encourage them to offer some of their own nick-names and ex-
plain how those nick-names came about,
Mention my family or friend’s history/news e.g., recent events, show relevant materials such as photos or
other mementos. Invite participants to mention any recent special events (birthdays, anniversaries etc),
Pass an item around e.g., scarf, hat. Ask “what is this item, tell me about one you had and why is it useful?”
Display and pass around an interesting insect in a jar or fresh flower/plant cutting,
Display an impressive tree from tree encyclopedia and briefly discuss attributes,
Read short story from “Chicken Soup for the Soul” or poetry about human relationships,
Writing poetry: for three participants, construct poem about their loved ones prompted by my lines e.g., “Ron
is my friend, JP loves Ron, Ron likes to go for walks and work with timber ... what was your friend’s name?”
Thank each participant by name for attending and remind them of the day and time of the next session.
*All sessions adopted this format although topics and activities varied to maintain participant’s interest.
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family and friends, physical health, mood, financial concerns, and overall QOL, and each item
is rated using a 4-point scale, from 1 (poor) to 4 (excellent). Total scores range from 1 to 52,
with higher scores indicating better QOL.
The Medical Outcomes Study 36-Item Short Form Health Survey Version 1.0 (SF-36;
McHorney et al. 1994) was also administered to participants as a broader measure of self-re-
ported health-related QOL. The SF-36 is a psychometrically sound, 36-item instrument with
eight subscales: physical functioning, role limitations due to physical health problems, bodily
pain, social functioning, general mental health (psychological distress and psychological well-
being), vitality (energy/fatigue), role limitations due to emotional problems, and general health
perceptions. Raw scale scores are transformed to a 0 to 100 scale, with higher scores re-
flecting better health status. The SF-36 has been used extensively and has been previously
used with frail, older patients with dementia (Cohen et al.2002). High levels of internal consis-
tency (= 0.8–0.9; Shadbolt, McCallum and Singh 1997) and test-retest reliabilities for each
subscale have been reported (Sanson-Fisher and Perkins 1998).
The Geriatric Depression Scale Short Form (GDS-SF; Sheikh and Yesavage 1996), a 15-
item self-report measure of depression, was also administered. It is suitable for use in people
with a MMSE of 14 or greater (Royal Australian College of General Practitioners 2006), and
scores range from 0 to 15, with scores of 6 or more suggestive of depression. The GDS-SF
has been found to correlate significantly with major depression (p< 0.001), and the sensitiv-
ity and specificity of the GDS-SF has been reported to be 81.5% and 75.4%, respectively,
using a cut-off of 6 (Friedman, Heisel and Delavan 2005).
Residents’ psychosocial functioning and behavior was measured using the Multidimensional
Observational Scale for Elderly Subjects (MOSES; Helmes, Csapo and Short 1987). The scale
consists of 40 items that yield five subscales measuring self-care (the ability to independently
bathe and groom oneself), disoriented behavior, depressed/anxious moods, irritable behavior,
and withdrawn behavior. Each item is rated on a 4-point Likert scale (1–4), with lower scores re-
flecting better functioning (subscale scores range: 1–32). The MOSES has sound psychometric
properties, with inter-rater reliabilities of 0.58–0.97 and internal consistency reliabilities of
0.78–0.88 reported for the five subscales (Helmes, Csapo and Short 1987). Facility staff completed
the MOSES for each participant. They were not blinded to participants’ group status.
Data Analyses
Outcome scores were treated as continuous (interval) data. For each measure, mean scores
following therapy were compared between the two groups using multivariable linear regres-
sion, using Stata Version 11 (StataCorp, College Station, TX, USA), with facility fitted as fixed
effect. Covariates were fitted and retained in the model if either the regression coefficient for
therapy group changed and/or the standard error for this coefficient reduced by non-negligi-
ble amounts. When analyzing variables other than SF-36 measures, covariates assessed were
the baseline value for the same measure, baseline MOSES depression subscale score, and
marital status (currently married or not), in that order. When analyzing SF-36 measures, co-
variates assessed were the baseline value for that measure, baseline MOSES depression sub-
scale score, marital status, and baseline SF-36 bodily pain subscale score, in that order. Once
this model was finalized, to assess whether the effects of therapy differed by facility, interac-
tions between therapy group and facility were assessed, with facility fitted as a fixed effect; both
interaction terms (one for each of facilities B and C) were retained if the joint p-value based on
a partial F-test was low. To assess whether the effects of therapy differed by baseline scores,
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the interaction between therapy group and baseline scores for the same measure fitted as
continuous variables was then assessed in the same way with baseline scores also fitted as
a main effect. As there was evidence of an interaction between baseline MOSES depression
score and therapy group, effects of therapy (dog-assisted therapy relative to human-therapist-
only therapy) were reported at three arbitrary depression scores to represent low (mean minus
1 SD), moderate (mean), and high baseline values (mean plus 1 SD) on this continuum while
avoiding extreme values. Although the alternative hypothesis was a one-sided question, the
possibility that dog-assisted therapy has adverse effects could not be eliminated, so two-sided
p-values were used throughout.
Results
Participant Characteristics
Nineteen residents from Facility A, 16 from Facility B, and 20 from Facility C completed the
study, and key characteristics of the two groups are presented in Table 2. The mean age of
participants was 85 years, and they had lived in the facility an average of 2.45 years. Partici-
pants’ baseline scores on measures of cognitive functioning, psychosocial functioning, and
Travers et al.
219 Anthrozoös
Table 2. Demographic and other key characteristics of the dog-assisted therapy and human-
therapist-only groups at baseline.
Dog-Assisted Human-Therapist-Only
Therapy Therapy
(n= 27) (n= 28)
Age (years) M = 84.9; SD = 6.1 M= 85.1; SD = 6.6
Gender
Male 8 (29.6%) 4 (14.3%)
Female 19 (70.4%) 24 (85.7%)
Years in Facility M = 2.5; SD = 2.2 M= 2.4; SD = 2.1
Number of Medications (average) M = 9.2; SD = 3.5 M= 8.1; SD = 4.0
Number Regularly Taking Behavior Modifying Drugs 11 (40.7%) 11 (39.3%)
Number Regularly Taking:
Cholinesterase inhibitors 2 (7.4%) 3 (10.7%)
Antidepressants 5 (18.5%) 6 (21.4%)
Benzodiazepines 5 (18.5%) 4 (14.3%)
Antipsychotics/mood stabilizers 1 (3.7%) 4 (14.3%)
Marital Status
Widowed 17 (62.9%) 24 (85.7%)
Married 8 (29.6%) 2 (7.1%)
Divorced 0 1 (3.6%)
Never married 0 1 (3.6%)
No answer 2 (7.4%) 0
Level of Education
Primary school 10 (37.0%) 7 (25%)
High school 15 (55.6%) 18 (64.3%)
Trade certificate 2 (7.4%) 3 (10.7%)
Previous Dog Ownership
Yes 20 (74.1%) 21 (75%)
No 6 (22.2%) 4 (14.3%)
Don’t Know 1 (3.7%) 3 (10.7%)
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QOL are presented in Table 3. MSE-3MS scores were indicative of mild-moderate cognitive
impairment, and the GDS-SF indicated low levels of depression. Participants’ scores on the
SF36 physical functioning subscale were low relative to Australian age-based population norms
(Australian Bureau of Statistics 1995), indicating poor physical functioning (the normative SF36
physical functioning score was 53/100 for Australian adults aged 75 years and older, compared
with means of 24 and 28 for participants in the dog-assisted and human-therapist-only groups,
respectively). Their remaining subscale scores were consistent with mean scores for their age
group (Australian Bureau of Statistics 1995). Their MOSES subscales scores indicated that, on
average, both groups required some supervision with self-care activities, had mild- moderate
levels of withdrawn behavior and disorientation, and relatively low levels of irritability.
Attendance at Therapy Sessions
Attendance at therapy sessions of participants completing the study was high in both groups,
with the percentage attendance averaging 88% for participants in the dog-assisted therapy
group and 90% for those in the human-therapist-only intervention.
Effects of Dog-Assisted Therapy
Participants’ post-therapy scores for each outcome measure, and estimated effects of dog-
assisted therapy relative to human-therapist-only therapy are shown in Table 4. No adverse
events (skin tears, bruising, skin irritation) were associated with the dog-assisted therapy.
After therapy, the mean QOL-AD score in the dog-assisted therapy group was significantly
higher (better) than in the human-therapist-only group (p= 0.02) in one facility (Facility B), but
An Evaluation of Dog-Assisted Therapy for Residents of Aged Care Facilities with Dementia
220 Anthrozoös
Table 3. Baseline scores of the dog-assisted therapy and human-therapist-only groups on
measures of cognition, quality of life, and psychosocial functioning (< indicates better func-
tion is associated with lower scores, and > indicates that higher scores are better).
Measure Dog-Assisted Therapy Human-Therapist-Only
(n= 27) Therapy
Mean (SD)(n= 28)
Mean (SD)
MSE-3MS (>, scale 0–100) 58.1 (19.8) 59.8 (17.2)
Range = 28–93 Range = 24–88
QOL-AD (>, scale 13–52) 34.9 (5.7) 37.0 (4.8)
GDS-SF (<, scale 0–15) 4.1 (3.5) 2.6 (2.2)
MOSES Subscales (<, scale 8–32)
Self-care 18.1 (5.7) 16.6 (6.2)
Disoriented 16.4 (5.2) 17.3 (6.7)
Depression 14.5 (6.1) 15.3 (4.7)
Irritability 11.4 (3.5) 11.4 (4.5)
Withdrawn 17.6 (6.3) 17.1 (5.3)
SF-36 Subscales (>, scale 0–100)
Physical functioning 23.7 (25.1) 28.0 (26.5)
Role limitations due to physical health problems 54.6 (44.9) 70.5 (43.1)
Bodily pain 71.9 (25.5) 71.7 (25.8)
General health perceptions 66.0 (25.9) 71.0 (20.3)
Vitality 53.3 (26.3) 58.0 (24.6)
Social functioning 76.9 (30.8) 83.0 (24.8)
Role limitations due to emotional problems 80.3 (36.1) 77.4 (41.6)
Mental health 75.3 (24.2) 84.3 (12.6)
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Table 4. Post-therapy scores and estimated effects of dog-assisted therapy relative to human-
therapist-only therapy. Participants’ scores for each outcome measure, and estimated effects
of dog-assisted therapy relative to human-therapist-only therapy are shown. Where there was a
significant interaction between therapy group and baseline value, that is, the magnitude of
change in scores differed depending on baseline value (with or without a difference in direction),
separate estimated changes are shown, otherwise estimated changes pooled across all base-
line values are shown. Adjusted estimates indicate how much better or worse participants were
who received dog-assisted therapy compared with predicted scores if they had received
human-therapist-only therapy.
Measure Post-Therapy Scores Effect of Dog-Assisted Therapy
Mean (SD) (Relative to
Human-Therapist-Only Therapy)
Dog-Assisted Human-Therapist- Adjusted Estimate p-value
Therapy Only Therapy (95% CI)
(n= 27) (n= 28)
QOL-AD (>, scale 13–52)
Facility A 34.0 (7.2) 38.9 (5.9) –1.6 (–6.1 to 3.0)* 0.49
Facility B 38.1 (4.4) 33.2 (5.3) 5.6 (0.8 to 10.3)* 0.02
Facility C 34.7 (4.9) 39.6 (6.1) –4.8 (–8.9 to –0.8)* 0.02
GDS–SF (<, scale 0–15¥¥)4.0 (2.9) 2.6 (2.1) 0.3 (–0.7 to 1.4)** 0.51
MOSES Subscales (<, scale 8–32)
Self-care 17.5 (6.5) 17.4 (6.1) –0.8 (–2.9 to 1.2)0.42
Disoriented 15.9 (6.6) 16.8 (6.4) 0.4 (–2.1 to 2.8)¶¶ 0.75
Depression Baseline score¥: 12.5 (3.7) 14.6 (3.9)
9.51 (mean minus 1 SD) 0.4 (–2.1 to 2.9) 0.75
14.91 (mean) –1.6 (-3.4 to 0.1) 0.07
20.31 (mean plus 1 SD) –3.6 (-6.1 to -1.1) < 0.01
Irritability 10.0 (3.6) 11.1 (3.9) –0.1 (–2.1 to 1.8)¶¶¶ 0.88
Withdrawn 16.0 (4.5) 16.6 (5.2) –0.1 (–2.7 to 2.4)¶¶¶¶ 0.91
SF36 Subscales (>, scale 0–100)
Physical functioning 24.8 (20.5) 23.6 (22.3) 1.0 (–10.3 to 12.3)#0.86
Role limitations due to
physical health problems 66.7 (41.0) 51.8 (41.9) 19.2 (–3.1 to 41.5)## 0.09
Bodily pain 68.0 (25.3) 70.9 (29.4) –4.9 (–19.2 to 9.3)### 0.49
General health perceptions 62.3 (24.6) 71.4 (18.6) –7.8 (–17.5 to 2.0)#### 0.12
Vitality 57.0 (24.5) 69.1 (21.7) –7.8 (–17.4 to 1.8)^0.11
Social functioning 80.1 (24.1) 81.7 (24.4) 3.6 (–9.5 to 16.8)^^ 0.58
Role limitations due to
emotional problems 87.7 (32.2) 85.7 (33.3) 8.6 (–9.0 to 26.2)^^^ 0.33
Mental health 76.6 (18.9) 76.9 (18.3) 1.7 (–7.8 to 11.3)^^^^ 0.72
*Adjusted for baseline QOL-AD and baseline MOSES depression subscale; **adjusted for baseline GDS-SF.
Adjusted for baseline MOSES self-care subscale; ¶¶ adjusted for baseline MOSES disoriented subscale;
¶¶¶adjusted for baseline MOSES irritability subscale and current marital status; ¶¶¶¶adjusted for baseline MOSES
withdrawn subscale and current marital status.
#Adjusted for baseline SF-36 physical functioning and bodily pain subscales and current marital status;
##adjusted for baseline SF-36 physical health problems and bodily pain subscales and current marital status;
###adjusted for baseline SF-36 bodily pain subscale, baseline MOSES depression subscale and current mari-
tal status; ####adjusted for baseline SF-36 general health perceptions and bodily pain subscales and current
marital status.
^Adjusted for initial SF-36 vitality and bodily pain subscales, baseline MOSES depression subscale and current
marital status; ^^adjusted for baseline SF-36 social functioning and bodily pain subscales, baseline MOSES
depression subscale and current marital status; ^^^adjusted for baseline SF-36 role limitations due to emotional
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PROOF #1 3/19/2013
was significantly lower (p= 0.02) in another (Facility C; significance of interaction p < 0.01).
Importantly, there was an outbreak of gastroenteritis in Facility C in the final week of the inter-
vention (week 11) that affected many of the participants and may have negatively influenced
their outcome scores.
Relative to the human-therapist-only intervention, MOSES depression subscale scores fol-
lowing therapy were moderately lower (better) in participants in the dog-assisted therapy group
with higher (worse) baseline scores, but not in those with low baseline scores (p= 0.03) (see
Table 4). No significant differences post-therapy between the dog-assisted and the human-
therapist-only interventions were observed for any of the remaining measures (see Table 4).
Discussion
This RCT of dog-assisted therapy for people with dementia living in aged care facilities demon-
strated that participants who received dog-assisted therapy had better depression scores on
one measure of depression in those with worse baseline depression scores, and improved
QOL scores in one facility (Facility B) but worse in another (Facility C). Importantly, there was
an outbreak of gastroenteritis in Facility C in week 11 of the intervention, and this may have
negatively affected participants’ QOL-AD scores, although it is not known which participants
were affected by the illness.
Overall, these findings are compatible with the hypothesis that dog-assisted therapy ad-
dressed some of the unmet needs of participants by providing meaningful activity, stimulation,
pleasurable social interaction, and comfort through physical contact. This theory is supported by
one participant who commented: “Seeing the dog makes me feel good; not so lonely.” Enjoy-
ment and engagement in novel, stimulating activity may account for the improved depression
scores in participants in the dog-assisted therapy group which may in turn, underlie the ob-
served improvement in QOL-AD scores in Facility B. Addressing unmet needs through the in-
troduction of a novel, mentally stimulating activity and attention from the therapist may also
account for the improvement in vitality scores in the human-therapist-only group, and the find-
ing that empathic human attention provides therapeutic benefits in this population has been
documented previously (Cohen-Mansfield and Werner 1997). It is likely that the two interventions
addressed a range of needs that varied among participants, and those who really liked dogs
might have derived more enjoyment and benefited more from dog-assisted therapy than other
participants, while the human-therapist-only intervention might have suited other participants
better. Previous studies have demonstrated marked differences in the responses of patients with
dementia to psychosocial interventions, with interventions specifically tailored to address the re-
cipient’s specific preferences being more effective than those that do not (O’Connor et al. 2009).
The variability in findings across facilities in the present study also suggests that the facility
in which the intervention is implemented may have important modifying effects. For example,
An Evaluation of Dog-Assisted Therapy for Residents of Aged Care Facilities with Dementia
222 Anthrozoös
problems and bodily pain subscales and current marital status; ^^^^adjusted for baseline SF-36 mental health
subscale, baseline MOSES depression subscale and current marital status.
¥Significant interaction between therapy group and baseline score so effects of therapy were assessed at mean
baseline value (14.91) minus one SD (5.40), at the mean value, and at the mean value plus one SD.
<Indicates better function is associated with lower scores, and > by higher scores; Adjusted estimates indicate
how much better or worse participants were that received dog-assisted therapy compared to predicted scores
if they had received human only therapy (that is, adjusted estimates do not indicate how much better partici-
pants would have been from their initial baseline scores).
¥¥Scores greater than 6 are suggestive of depression and scores greater than 10 indicate that depression is likely.
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PROOF #1 3/19/2013
participants in the dog-assisted therapy group showed improved QOL scores in Facility B,
but declined on this measure in Facility C. Hence, facility characteristics should be considered
in further studies of this kind, and further research is required to identify features of facilities that
may influence the effectiveness of a therapeutic intervention.
Strengths of the Study
The strengths of this study include its large sample size relative to previous studies of dog-as-
sisted therapy in this population, and the random allocation of participants to the interven-
tions, allowing the treatment to be rigorously evaluated without risk of confounding by factors
that may vary across time, a major limitation of test-retest studies. Additional strengths of this
study include the assessment of potentially confounding variables including the use of psy-
chotropic medications that may influence mood and functioning, previous dog ownership,
and other important demographic and psychological variables. In addition, validated measures
of mood, psychosocial functioning, and QOL were used, and were administered by a psy-
chologist who was blinded regarding group allocation. With the exception of the dog, both
groups received a standardized semi-structured intervention delivered by the same therapist,
and a high level of attendance at therapy sessions by participants suggests a high level of
treatment fidelity. The possibility of contamination effects were minimized by ensuring the
human-therapist-only group did not have any dog contact.
Limitations of the Study
The outbreak of gastroenteritis that occurred in Facility C during week 11 of the interven-
tion is an important threat to the validity of the treatment delivered and may have influenced
the results. Participants may have engaged less in therapy sessions if they felt unwell, and
although illnesses such as this regularly occur in residential aged care facilities, it was out-
side our control. In hindsight, it may have been better to reschedule the final session to
another time; this highlights the importance of being flexible when conducting interventions
in this setting.
There is the possibility of selection bias, as approximately 10% of participants were lost
to follow-up. However, as the proportions of participants that withdrew or were lost to follow-
up were similar for both groups, we consider the impact of any such bias to be relatively
small. The non-blinding of facility staff who completed the MOSES questionnaire for partici-
pants may have also introduced some measurement bias. For instance, staff may have sub-
consciously expected improvement in participants’ behavior from participating in a
therapeutic activity, and consequently perceived improvement. However, it was imperative
that the MOSES be completed by someone with good knowledge of participants’ function-
ing and behavior. Finally, it is possible that we failed to detect some true effects of dog-as-
sisted therapy relative to human-therapist-only therapy due to imprecise effect estimates,
insensitivity of the measures used, or insufficient power to detect treatment effects (if they ex-
isted). In addition, the relatively low prevalence of behavioral problems including depression
and irritability in participants at baseline may have limited the potential for improvement. How-
ever, resource limitations precluded undertaking a larger study. Additional studies, ideally
using larger sample sizes (although challenging in this population) are required to further as-
sess the effects of dog-assisted therapy in this population and to assess the validity of our
findings, which, if confirmed, have important implications for both residents with dementia and
aged care facility staff, as even a slight reduction in residents’ care requirements is likely to
reduce the burden of care experienced by staff.
Travers et al.
223 Anthrozoös
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Conclusions
We conclude that dog-assisted therapy appears to be beneficial for some residents of aged
care facilities with mild to moderate dementia. The results have important implications for both
residents with dementia and staff in aged care facilities. Because of the importance of identi-
fying effective treatments for patients with dementia, especially those with severe behavioral
and psychological symptoms, further investigation of dog-assisted therapy for this population
is warranted. This will assist in better identifying those who are most likely to benefit, so that
the intervention can be tailored for, and directed to, this group. The impact of therapy also
appeared to be influenced by facility characteristics; this requires further investigation.
Acknowledgement
We acknowledge the financial support provided by the JO & JR Wicking Trust that made this
study possible.
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... After excluding 752 ineligible studies based on title and abstract screening, 56 were screened by checking the full texts. Finally, 19 studies (Moyle et al., 2013(Moyle et al., , 2017(Moyle et al., , 2019Robinson et al., 2013;Travers et al., 2013;Bono et al., 2015;Friedmann et al., 2015;Jøranson et al., 2015Jøranson et al., , 2016Valenti Soler et al., 2015;Pope et al., 2016;Olsen et al., 2016a,b;Liang et al., 2017;Petersen et al., 2017;Pu et al., 2020;Briones et al., 2021;Quintavalla et al., 2021;Vegue Parra et al., 2021) were included in this network meta-analysis after excluding 37 ineligible studies due to ineligible patients (n = 1), unrelated to the topic (n = 7), lack of outcomes (n = 5), ineligible study designs (n = 15), lack of essential data (n = 4), ineligible language (n = 1), and ineligible aims (n = 4). The process of study selection is depicted in Figure 1. ...
... We summarized the basic characteristics of the included studies in Table 1, and listed the detailed information on AAT and PRT of the included studies in Supplementary Table 2. The outcomes and measurements of the included studies are documented in Supplementary Table 3. Overall, 18 studies (Moyle et al., 2013(Moyle et al., , 2017(Moyle et al., , 2019Robinson et al., 2013;Travers et al., 2013;Bono et al., 2015;Friedmann et al., 2015;Jøranson et al., 2015Jøranson et al., , 2016Pope et al., 2016;Olsen et al., 2016a,b;Liang et al., 2017;Petersen et al., 2017;Pu et al., 2020;Briones et al., 2021;Quintavalla et al., 2021;Vegue Parra et al., 2021) were two-arm design and one study (Valenti Soler et al., 2015) was three-arm design, and all studies were published between 2013 and 2021. The sample size of the included studies ranged from 24 to 334, accumulating a total sample size of 1464. ...
... Nine studies (Moyle et al., 2013(Moyle et al., , 2019Friedmann et al., 2015;Jøranson et al., 2015;Pope et al., 2016;Olsen et al., 2016b;Liang et al., 2017;Pu et al., 2020) reported the data of agitation. Five studies (Bono et al., 2015;Jøranson et al., 2016;Liang et al., 2017;Quintavalla et al., 2021;Vegue Parra et al., 2021) reported the data on cognitive function, and eleven studies (Moyle et al., 2013;Robinson et al., 2013;Travers et al., 2013;Bono et al., 2015;Friedmann et al., 2015;Jøranson et al., 2015;Olsen et al., 2016b;Liang et al., 2017;Petersen et al., 2017;Pu et al., 2020;Vegue Parra et al., 2021) reported the data of depression. Eight studies (Moyle et al., 2013;Robinson et al., 2013;Travers et al., 2013;Valenti Soler et al., 2015;Jøranson et al., 2016;Olsen et al., 2016a,b;Briones et al., 2021) reported the data of QoL. ...
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Objective This network meta-analysis aimed to compare and rank the efficacy of animal-assisted therapy (AAT) and pet-robotic therapy (PRT) in the management of dementia. Methods Relevant studies were identified by searching PubMed, EMBASE, the Cochrane Library, SCOPUS, and Web of Science (WoS) until October 13, 2022. Traditional meta-analysis was first conducted based on the random-effects model, then random network meta-analysis was conducted to determine the relative efficacy and rank probability of AAT and PRT. Results Nineteen randomized controlled trials (RCTs) were included in this network meta-analysis. Network meta-analysis revealed that PRT marginally benefited agitation alleviation compared with control (standard mean difference [SMD]: −0.37, 95% confidence interval [95%CI]: −0.72 to −0.01) although both AAT and PRT did not improve cognitive function, reduce depression, and improve Quality of Life (QoL). The SUCRA probabilities indicated that PRT ranked better than AAT in agitation, cognitive function, and QoL, although there were no differences between the two therapies. Conclusion The present network meta-analysis reveals that PRT may help alleviate agitated behaviors in people with dementia. However, future studies are warranted to establish evidence of the effectiveness of PRT and further evaluate the differences between different robot types in managing dementia.
... Interventions were described as pet encounter therapy, pet-facilitated therapy, pet-assisted living, animal assisted intervention, animal assisted therapy, animal assisted activity or simply dog visits/therapy. The majority of studies were from the USA (n = 11), and the remainder were conducted in Norway [64], Italy [59], South Africa [63], Australia [69], Spain [58,70] and Denmark [67,68]. Nine of the studies had a specific focus on residents living with dementia [58,60,61,64,66,67,68,69,70]. ...
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... Preferred facilitated activities occurring in group settings included: music sessions (Mjørud et al., 2017), dancing (Guzmán-García et al., 2012;Tak et al., 2015), bingo (Cahill & Diaz-Ponce, 2011); pet therapy (Travers et al., 2013), and group storytelling (George & osHouser, 2014). A reading group was shown to increase feelings of belonging (Cooke et al., 2010), and residents experienced improvements in wellbeing (Conradsson et al., 2010) and increased mobility, independence and self-esteem from regular exercise classes (Olsen et al., 2015). ...
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Metodinis studijų vadovas yra skirtas visiems, kurie domisi kultūros ir meno metodais savo psichikos sveikatos stiprinimui. Jis skirtas ir tėvams, auginantiems vaikus su negalia ar specialiaisiais poreikiais, išgyvenantiems sudėtingas gyvenimo situacijas ar tėvystės perdegimą. Šis metodinis leidinys taip pat skirtas aukštųjų mokyklų studentams, kurie studijuoja, domisi ar jau dirba negalios, psichikos sveikatos, psichopatologijos, socialinio darbo, reabilitacijos, visuomenės sveikatos, kultūros ir meno kryptyse.
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A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
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The Mini-Mental State Examination (MMSE; M. F. Folstein, S. E. Folstein, & P. R. McHugh, 1975) and the Modified MMSE (E. L. Teng & H. C. Chui, 1987) were compared psychometrically. In this study, 525 community-dwelling participants, aged 65–89, were divided into 2 groups: no cognitive impairment (NCI; n = 406) and Alzheimer's disease (n = 119). Both tests yielded comparable reliability estimates. Fewer years of education decreased specificity and increased sensitivity, whereas increasing age primarily decreased specificity. It is concluded that although the 2 tests produce comparable effects, the inclusion of a verbal fluency test would increase the sensitivity of the MMSE. Normative data for the NCI group, stratified for 2 age levels (65–79 and 80–89) and 2 educational levels (0–8 and 9+ years), are presented.
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A pets as therapy (PAT) programme was initiated in a closed ward of a major psychiatric hospital. The effect of regular contact with a dog on a selected group of chronic ward-bound patients suffering from dementia was assessed over a 12 week period using a number of measures. These included global measures of daily functioning, physiological measures (blood pressure and heart rate) and a measure of general ward noise levels. A matched group from a similar closed ward was used as a control. Results indicated significant experimental group changes in heart rate and a substantial drop in noise levels in the experimental ward during the presence of the dog.
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The term behavioral and psychological symptoms of dementia (BPSD) encompasses a diverse cluster of behavioral disturbances, such as restlessness (Hope et al., 1994), aggression (Patel & Hope, 1992), and shouting (Cohen-Mansfield & Werner, 1997), and a variety of psychiatric symptoms, including delusions (Burns et al., 1990), hallucinations (Holroyd & Sheldon-Keller, 1995), depression (Greenwald et al., 1989), and anxiety (Ballard et al., 1996a). Such symptoms are extremely common in patients with dementia and have important associations with burden and depression in caregivers.