Am j Alzheimers Dis Other Demen-2012-Nordgren-625-32

7/29/2019 Am j Alzheimers Dis Other Demen-2012-Nordgren-625-32

1/9

http://aja.sagepub.com/Other Dementias

American Journal of Alzheimer's Disease and

http://aja.sagepub.com/content/27/8/625The online version of this article can be found at:

DOI: 10.1177/1533317512464117

2012 27: 625 originally published online 25 October 2012AM J ALZHEIMERS DIS OTHER DEMENLena Nordgren and Gabriella Engstrm

Case Reportffects of Animal-Assisted Therapy on Behavioral and/or Psychological Symptoms in Dementia :

Published by:

http://www.sagepublications.com

can be found at:American Journal of Alzheimer's Disease and Other DementiasAdditional services and information for

http://aja.sagepub.com/cgi/alertsEmail Alerts:

http://aja.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

http://aja.sagepub.com/content/27/8/625.refs.htmlCitations:

What is This?

- Oct 25, 2012OnlineFirst Version of Record

- Nov 9, 2012Version of Record>>

by guest on February 26, 2013aja.sagepub.comDownloaded from
http://aja.sagepub.com/http://aja.sagepub.com/http://aja.sagepub.com/content/27/8/625http://aja.sagepub.com/content/27/8/625http://www.sagepublications.com/http://www.sagepublications.com/http://aja.sagepub.com/cgi/alertshttp://aja.sagepub.com/cgi/alertshttp://aja.sagepub.com/cgi/alertshttp://aja.sagepub.com/subscriptionshttp://aja.sagepub.com/subscriptionshttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsPermissions.navhttp://aja.sagepub.com/content/27/8/625.refs.htmlhttp://aja.sagepub.com/content/27/8/625.refs.htmlhttp://aja.sagepub.com/content/27/8/625.refs.htmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://aja.sagepub.com/content/early/2012/10/22/1533317512464117.full.pdfhttp://aja.sagepub.com/content/early/2012/10/22/1533317512464117.full.pdfhttp://aja.sagepub.com/content/27/8/625.full.pdfhttp://aja.sagepub.com/content/27/8/625.full.pdfhttp://aja.sagepub.com/http://aja.sagepub.com/http://aja.sagepub.com/http://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://aja.sagepub.com/content/early/2012/10/22/1533317512464117.full.pdfhttp://aja.sagepub.com/content/27/8/625.full.pdfhttp://aja.sagepub.com/content/27/8/625.refs.htmlhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsReprints.navhttp://aja.sagepub.com/subscriptionshttp://aja.sagepub.com/cgi/alertshttp://www.sagepublications.com/http://aja.sagepub.com/content/27/8/625http://aja.sagepub.com/


2/9

Current Topics in Research

Effects of Animal-Assisted Therapy onBehavioral and/or Psychological Symptomsin Dementia: A Case Report

Lena Nordgren, PhD1,2 and Gabriella Engstrom, PhD1

Abstract

Background: Recently, interest in nonpharmaceutical interventions in dementia care has increased. Animal-assisted therapy hasbeen shown to be one promising intervention but more knowledge is needed. The present article reports on a pilot study involv-ing an 84-year-old woman with vascular dementia who was systematically trained with a therapy dog team for 8 weeks. Methods:A quasi-experimental longitudinal interventional design with pre-post measures was used. Data were collected on 3 occasions.Descriptive statistics were used for data analysis. Results: Some effects on the womans ability to walk and move were identified.In addition, some effects in the womans cognitive state were observed. Conclusions: Physical, psychological, and/or social train-

ing with certified therapy dog teams can have effects on behavioral and psychological symptoms in people living with dementia.Further research is needed.

Keywords

animal-assisted therapy, BPSD, dementia care, dog therapy, nonpharmaceutical interventions

Introduction

Different dementia diagnoses have different symptoms, but

all types of dementia involve behavioral and/or psychological

symptoms (behavioral and psychological symptoms ofdementia [BPSD]).1 Behavioral and psychological symptoms

of dementia include behaviors such as screaming, wandering,

aggression, and also psychiatric manifestations such as

depression or psychosis.2,3 All types of dementia disease lead

to deteriorated performance of daily activities such as dres-

sing or eating.4 As a result, living with dementia leads to suf-

fering for the people with dementia, their families, and for

professional caregivers.

In order to alleviate suffering and to reduce symptoms, phar-

maceutical interventions are used. However, for persons with

dementia, side-effects from medication can diminish the quality

of life. The importance of identifying alternatives or comple-ments to pharmaceutical treatment, thus, is increasingly

emphasized. In addition, scientific support and evidence for non-

pharmaceutical interventions is increasing.5 One important

justification for nonpharmaceutical interventions is the poor

safety profile of antipsychotics in cases of dementia. The aims

of nonpharmaceutical interventions are to improve the quality

of life for people with dementia and to maintain their remaining

abilities as much as possible. Nonpharmaceutical interventions

are not limited to specific types of dementia. No serious side

effects from nonpharmaceutical treatments in dementia have

been reported. It is, however, a challenge to identify

nonpharmaceutical interventions that minimize or alleviate

BPSD. Examples of nonpharmaceutical interventions are physi-

cal training,4,6 music therapeutic caregiving,7 music therapy8 or

animal-assisted therapy (AAT).9,10 Animal-assisted therapy pro-

grams exist in the United States, Canada, India, Japan, Korea,

Mexico, Sweden, and elsewhere.11

Animal-Assisted Therapy

Animal-assisted therapy has been defined in a variety of

ways: resident dogs, assisted animal interventions, animal vis-

itation, pet therapy, and so on,12 which also reflects a diversity

of practices. However, AAT is usually described as the inter-

action between a client and a trained animal, facilitated by a

human handler, with a therapeutic target such as relaxation

or pleasure.13 Fine14 proposes defining AAT as a goal-

oriented intervention in which an animal meeting specific cri-teria is an integral part of the treatment process. This service is

1 School of Health, Care and Social Welfare, Malardalen University, Eskilstuna,

Sweden2 Centre for Clinical Research, Sormland/Uppsala University, Eskilstuna,

Sweden

Corresponding Author:

Lena Nordgren, PhD, School of Health, Care and Social Welfare, Malardalen

University Box 325, SE-63105 Eskilstuna, Sweden

Email: [email protected]

American Journal of Alzheimers

Disease & Other Dementias

27(8) 625-632

The Author(s) 2012

Reprints and permission:

sagepub.com/journalsPermissions.nav

DOI: 10.1177/1533317512464117

http://aja.sagepub.com

http://aja.sagepub.com/http://aja.sagepub.com/http://aja.sagepub.com/http://aja.sagepub.com/


3/9

delivered by a health or human service professional working

within the scope of his or her professional role. It is believed

that the efficacy of AAT involves a positive emotional

response by the client to the animal.

Animal-Assisted Therapy in Dementia Care

When used in dementia care, AAT takes advantage of the

humananimal bond to reduce behavioral and/or psychological

symptoms and to increase social engagement and communica-

tion. The purpose is to reduce symptoms of BPSD and/or to

train daily activities or functions (Table 1). In AAT, dogs are

used commonly.11,12 The training is always tailored in accor-

dance to the needs of the person with dementia.

A review of the literature suggests that AAT can be bene-

ficial in cases of dementia. Animal-assisted therapy can

decrease agitated behaviors and increase social interac-

tion.10,13 The presence of a dog in nursing homes reduces

aggression and agitation among people with dementia.13 They

smile and laugh more when a dog visits or lives amongthem.13 Other social behaviors that are significantly more

displayed are looks, leans, and touches.13 Dog-visitation

therapy can reduce the incidence of yelling and screaming and

reduces the heart rate as well.12

To sum up, AAT with dogs seems to be well suited for

persons with dementia because the dog provides companion-

ship regardless of the persons cognitive function, and the dog

listens without judgment.15 Despite studies suggesting AAT as

a valuable tool in dementia care, scientific knowledge about the

effects is limited, bringing several questions to mind: Does

AAT affect BPSD? What are the effects of AAT on the activ-

ities of daily living (ADLs)? Is cognitive ability in dementiaaffected by AAT? What is the impact of AAT concerning

quality of life for people with dementia?

In Sweden, AAT usually involves systematic training with a

certified therapy dog and a dog handler (DH). With the aid of the

therapy dog team, different functions such as balance, walking

ability, and much more are trained (Table 1). The therapy dogs

are selected and systematically trained to work in a variety of

health care settings, for example in the care of people with

dementia. Hence, a therapy dog is a kind of assistance dog.

The dog and the DH form a therapy dog team. The ther-

apy dog team is trained for about 40 hours with an instructor. In

addition, the therapy dog team is trained clinically for

approximately 200 hours (6-12 months) in different environ-

ments. The breed is not important for the dogs suitability.

Instead, the dogs personality is crucial. Since AAT is provided

on prescription, licensed health care professionals (eg,

registered nurses, occupational therapists [OTs], and/or

physiotherapists) are also educated.

However, in spite of promising results, some criticismagainst previous research has been raised. The criticism

concerns matters such as small sample sizes, lack of randomi-

zation, and either inappropriate or no control groups.15,16

Therefore, before AAT can be accepted as a valid treatment

in dementia care, more evidence-based research is needed.

This article reports on a pilot study conducted in 2011 in

Sweden. The purpose for the present single-case study was to

gain detailed descriptions of possible effects of AAT in 1 case

of dementia. The aim of the pilot study was to investigate the

effects of AAT on pharmaceutical treatment; behavioral and

psychiatric symptoms; ADLs; cognition and orientation;

quality of life; pain and fall risk.

Methods

The pilot study was undertaken as a quasi-experimental longi-

tudinal intervention study in a municipal nursing home in the

middle part of Sweden. The nursing home comprises a total

of 12 care units (129 apartments). Each resident has 1 or 2

contact personnel (primarily enrolled nurses) that in collabora-

tion with other staff (registered nurses, OTs, and/or phy-

siotherapists) are accountable for providing help and care

according to the residents needs.

Indications for AAT were increasing anxiety, regression

(the person is an introvert and does not participate in activitiesor social relations), communication problems leading to loss of

or reduced ability to engage in social relations, reduced physi-

cal capabilities, or unwillingness to train otherwise, low mood,

behavioral, and/or psychological symptoms.

Inclusion criteriafulfilling one or more indications for

AAT, diagnosed with dementia, living at the nursing home for

more than 4 weeks prior to the intervention, not allergic to

dogs. Exclusion criteriaknown to have expressed anxiety

toward dogs earlier in life or otherwise not considered by staff

as appropriate for AAT (for instance being very aggressive or

getting upset when meeting the dog).

Study Design

A pre-post study with follow-up measurement was used. Mea-

surements were performed before the intervention (prestudy)

and immediately after intervention (poststudy). The interven-

tion lasted for 8 weeks. Follow-up was performed 3 months

after the intervention was ended.

The Participant

The present case report involved Mrs Johnson (fictitious name)

aged 84. She was a widow and had 1 daughter and 1 grandchild.

Table 1. Examples of Capabilities and Features That can be TrainedWith a Certified Therapy Dog Memory

Communication and languageAbility to solve problemsIncreased well-being and self-esteemSocial commitment

Focus and concentrationBalance and muscle strengthFine motor skillsGrip ability and accuracyMovement

626 American Journal of Alzheimers Disease & Other Dementias 27(8)



4/9

Mrs Johnson used to work as a clothing retailer. Mrs Johnson

was known to enjoy nature and animals and was active and

goes for regular walks.

In 2007, Mrs Johnson was diagnosed with cancer in the ton-

gue base. After surgery, she moved to a short-term nursing

home. She then lived in 3 different nursing homes. Eventually,

in 2010, she moved to the current nursing home. Mrs Johnsonsmedical history also included atrial fibrillation, collapsed ver-

tebra, and osteoporosis. In addition, Mrs Johnsons body

weight was low. Other limiting symptoms were chest pain and

back pain. During Fall 2010, Mrs Johnson had swallowing

problems which were believed to be caused by a cancer relapse.

However, she was cleared. During 2011, the cancer relapsed

and was not treatable.

According to her medical records, Mrs Johnson was diag-

nosed of vascular dementia, after surgery in 2007. The diagno-

sis was obtained through computed tomography (CT) and

Mini-Mental State Examination (MMSE).

Recently, Mrs Johnson had started to wander and seemed to

be upset and angry with staff or fellow patients. She did not get

on with 1 new resident in particular. Nursing staff tried to calm

Mrs Johnson through outdoor activities and other actions, with

no obvious results.

Prescription of AAT

The need for AAT was first discussed at a meeting between

staff nurses, registered nurses, and the branch manager of the

nursing home. Under the circumstances Mrs Johnson was

assessed to be in urgent need of AAT, she was therefore prior-

itized before other residents. Grooming and walking the dog

seemed to be a possible way to make Mrs Johnson feel appre-

ciated and needed. The aim was to reduce Mrs Johnsons

psychological symptoms.

In accordance with the nursing homes guidelines, AAT

was prescribed by an OT. Mrs Johnson was prescribed AAT

once a week for 8 weeks. Every session lasted for approxi-

mately 60 minutes and was evaluated and documented in the

care plan. The total time of observation was 5 months (April

2011-September 2011).

Intervention

The therapy dog team consisted of a 4-year-old flat-coated

retriever and its handler who was an experienced enrolled

nurse. The AAT involved grooming and walking the dog. The

goals for the AAT included Mrs Johnson to spend time with the

therapy dog, to walk, and to groom the dog. Every session

included outdoor walking.

At every session, the dog stood next to Mrs Johnson, leaning

against her legs, while she stroked him. She would tell the dog

he was very handsome and then say to the DH I think he

recognizes me. I say, he is very handsome and clever as well!

She would also tell anyone near about the dog and how hand-

some and beautiful he was.

At most sessions, Mrs Johnson brushed the dog and gave

him treats or water. She spoke to the DH about the dogs fur,

if it was wet, soft, warm, and so on. She also talked about the

hard work of being an animal owner. Mrs Johnson told the DH

she once owned dogs and horses. Indeed, Mrs Johnson earlier

competed in horse dressage. She also told the DH she was no

longer able to have a dog on her own since she was very oldand was no longer able to exercise a dog.

The DHs task was to acknowledge Mrs Johnson. Hence,

she said things like Yes, you are right about [whatever Mrs

Johnson told]. When the dog sat in front of Mrs Johnson who

stroked his fur, the DH talked to Mrs Johnson about the dog

Look, can you see that he closes his eyes when you touch his

cheek? That is because he likes your touch, he enjoys it, and he

is feeling good right now! When the dog made eye contact

with Mrs Johnson the DH said What do you think he is trying

to tell you by looking into your eyes? At that point Mrs

Johnson would stroke the dog or give him treats, water, or

similar. Sometimes the DH and Mrs Johnson enjoyed just

sitting down together, watching the dog quietly. Often they

held hands and frequently Mrs Johnson hugged the DH

spontaneously. Sometimes Mrs Johnson picked flowers to give

to the DH when they went back to the nursing home.

Care Plan Documentation

The systematic training was evaluated and documented by the

OT and the DH 3 times during intervention: weeks 1, 4 and 6.

Week 1 (OT): . . . the training works very well. Mrs Johnson

is laughing and joking; she pets the dog and tosses balls. She

also brings the dog water. Today, I photographed Mrs Johnson

and the dog. Later, I will bring her a photo album.Week 4 (DH): Mrs Johnson joinedme and the dog for a walk.

She took the opportunity to pick some flowers along the way.

We talked a lot about the flowers, their scent, and colors. Isnt

my bunch lovely? Mrs Johnson said. I answered It looks like a

bridal bouquet; all you lack is a man! Yes . . . Mrs Johnson

answered, and in the next moment she said I guess I can choose

that fury one! She pointed at the dog and laughed.

Week 4 (OT):Today, I brought Mrs Johnson a photo album

with photos picturing her with the dog. She was very happy

about the pictures.

Week 6 (DH): Mrs Johnson and I went for a walk with the

dog. She picked a bunch of flowers. We talked about the flow-ers, about their beauty, and their scent. Mrs Johnson talked to

people we met and asked a gentleman whether he found her

flowers beautiful. She was very chatty and happy during the

whole walk.

Data Collection

Data were collected on 3 occasions: (1) 1 week prior to AAT

(baseline), (2) when AAT was completed, and (3) 3 months

later. Data collection was conducted by a project assistant who

was a registered nurse, 1 project assistant who was an OT and

by Mrs Johnssons contact person who was an enrolled nurse

Nordgren and Engstrom 627



5/9

with good knowledge of Mrs Johnson. At baseline, the contact

person completed the questionnaire together with one of the

project assistants. Later, the contact person completed the ques-

tionnaires herself.

Background data (diagnosis, time at the nursing home and

pharmacological treatment) were collected from medical

records. The level of cognitive impairment was determined bythe MMSE. Five instruments were used for the evaluation of the

effects of AAT: Cohen Mansfield Agitation Inventory (CMAI),

Multi-Dimensional Dementia Assessment scale (MDDAS),

MMSE, ADL taxonomy, and Quality of Life in Late-stage

Dementia scale (QUALID). The selection of instruments are

widely in use, with validated versions available in Swedish, and

easy to complete.

The CMAI is a caregiver questionnaire to assess elderly

persons agitated or not agitated status. It was originally devel-

oped for research purposes in nursing homes17 but is also used

for clinical purposes by caregivers. The CMAI is also used to

assess the impact of pharmacological or nonpharmaceutical

interventions. The scale consists of 29 behaviors. Each item

is rated on a 7-point frequency scale ranging from never

( 1) to several times an hour ( 7). Low scores indicate

no agitated status. The CMAI has been validated with Cron-

bach a of 0.63 to 0.82. The behaviors are divided into 3 groups:

physical aggressive behaviors (11 items; range 11-77); physical

nonaggressive behaviors (10 items; range 10-70), and verbal

agitation (8 items; range 8-56). Each item is based on an

average frequency of occurrence over the last 2 weeks.

The MDDAS was originally designed in Swedish and has

been used in several studies.18-20 The MDDAS has good inter-

and intrarater reliability.18 The MDDAS is designed to be

answered by staff based on observations of the resident. Thescale includes subscales concerning functioning in ADLs, beha-

vioral symptoms (such as wandering, undressing in the lunch

room, packing stuff), psychological symptoms (such as aggres-

sive behavior, restless, passiveness), and cognition. The ADL

subscore is calculated on the persons ability to manage hygiene,

dressing, eating, and bladder and bowel control. All categories

are scored using scale of 1 to 5, except for bladder control which

is scored between 0 and 4. Total scores range from 4 to 24. A

higher ADL score indicates greater independence. The 25 beha-

vioral symptoms (total score ranging from 0 to 75) and the 14

psychological symptoms (total score range from 0 to 42) are

rated on a 3-point scale (3

daily, 1

some times per week,and 0 never). Higher scores indicate more symptoms. Cogni-

tion is measured on a subscale of MDDAS.21 It was designed to

be answered by staff based on observations of the resident. The

scale comprises 27 items measuring the persons orientation

ability. A score of less than 24 is considered to indicate cognitive

impairment. In addition to the MDDAS, separate questions con-

cerning pain and fall risk were included.19,20 The caregiver rates

the residents pain (from no pain [0] to worst thinkable pain

[100]) and fall risk (from low risk [0] to high risk [100]) on a

100-mm Visual Analogous Scale (VAS).

The ADL taxonomy is used for different purposes in clinical

work at individual level. In Sweden, the ADL taxonomy is an

accepted way to describe capacity of activities in daily life. The

ADL taxonomy covers 12 activities: eating and drinking, mobi-

lity, going to the toilet, dressing, personal hygiene, grooming,

communication, cooking, transportation, shopping, cleaning,

and washing.22 Evaluation is made either through interviews

or through observations. The results are then placed in a circle

or in a form. When OTs use the circle, they are free to choosewhat information to code and how to code it. Because data are

collected at ordinal level, numbers are not recommended for

assessment.23 In the present study, the ADL taxonomy circle was

used to record what the persons with dementia could do on a

5-graded scale. Color coding was used.

The MMSE is a brief structuredtest to assess cognitive impair-

ment. The test was originally developed for assessing cognitive

impairment among psychiatric patients.24 Currently, MMSE is

primarily used in relation to dementia and can also be used to

follow a persons cognitive development over time. The test is

carried out by an interviewer who asks the person with dementia

to answer a number of questions, refer to subjects and draw a

shape. The test takes approximately 10 to 15 minutes and should

be performed by a trained person. The results are interpreted as

points (max 30) to express the degree of dementia: normal >25

points; mild impairment 25-20 points; moderate impairment

19-10 points; severe impairment 9-0 score. Reliability and con-

struct validity have been judged to be satisfactory.24,25

The QUALID is a late-stage dementia-specific question-

naire with a 1-week recall period.26 The Swedish version has

been validated.27 Assessments are made by staff. The Swedish

version of QUALID has shown a satisfactory level of internal

consistency and inter-rater reliability. It has also shown good

criterion validity.27 The scale measures 11 observable

behaviors including both positive and negative dimensions ofobservable activity and emotional states. The items are rated

on a 5-point Likert-type scale and total scores range from 11

to 55, with 11 representing best quality of life.

Ethical Considerations

The study was approved by The Regional Board of

Research Ethics in Uppsala, Sweden. Since Mrs Johnson

had dementia, proxy consent was obtained from her next

of kin who were informed both orally and in writing about

the study. The information included the aim of the pilot

project, that participation in the study was voluntary, and

that they could withdraw at any time without experiencing

any loss of care. During AAT the DH carefully observed

Mrs Johnson for any signs that indicated that she objected

to participating in the study.

Results

Pharmaceutical Treatment

At baseline, Mrs Johnson was treated with aspirin (160 mg 1)

and lactulose once a day. During the training period, no

changes were made to Mrs Johnsons pharmaceutical




6/9

treatment. Occasionally, when upset, she was treated with extra

oxazepam (5 mg). However, at 3 months follow-up, she was

treated with aspirin (160 mg 1 1), paracetamol (500 mg 2

2), oxazepam (5 mg 1 1), memantine (20 mg 1 1), and

fentanyl patches.

Behavioral and Psychiatric Symptoms

Behavioral symptoms (CMAI). According to the CMAI man-

ual, Mrs Johnson did not fulfill the criteria for agitated status

during the observational period. Yet, some changes were

noticed. Total score at baseline, after AAT, and at follow-up

was 36, 35, and 36, respectively (see Figure 1).

Physically aggressive behaviors: immediately after AAT, a

new behavior was observed, that is Mrs Johnson was

grabbing on to people. At 3 months of follow-up, grab-

bing was not observed.

Verbally agitated behaviors: at baseline, Mrs Johnson

expressed repetitious sentences/questions several times

a day. The behavior vanished immediately after AAT and

at 3 months of follow-up. In addition, at 3 months of

follow-up, Mrs Johnson was observed cursing, although

less than once a week.

Physically nonaggressive behaviors: No changes.

Behavioral symptoms (MDDAS). During the observational

period, Mrs Johnson exhibited a low frequency of behavioral

symptoms. However, some changes were observed. Total score

at baseline, after AAT, and at follow-up was 5, 9, and 8, respec-

tively (see Figure 1).

Resistance: at baseline Mrs Johnson resisted being dressed or

undressed at least once a week. However, immediately

after AAT the resistance increased to every day. Then

again, at three months follow-up resistance was exhibited

no less than once a week.

Attention seeking: immediately after AAT and at 3 months

of follow-up Mrs Johnson sought attention from staff atleast once a week, which she previously never used to.

Nighttime sleep: at 3 months of follow-up, Mrs Johnsons

nighttime sleep was interrupted at least once a week.

Wandering: at 3 months of follow-up, Mrs Johnson had

started to wander back and forth alone or with other

patients at least once a week.

Psychological symptoms (MDDAS). Mrs Johnson manifested a

low frequency of psychological symptoms. Total score at base-

line, after AAT, and at follow up was 7, 6, 4, respectively (see

Figure 1). Nevertheless, some changes were observed.

Figure 1. Illustration of results.




7/9

Ability to cooperate: At baseline, Mrs Johnson never coop-

erated with staff. However, immediately after AAT she

cooperated at least once a week. At 3 months follow-

up, she cooperated every day with staff.

Initiatives: Mrs Johnsons exhibited capability of taking

initiatives at least once a week immediately after AAT,

while never at baseline or at 3 months follow-up.Being suspicious: At baseline and immediately after AAT,

Mrs Johnson was observed being suspicious at least once

a week. However, at 3 months follow-up, this symptom

was never observed.

Help-seeking: At baseline and immediately after AAT, Mrs

Johnson was observed seeking help at least once a week.

However, at 3 months follow-up, this symptom was

never observed.

Distortion: At baseline, Mrs Johnson manifested distortion

every day. Immediately after AAT, distortion was mani-

fested not less than every week, although not every single

day. Then again, at 3 months follow-up, distortion was

not observed at all.

Restlessness: At baseline, Mrs Johnson displayed restless-

ness every day. Immediately after AAT, restlessness was

displayed not less than every week, although not every

single day. Then again, at 3 months follow-up, restless-

ness was not observed at all.

Activities of Daily Living

Taxonomy of ADLs. Movement: At baseline and immediately

after AAT, Mrs Johnson needed assistance when movingbetween floors, walking into or out of the house, or when

moving in the close external environment. However, at 3

months follow-up, she was able to move around on her own.

Indeed, immediately after AAT, Mrs Johnsons ability to move

between rooms had improved from needing assistance to being

able to move around on her own.

Communication: At baseline and immediately after AAT,

Mrs Johnson did not need any kind of assistance to con-

verse with other people. But at 3 months follow-up, she

had to be encouraged to converse with other people.

Eating and/or drinking: At baseline, Mrs Johnson managed

eating and drinking herself. However, at 3 months

follow-up, she needed concrete help.

Grooming: At baseline and immediately after AAT, Mrs

Johnson was able to comb her hair fully on her own. How-

ever, at 3 months follow-up, she needed encouragement

in order to comb her hair.

Activities of daily living (MDDAS). Mrs Johnsons ADL scores

during the observation period indicated only slight impairment.

Total score at baseline, after AAT, and at follow up was 22, 20,

and 21, respectively (see Figure 1).

Dressing: At baseline, Mrs Johnson was able to dress herself

on her own initiative. Immediately after AAT and at 3

months follow-up she needed certain help.

Hygienic procedures: At baseline and immediately after

AAT, Mrs Johnson required some help with her hygienic

procedures. Conversely, at 3 months of follow-up, she

accomplished her hygienic procedures after encourage-ment from staff.

Effects on Cognition and Orientation

Mini-Mental State Examination. Total MMSE score at base-

line, after AAT, at 3 months, and 6 months follow up was

1, 9, 10, and 7, respectively (see Figure 1). Thus, Mrs Johnson

had severe dementia. At baseline, Mrs Johnson refused to coop-

erate with the project interviewer as with staff in general, and

she would only answer one question in the MMSE (score 1).

However, immediately after AAT she willingly cooperated and

scored 9. At 3 months follow-up, Mrs Johnsons willingness tocooperate remained, scoring 10 on the MMSE scale.

Orientation (MDDAS). Mrs Johnsons orientation scores

during the observation period indicated moderate impairment.

Total score at baseline, after AAT, and at follow-up was 13,

8, and 9, respectively (see Figure 1). Some changes were

observed.

At baseline, Mrs Johnson was able to account for her own

age; she knew in which town the nursing home was situated;

she could distinguish between staff and patients; and she also

understood when there were visitors. Immediately after AAT

and at 3 months follow-up Mrs Johnson was no longer ableto do any of that. In addition, at baseline and immediately after

AAT, she knew her own birthday, which she did not know at 3

months follow-up.

Quality of Life (QUALID)

Even though Mrs Johnson was considered to have a good qual-

ity of life during all of the observational period, some changes

were noted. Total score at baseline, after AAT, and at follow up

was 11, 16, and 12, respectively (see Figure 1).

Immediately after AAT, Mrs Johnson exhibited facial

expressions of discomfort, albeit, less than once a day. In addi-

tion, immediately after AAT, Mrs Johnson stopped enjoying

touching or being touched. She also seemed to stop enjoying

interacting with other people. At 3 months follow-up, none

of these changes were present.

Pain and Fall Risk

Pain (MDDAS subscale). Total score at baseline, after AAT,

and at follow up was 0, 0, and 25, respectively (see Figure 1).

At the end of the observational period, Mrs Johnson (according

to the medical records) was affected by a facial tumor that was

causing her pain.




8/9

Fall risk (MDDAS subscale). Total score at baseline, after

AAT, and at follow-up was 5, 10, and 10, respectively (see

Figure 1). The change may be due to Mrs Johnson starting

to walk on her own after AAT and she also started to wander

back and forth.

Discussion

Previous studies show positive effects of AAT in dementia

care.10,13,15 However, to our knowledge no previous studies

have studied the effects of systematic training with therapy

dogs in detail or for a longer period of time. Therefore, the pres-

ent study provides novel insights about the effects of systematic

training with a certified therapy dog.

Concerning Mrs Johnson, no major changes where observed

in her behavioral and/or psychological symptoms. Neverthe-

less, when results are summarized some of the observed

changes can be assumed to be connected with the AAT. First,

according to the ADL taxonomy there were effects on MrsJohnsons ability to walk and move around. Her improved

walking ability persisted at the 3-month follow-up, indicating

that physical training can improve or sustain physical capacity

in people with dementia. Yet, no certain conclusions can be

drawn since the present study was only a pilot study. There are

no previous studies about ADL and AAT, and this has been

largely unexplored in the literature which illustrates the impor-

tance of further research. However, the notion of being able to

walk on ones own is presumed to promote integrity and

autonomy.

In addition, effects on the MMSE were observed. Before

AAT, MMSE was not possible to conduct since Mrs Johnson

refused to cooperate, refusing to answer any questions. Accord-ing to Mrs Johnsons contact person, this symptom had been

evident for quite some time before AAT. After AAT, Mrs John-

son was observed to cooperate much more in general; she

gladly took her own initiative to engage in different activities

and MMSE was performed without any problems. In addition,

immediately after AAT, Mrs Johnson was considerably less

distorted and restless. The change remained at 3 months of

follow-up, implying that the contact with the therapy dog and

the DH stimulated Mrs Johnson and that she experienced more

well-being. The current results are supported by previous

findings.13 Other changes which were observed in Mrs Johnson

seemed to be rather random and/or depending on the progressof her disease.

Mrs Johnsons greater use of pain medication at the 3-month

follow-up visit was notable. It is difficult to assess how pain

affected her symptoms. It is possible that wandering and sleep

disturbances, in particular, were consequences of the pain

which she was in due to a facial tumor.

Strengths and Limitations

Some strengths and limitations need to be mentioned. To

choose a single case design offers an opportunity to elucidate

the exact effects of an intervention on an individual level,28

which in this case was accomplished through systematic train-

ing with a certified therapy dog during a specific period of time.

Through case studies, detailed and in-depth knowledge are

obtained. The findings of a case study, thus, take research

beyond statistical and quantitative variables. Instead, the

description focuses on the individual. When both qualitative

and quantitative data are used, case studies can be used to illus-trate both a process and an outcome.29 Considering this, we

decided to carry out a single case study.

A methodological strength was that Mrs Johnson served as

her own control with separate observations at baseline, imme-

diately after AAT, and 2 follow-up observations. A second

strength was the formulation of the intervention, which made

it possible to individualize the training in accordance to each

persons needs and resources. Third, the longitudinal design

is unique concerning research on AAT in dementia care.

However, some weaknesses need to be mentioned. First, the

lack of research control, in particular that the circumstances

around Mrs Johnson could not be controlled because the

research team could not control potential influences from other

sources or methods. Another weakness is that data were

collected in second hand. That is, observer biases may have

interfered with the observations, signifying reduced objectiv-

ity. In addition, it is possible that effects would have been more

pronounced or prolonged if Mrs Johnson had trained more

often or over a longer period of time. Finally, the major limita-

tion of a case study is that the results from one single case

cannot be generalized to other people with dementia. Still, it

is possible that the single case may represent other people.

Only further research will inform us about the extent to which

the results of the present study are generalizable.

Conclusions

Currently, there are endeavors in dementia care to find methods

that can complement or even constitute alternatives to pharma-

ceutical treatment, since psychotropic drugs and/or sedatives

are assumed to reduce quality of life for people with dementia

disease. Even if the present results are not possible to general-

ize, there is a tendency: physical, psychological, and/or social

training with certified therapy dog teams can have effects on

behavioral and psychological symptoms in people living with

dementia.

Acknowledgments

The authors would like to thank Eskilstuna Municipality; the Social

Contract (the City of Vasteras, Eskilstuna Municipality, and

Malardalen University); and KPs Jubileumsfond for funding.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors received financial support for the research, and/or

publication of this article from Eskilstuna Municipality; the Social




9/9

Contract (the City of Vasteras, Eskilstuna Municipality, and Malarda-

len University); and KPs Jubileumsfond.

References

1. Finkel SI. Behavioral and psychologic symptoms of dementia.

Clin Geriatr Med. 2003;19(4):799-824.

2. Buhr GT, White HK. Difficult behaviors in long-term carepatients with dementia. J Am Med Dir Assoc. 2007;8(3 suppl

2):e101-e113.

3. Finkel SI. Behavioral and psychological symptoms of dementia: a

current focus for clinicians, researchers, and caregivers. J Clin

Psychiatry. 2001;62(suppl 21):3-6.

4. Blankevoort CG, van Heuvelen MJ, Boersma F, Luning H,

de Jong J, Scherder EJ. Review of effects of physical activity

on strength, balance, mobility and ADL performance in elderly

subjects with dementia. Dement Geriatr Cogn Disord. 2010;

30(5):392-402.

5. Vasse E, Vernooij-Dassen M, Cantegreil I, et al. Guidelines

for psychosocial interventions in dementia care: a European

survey and comparison. Int J Geriatr Psychiatry. 2012;27(1):

40-48.

6. Jedenius E. Resource Utilization in Dementia a Question of

Collaboration. Stockholm, Sweden: Karolinska Institutet; 2010.

7. Marmstal Hammar L. Caregivers Singing Facilitates Mutual

Encounter: Implementation and Evaluation of Music Therapeutic

Caregiving in Complex Dementia Care Situations. Stockholm,

Sweden: Karolinska Institutet; 2011.

8. Guetin S, Soua B, Voiriot G, Picot MC, Herisson C. The effect of

music therapy on mood and anxiety-depression: an observational

study in institutionalised patients with traumatic brain injury. Ann

Phys Rehabil Med. 2009;52(1):30-40.

9. Hulme C, Wright J, Crocker T, Oluboyede Y, House A.Non-pharmacological approaches for dementia that informal

carers might try or access: a systematic review. Int J Geriatr

Psychiatry. 2010;25(7):756-763.

10. Richeson NE. Effects of animal-assisted therapy on agitated

behaviors and social interactions of older adults with dementia.

Am J Alzheimers Dis Other Demen. 2003;18(6):353-358.

11. Palley LS, ORourke PP, Niemi SM. Mainstreaming animal-

assisted therapy. ILAR J. 2010;51(3):199-207.

12. Williams E, Jenkins R. Dog visitation therapy in dementia care: a

literature review. Nurs Older People. 2008;20(8):31-35.

13. Filan SL, Llewellyn-Jones RH. Animal-assisted therapy for

dementia: a review of the literature. Int Psychogeriatr. 2006;

18(4):597-611.

14. Fine A. Animal-assisted therapy. In: Hersen M SW, ed. Encyclope-

dia of Psychotherapy. New york, NY: Elsevier Science; 2002:49-55.

15. Marx MS, Cohen-Mansfield J, Regier NG, Dakheel-Ali M,

Srihari A, Thein K. The impact of different dog-related stimuli

on engagement of persons with dementia. Am J Alzheimers Dis

Other Demen. 2010;25(1):37-45.

16. Kruger KAS JA. Animal-assisted interventions in mental health:

definitions and theoretical foundations. In: Fine AH, ed. Hand-

book on Animal-Assisted Therapy: Theoretical Foundations andGuidelines for Practice. 2nd ed. New York, NY: Academic Press;

2006:21-38.

17. Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of

agitation in a nursing home. J Gerontol. 1989;44(3):M77-M84.

18. Sandman PO, Adolfsson R, Norberg A, Nystrom L, Winblad B.

Long-term care of the elderly. A descriptive study of 3600 insti-

tutionalized patients in the county of Vasterbotten, Sweden.

Compr Gerontol A. 1988;2(3):120-132.

19. Lovheim H. Psychotropic and Analgesic Drug Use Among Old

People: With Special Focus on People Living in Institutional

Geriatric Care. Umea, Sweden: Umea University; 2008.

20. Pellfolk TJ, Gustafson Y, Bucht G, Karlsson S. Effects of a

restraint minimization program on staff knowledge, attitudes, and

practice: a cluster randomized trial. J Am Geriatr Soc. 2010;58(1):

62-69.

21. Adolfsson R, Gottfries CG, Nystrom L, Winblad B. Prevalence of

dementia disorders in institutionalized Swedish old people. The

work load imposed by caring for these patients. Acta psychiatr

Scand. 1981;63(3):225-244.

22. Sonn U, Tornquist K, Svensson E. The ADL taxonomyfrom

individual categorical data to ordinal categorical data. Scand J

Occup Ther. 1999;6(1):11-20.

23. Whrens EE, Fisher AG. Developing linear ADL ability

measures based on the ADL Taxonomy: a Rasch analysis. Scand

J Occup Ther. 2009;16(3):159-171.24. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A

practical method for grading the cognitive state of patients for the

clinician. J Psychiatr Res. 1975;12(3):189-198.

25. Tombaugh TN, McIntyre NJ. The mini-mental state examina-

tion: a comprehensive review. J Am Geriatr Soc. 1992;40(9):

922-935.

26. Weiner MF, Martin-Cook K, Svetlik DA, Saine K, Foster B,

Fontaine CS. The quality of life in late-stage dementia (QUALID)

scale. J Am Med Dir Assoc. 2000;1(3):114-116.

27. Falk H, Persson LO, Wijk H. A psychometric evaluation of a

Swedish version of the Quality of Life in Late-Stage Dementia

(QUALID) scale. Int Psychogeriatr. 2007;19(6):1040-1050.

28. Kazdin AE. Research Design in Clinical Psychology. 4th ed.

Boston, MA: Allyn and Bacon; 2003.

29. Tellis W. Introduction to case study. Qual Rep. 1997;3(2).


Am j Alzheimers Dis Other Demen-2012-Nordgren-625-32

Documents

Transcript of Am j Alzheimers Dis Other Demen-2012-Nordgren-625-32