Annals of Long-Term Care: Clinical Care and Aging. 2014;22(10):27-32.
Saint Barnabas Medical Center, Livingston, NJ
Abstract: Animals have long been part of the human experience, serving multiple purposes throughout history, from food to companionship. More recently, the therapeutic potential of animals in numerous clinical areas has been increasingly recognized, leading to more healthcare facilities providing animal-assisted therapy (AAT) to their patients. In this article, the author provides an overview of the history of AAT, outlines several benefits that are particularly relevant to geriatric patients, and describes how skilled nursing facilities can set up AAT programs, reviewing how to ensure proper animal selection and prevent zoonotic infections.
Key words: Animal-assisted activities, animal-assisted therapy, canine-assisted therapy, companion animal visits, pet visitation therapy, zoonotic infections.
Animal-assisted therapy (AAT), also known as companion animal visits and pet visitation therapy, is a scheduled encounter with a certified therapy team consisting of an animal and its handler for the purpose of supporting or improving patients’ social, emotional, physical, or cognitive functioning.1 This therapy can involve domesticated pets (eg, dogs, cats, guinea pigs), farm animals (eg, horses, potbellied pigs), and marine animals (eg, dolphins), with dogs being the most commonly used. Regardless of the animal involved, AAT provides a person-centered experience2 that can augment health and wellbeing by lowering blood pressure, decreasing anxiety, reducing loneliness, and improving mental outlook and quality of life.3 The pet visit can provide interaction between one person and one animal or include several participants in a group setting.4 These interactions may occur as an activity during a regular visit to a geriatric day care center or nursing home, be provided off-site at special AAT therapy locations (eg, dolphin center or equestrian center), or be provided as an event in public businesses, such as courthouses and local libraries.5 This article provides an overview of AAT, including its history, benefits, and how to start an AAT program, with a focus on providing canine visitations to nursing home residents. It also reviews how to ensure proper animal training and curtail the risk of zoonotic infections, which are two common concerns regarding pet visitations in healthcare settings.
Animal-Assisted Intervention Helps Patients with Dementia
Dog Licks Loneliness at Long-Term Care Facility
History of Animal-Assisted Therapy
Animals and behaviorally modern humans (ie, those who first shared traits with present-day humans) have been together for over 50,000 years,6 with animal domestication occurring approximately 15,000 years ago.7 Domesticated pets served as scavengers, objects of affection and worship, and food, with certain animals being considered noble and given status jobs like house guard and soldier.4
The therapeutic potential of animals was first recognized in the late 1800s, when Florence Nightingale, considered the founder of modern nursing, made substantial discoveries regarding AAT.4 She observed that small pets helped reduce anxiety in children and adults living in psychiatric institutions, and she wrote in her book Notes on Nursing that being with small animals helps patients recover.4 Subsequently, AAT grew as a treatment for anxiety and as a way to relax.
During the early 1930s, Sigmund Freud, best known as “the father of psychoanalysis,” became a proponent of AAT when he began using his favorite dog, Jofi, during his psychotherapy sessions.8 Freud believed that dogs had a special sense, and he thought that Jofi could signal a patient’s level of tension by how close the dog stayed to the patient. If Jofi stayed right by the patient, he or she was thought to be relatively free of tension, but if he stayed at the other end of the room, the patient was thought to be very tense.8 Freud would also use Jofi to facilitate communication with his patients. He found that many patients initially felt more comfortable talking through Jofi, and that this interaction served as a stepping stone until they felt comfortable speaking directly to him.9 However, Freud’s view on animals’ therapeutic potential did not become apparent until almost two decades after his death, when a series of books were released that included translations of his letters and journals.10
In the early 1960s, Boris Levinson, a respected child psychotherapist, discovered by chance that a disturbed, nonverbal 9-year-old boy began to communicate when Levinson’s dog, Jingles, sat with them during psychotherapy sessions.10 He proceeded to observe similar results in other children who had difficulty communicating. Based on his collective experience, Levinson presented a paper at an American Psychological Association meeting, but he was not taken seriously until Freud’s experiences with Jofi came to light.10 Levinson went on to author Pet-Oriented Child Psychotherapy and became known as “the father of AAT.”1
In 1989, the Delta society, a well-known animal education group now named Pet Partners, developed a certification program to ensure that animals are proficient in providing AAT.11 The organization’s recommendations for AAT continue to be used as a therapeutic intervention guideline today, and many AAT certification programs are now available throughout the United States. Subsequently, AAT has evolved to become a part of the services offered by many healthcare facilities, including nursing homes, rehabilitation centers, and hospitals, where it has shown numerous benefits and become a respected therapy.5
Benefits of Animal-Assisted Therapy
As AAT becomes more common, the benefits of this therapy are becoming increasingly recognized. What follows is a brief review of some of the cardiovascular, psychological, and cognitive benefits that have been reported, as well as AAT’s potential impact on the hospital experience and outcomes.
According to the American Heart Association (AHA) and the American Stroke Association, an estimated 83.6 million American adults (>33%) have one or more types of cardiovascular disease (CVD).12 Of these individuals, an estimated 42.2 million are 60 years of age or older, with about 66% of all CVD-related deaths occurring in people aged 75 years and older. In addition to increasing the risk of premature death, CVD increases the risk of nursing home admissions, necessitating interventions that reduce CVD risk and improve survival. Studies have shown that AAT may be one such intervention.
In 1995, a substudy of the Cardiac Arrhythmia Suppression Trial that included 369 participants who had a myocardial infarction found that those who owned dogs had a significantly increased survival rate at 1-year follow-up, with mortality being 4.05 times greater for those who did not own a dog (P<.05).13 This survival benefit was independent of physiologic severity, patient demographics, and other psychosocial factors.
In 2013, the AHA released a scientific statement regarding pet ownership and CVD risk.14 Through a critical assessment of data regarding the influence of pet ownership on the presence and reduction of CVD risk factors and CVD risk, the AHA concluded that pet ownership, particularly of dogs, is likely associated with decreased CVD risk, and that it may play a causal role in reducing CVD risk. Both of these conclusions were given a level of evidence rating of B.14
As previously noted, the therapeutic potential of animals was first observed in the psychological arena. Even today, one of the main indications for AAT is to improve psychological health, and surveys of psychiatrists and psychologists indicate that almost 50% of those questioned have “prescribed” a pet for their patients.11 This is not surprising given that AAT has been reported to be particularly effective in improving social and communication skills, easing anxiety, improving mood, facilitating independent living, and improving empathic skills.15 Animal interactions help achieve this by promoting positive emotions, which can boost confidence and reduce feelings of loneliness, sadness, anger, and insecurity. This may be particularly significant for elderly persons, particularly those residing in nursing homes, where such feelings are common experiences.
An article in the Journal of Psychosocial Nursing and Mental Health Services that described experiences with a dog named Cocoa reported that factors such as loneliness, depression, and social isolation can be reduced just by the act of petting a dog.16 During such encounters, the dog becomes a source of encouragement by being nonjudgmental and attentive to the patient. As the pet stands next to the wheelchair or bedside and makes eye contact, a relationship develops between the dog and the patient, fostering a healing environment.16
A more recent 6-month study that included a small group of geriatric nursing home residents (n=21; mean age, 80 years) gave credence to the observations made with Cocoa.17 The investigators reported that dog companionship, which was provided three times weekly for 90 minutes, reduced the perception of loneliness, as measured using the short version of the UCLA Loneliness Scale at baseline and following the intervention.17
As dementia progresses many patients experience a variety of behavioral and psychological symptoms, including agitation and aggression, which are collectively known as the behavioral and psychological symptoms of dementia (BPSD). Clinically significant BPSD has been reported to affect approximately 33% of community-dwelling persons and nearly 80% of skilled nursing facility residents.18
In 2013, a randomized controlled trial that investigated the efficacy of AAT on agitation, aggression, and depression in nursing home residents with dementia found that this intervention may delay the progression of neuropsychiatric symptoms in this population.19 The 10-week study included 65 nursing home residents with dementia (mean Mini-Mental State Examination [MMSE] score, 7.1) who were randomly assigned to treatment as usual or treatment as usual combined with AAT. Blinded raters assessed residents’ cognitive impairment with the MMSE, agitation/aggression with the Cohen-Mansfield Agitation Inventory, and depression with the Dementia Mood Assessment Scale, all of which were measured at baseline and during a 4-week period after the AAT intervention. Residents in the control group experienced a significant increase in their symptoms of agitation, aggression, and depression over the 10 weeks, whereas the symptoms remained constant in residents in the intervention group. Although no amelioration of symptoms was observed in the intervention group, the investigators concluded that the lack of symptom progression indicates a potential benefit of AAT that warrants more long-term evaluation.19
An article in the American Journal of Alzheimer’s Diseases & Other Dementias reported that AAT can help engage residents with dementia in social activities.20 The article outlined the results of a study that assessed various dog-related stimuli, including visits with three different sized dogs (ie, small, medium, large); viewing a puppy video; engaging in a dog-themed coloring activity; interacting with a plush dog; and interacting with a robotic dog. Although all of these activities engaged residents on some level, visits with the real dogs elicited the greatest number of verbal responses from residents.20 Although the investigators did not focus on this finding, it may be an important one, particularly because verbal abilities decrease as dementia progresses. Having a stimulus that encourages verbal responses may warrant further investigation. Furthermore, even if the benefits of AAT on verbal abilities were ultimately deemed negligible, decreasing verbal abilities make it more difficult for these individuals to receive the social stimulation that they require. As the study investigators note, dogs are adept at reading subtle body language and responding appropriately, are able to initiate interactions, and show genuine affection and pleasure during interactions, even if those interactions are sparse or repetitive, which may make them ideally suited to interacting with cognitively impaired patients.20
Hospitalization Experience and Outcomes
Hospitalizations are often traumatic for older adults, and the stress of being admitted can further compound any condition. Pharmacological support and other medical interventions can help patients improve, but these individuals remain vulnerable to the psychological stressors of their illness, which may leave them feeling fearful, lonely, and anxious.3 In addition, in such acute care settings, sensory deprivation occurs due to the lack of touch and physical support, yet there is also sensory overload due to alarms and the sounds of various medical equipment. AAT can address both of these issues by providing a soft, gentle touch while enabling patients to focus their attention away from their environment, alleviating feelings of fear, loneliness, and anxiety.
AAT has been used in acute care settings to help counterbalance the psychological cascade of events that increase blood pressure, heighten anxiety, and induce dyspnea. In 2007, a study was conducted to evaluate the impact of a 12-minute hospital visit with a therapy dog on hemodynamic measures, neurohormone levels, and anxiety in adults with advanced heart failure.3 The study showed that patients who participated in a visit with the dog therapy team experienced a reduction in both the mental and physical effects of the excited sympathetic nervous system, as demonstrated by improved cardiopulmonary pressures and decreased epinephrine and norepinephrine levels.3
In 2011, a pilot study was conducted to evaluate the impact of AAT on ambulation.21 The study showed that hospitalized patients with heart failure who received canine-assisted ambulation started to walk sooner than those who did not receive this intervention. These individuals also walked further, taking 235.07 steps compared with 120.2 steps taken by a randomly selected sample (P<.0001), and were more motivated than those who did not work with the dog team. Based on these findings, the authors conclude that canine-assisted ambulation may shorten hospital stays, thereby decreasing the costs of heart failure care, and they urge additional research on this intervention for other disease processes and in other settings.21
Examining Pet Visitations
Although AAT is the focus of this paper, as previously mentioned, pet visits can involve numerous types of animals and have different objectives. In addition to AAT, there are currently two other forms of animal interactions that may confer health benefits and provide a sense of wellbeing through nurturing the human–animal bond22:
• Animal-assisted activities (AAA). These activities use animals that meet specific criteria (eg, hypoallergenic, behavioral) to provide opportunities to enhance quality of life. Specially trained professionals, paraprofessionals, or volunteers deliver the activities in a variety of environments. Unlike AAT, specific treatment goals are not planned for each AAA visit; a credentialed therapist is not necessary, as volunteers can provide this service; the process does not need to be formally documented; and the visits can be spontaneous and last as long or as short as needed.22 An example would be a group of volunteers bringing their dogs or cats to the local nursing home every month to visit the residents. It is important to note, however, while these interactions do not seek to achieve concrete goals in the same manner as AAT, they may still provide therapeutic benefits. For example, the presence of a dog or cat may be enough motivation for a patient to move and stretch his or her injured hand to pet the animal, thereby reducing stiffness and promoting healing (see sidebar, A Personal Perspective).
• Use of resident animals. A resident dog or cat is becoming more common in a variety of healthcare settings, including nursing homes. In this situation, the animal lives in the facility full time and is cared for based on the institution’s policies.23 Some resident animals may be formally included in facility activities and therapy schedules after proper screening and training, whereas others may participate in spontaneous or planned interactions with facility residents and staff.24 In 2010, a resident cat named Oscar made headlines after he was consistently reported to detect imminent death among the residents of a Rhode Island nursing home by curling up next to them in their final hours.25
Starting an Animal-Assisted Therapy Program
Bringing animals into any institution starts with a careful review of any applicable current policies and procedures. These can serve as guidelines that can be used to control most issues, standardize the process, and ensure safety. It is also helpful to contact other departments within the institution or sister facilities to see if they have any such programs in place, which can potentially provide access to an AAA or AAT champion (ie, someone within the organization who is supportive of encounters between animals and patients) who can provide further guidance.
Once policies and procedures are carefully reviewed, the following steps should be taken to establish the program:
• Outline the need and desire for the AAT program or other animal intervention, such as AAA or the adoption of a resident animal.24
• Establish realistic and measurable goals and objectives to ensure successful visits.24 Examples of appropriate goals may include reducing loneliness and isolation, improving communication, fostering trust, stimulating cognitive function, enhancing quality of life, motivating patients to participate in physical therapy, and developing compliance with self-care behaviors like washing and dressing.5
• Gain approval of the program from key administrators and, whenever possible, enlist their assistance with developing protocols.24
• Determine which types of animals will best be accepted and serve the needs of program participants.24 As previously mentioned, although dogs are most commonly used, any number of animals can be employed, from rabbits to potbellied pigs. Important considerations when deciding on animals include patients’ or residents’ allergies, whether patients or residents fear or dislike any animals, and the animal’s temperament. Once the type of animal is decided upon, then specific factors for that animal type need to be considered, such as breed, size, age, sex, and behavioral traits.24 This ensures that the appropriate animal is selected. For example, if deciding on using dogs for nursing home visits, large, young, energetic male dogs, which tend to jump on people or get underfoot, may not be the best choice due to the high prevalence of frailty, risk of falls, and use of assistive devices (eg, walkers) in this setting.
• Consider what training programs will be required for the animals and those providing the therapy or interaction.24 If the goal is to use pets from an agency, then such agencies should be contacted to obtain details on their programs and policies, including the standards their visiting pets and handlers must meet.23 See next section for more details.
• Assess zoonotic disease risks and develop appropriate procedures for minimizing these risks.26 These are reviewed later in the article.
Generally, animals involved in AAA and AAT programs must have basic obedience skills, behave in predictable ways, and like being with people.24 Dogs, for example, should be able to demonstrate appropriate responses to voice commands, know how to sit for petting, and be accepting of strangers and other animals.27 Therefore, proper training is essential. When an AAT agency is involved, each dog will train with one handler, which then becomes the therapy team; however, before being able to go out in the field, any potential AAT team is carefully evaluated. This ensures the animal has the correct temperament for the job and that the handler has complete control of the dog at all times.24 During the evaluation, AAT teams are typically tested on the following:
• Dog’s response to “Sit,” “Come,” “Down,” and “Stay” commands, as well as the “Leave it” command to ensure the animal does not eat anything found on the floor, such as dropped medications and food.16
• Dog’s tolerance of loud noises, crowds of people, and a simulated elevator ride. Pet therapy animals going into healthcare settings will generally be exposed to medical equipment and be observed walking in a crowd with wheelchairs and walkers,2 ensuring they can handle these environments.
• Handler’s ability to control the dog at all times, as demonstrated by the dog obeying its handler regardless of the situation encountered.
Infections are a major concern in healthcare facilities, and the risk of zoonotic infections are sometimes suggested as a contraindication to AAT in nursing homes and other healthcare settings. While infections are an important consideration, they are generally not an issue.27 In fact, the Centers for Disease Control and Prevention’s guidelines that address use of animals in healthcare settings state that there are limited data to indicate that outbreaks of infectious disease have occurred as a result of human–animal interactions in healthcare settings.26 Nevertheless, there are many steps healthcare facilities can take to reduce the risk of infections, including the following:
• Establish and enforce hand-washing protocols, which is critical in curtailing the spread of any infection. Hands should be washed after touching or handling an animal or its waste.26
• Include polices that identify and monitor animals’ open wounds, hot spots, ear infections, or other signs of illness (eg, diarrhea, vomiting). While routine screening of potential zoonotic microorganisms is not recommended, it is important to monitor the health of all AAA and AAT animals.26,28
• Ensure all AAA and AAT animals receive regular check-ups with a veterinarian. If using an agency, handlers should provide verification of check-ups, vaccination records, and use of heartworm preventive therapy.26,28
• Confirm pets are well groomed, which requires them to receive regular baths, have trimmed nails, and be free of fleas, ticks, and other parasites.26,28
• Make sure pets are exercised and allowed to relieve themselves prior to visits. If an accident occurs, it needs to be cleaned up promptly following the policies of the facility being visited.4
• Select animals with the best temperaments. Animals with unpredictable behaviors and those that are prone to scratching or biting should be excluded due to their increased potential to transmit pathogens.26
• Consider the animal’s diet. Use of raw food diets, which consist of feeding raw meats only, is a reported risk factor.26 A 1-year study that included 200 healthy dogs showed that dogs on raw-meat diets were significantly more likely to test positive for Salmonella. Although no determination has been made as to the safety risks this might pose to humans,24 many institutions are now cautious about using such dogs in situations that have people with compromised immune systems, with some agencies refusing to use dogs on such diets altogether.26
• Require successful completion of an animal-assisted certification program. This recommendation, which is made by the Association for Professionals in Infection Control and Epidemiology, will help maintain consistency in general infection-control strategies.28
• Adjust the program to the setting. For example, most hospice programs that offer AAA or AAT have protocols in place that direct the pet therapy visit and give guidance on infection control strategies and procedures for interacting with immunocompromised patients.4 Although these visit may offer the same type of interactions as provided to immunocompetent patients, they may be modified for comfort and protection, such as propping up the patient with pillows during the visit and using a smaller dog and barrier sheet so that the animal can safely sit next to the patient. Alternatively, if the patient or resident does not want direct contact with the animal, a “distance visit” from the doorway can be considered.
Animals can offer healing, support, and comfort to those who are physically, mentally, emotionally, and/or spiritually compromised. The healing occurs in the form of present-moment experiences that are nonjudgmental, enabling AAT recipients to better express their emotions. The animal encounters can also serve as a bridge for patients to bond with their healthcare providers, as the presence of the animal may help them feel safe and secure. In addition, animals provide patients with the motivation to undertake more difficult tasks, such as performing physical therapy exercises. Even if the animal encounter is not goal-driven, many patients use the visits to pet the animals and speak with them, which alone can be therapeutic. In many cases, just seeing a therapy dog elicits a positive response from both families and the patient.
There are already many clinical areas where concrete benefits have been observed with AAT, including in the cardiovascular, psychological, and cognitive arenas, but there are many others that require further exploration and evidence-based practice guidelines and principals. Nevertheless, AAT is becoming more widely recognized and respected as our understanding of this intervention increases.
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23. Arkow P. Animal-Assisted Therapy and Activities: A Study Resource Guide and Bibliography for the Use of Companion Animals in Selected Therapies. Stratford, NJ: self-published, 2004.
24. Guidelines for animal assisted activities, animal-assisted therapy and resident animal programs. American Veterinary Medical Association (AVMA) website. www.avma.org. Accessed May 10, 2014.
25. Leonard T. Cat predicts 50 deaths in RI nursing home. The Telegraph. www.telegraph.co.uk/news/newstopics/howaboutthat/7129952/Cat-predicts-50-deaths-in-RI-nursing-home.html. Published February 1, 2010. Accessed June 17, 2014.
26. Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf. Published 2003. Accessed June 18, 2014.
27. Ernst L. Animal-assisted therapy: using animals to promote healing. Nursing. 2012;42(10):54-58.
28. Writing Panel of Working Group, Lefebvre SL, Golab GC, et al. Guidelines for animal-assisted interventions in health care facilities. Am J Infect Control. 2008;36(2):78-85.
Disclosures: The author reports no relevant financial relationships.
Address correspondence to: Lorraine Ernst, RN, MS, AHN-BC, Saint Barnabas Medical Center, 94 Old Short Hills Road, Livingston, NJ 07039; LErnst@barnabashealth.org