admin
Wed, 01/10/2024 - 19:04
Edited Text
Comparative Effectiveness of Canine or Equine-Assisted Therapy for Residents with Dementia
Elizabeth Kemeny Ph.D., CTRS, Deborah Hutchins Ed. D., CTRS, Courtney Gramlich, CTRS, Emily Jones, Hope Gettemy, Megan Hutchman, Deborah Walton
Recreational Therapy, Slippery Rock University
Measures
Findings
Apathy (withdrawal from social engagement) was measured before and
after the entire program using the Dementia Interview and Rating
Scale(Strauss & Sperry, 2002). Four distinct outcomes were measured
using previously reliability and validity-tested measures: Engagement in
Preferred Activities Scale (EPASS) (Nelson et al., 2014), an observational
measure, measured the 1) duration, 2) attentiveness, and 3) positive
attitude, and 4) Heart rate variability, a measure of coherence, was
measured using the Emwave pro (Heart Math Institute, 2018). Frequency
of in-person observations of targeted social behaviors were recorded
during each session.
As seen in Figure 1, participants started and ended the canine session with a
high engagement. In Figure 2, significant improvement (p < .05) can be seen
in equine sessions 3 and 4 with duration, attitude, and attentiveness and in
the control for session 2 with duration and 5 with attitude. Mean difference
scores vary in range: 1) for canine, range is -4 to 7.5 with average mean diff
score of 3.46; 2) for equine, range is -8 to 12.7 with average mean difference
score of 3.76; and 3) for control range is -4 to 12.2 with average mean diff
score of 1.89. Participants displayed a higher frequency of all targeted social
behaviors with canine than equine in every incidence but two. The
participants’ average HRV showed lower average coherence during equineinteraction than dog-interaction or control.
Background
Research Question
Which type of animal-assisted intervention is the most effective in
improving the social and engagement responsiveness of an older
adult with dementia?
Methods
Following IRB/IACUC approval, in five two-hour sessions, 10
volunteer participants with dementia from two LTC facilities were
randomly assigned to the order in which each resident received every
intervention per session (AAI with dog, AAI with horse, and control
(social group). Informant-reported apathy, using the Apathy Evaluation
Scale (Marin, Biedrzycki, Firingiogullari, 1991) was collected before
and after the entire five-week period. During each session,
Engagement in Preferred Activities Scale (EPASS) (Nelson et al.,
2014), targeted observed AAI social responses, and heart rate
variability (HRV) Emwave pro, which is impacted by dementia (Britton,
2008; HeartMath Institute, 2020).
Participants
Five participants were recruited through flyers, word-of-mouth, and
LTC that serve older adults with dementia. Participation in the
research was voluntary. Inclusion criteria were age 60 and above,
with a diagnosis of dementia or related disorder. Exclusion criteria are
anxiety or fearfulness of dogs or horses. An IRB/IACUC approved
protocol assured protection of human and animal subjects.
Procedures
To promote fidelity, the same CTRS dog-handler and the same CTRS
PATH instructor incorporated grooming, walking and interaction with the
dog or horse during every session for the same amount of time. The
control, a social group, was facilitated under the supervision of a CTRS.
Analysis
Observational data and heart rate variability was analyzed through
charting, visual inspection, and interpretation of the data. Experimental
control is demonstrated by a consistent level and/or trend difference
,
between the conditions (Wolery, Dunlap, & Ledford, 2011).
The Wilcoxon
Rank Sum Test, was used to compare 1) apathy index before and after
the entire protocol; and 2) the engagement (duration, attention, attitude)
before and after each canine, equine, and control sessions.
Implications /Significance to Recreational Therapy
*
Figure 1 Comparison of Pre and Post EPASS Scores for each Canine Session
*
**
**
**
**
Table 1
Comparison of Apathy Evaluation Scale Before and After Intervention Period
References
Pre
Baseline
Post
Baseline
Mean
Difference
Interested in things
3.360
3.450
0.090
Wilcoxon
Value
* if <.05
.739
Gets things done during day
Gets important things started on his/her own
2.730
2.90
2.550
2.09
-0.180
-0.810
.527
.066
Interested in having new experiences
2.82
3.90
1.080
.102
Interested in new things
Puts little effort into anything
Approaches life with intensity
2.81
1.73
2.27
2.54
2.45
2.91
-0.270
0.720
0.640
.334
.039*
.053
Seeing a job through to end is important to him/her
2.81
2.36
-0.450
.197
Spends time on things that interest him/her
3.63
3.63
0.000
1.00
Someone has to tell him/her what to do each day
2.45
3.45
1.000
.015*
Less concerned about problems than she/he should be
3.09
3.27
0.180
.414
Has friends
3.00
3.36
0.270
.157
Getting together with friends is important to him/her
1.91
2.91
1.000
.013*
When something good happens, he/she gets excited
3.34
3.45
0.110
.527
Has an accurate understanding of her/his problems
1.81
2.45
0.640
.102
Getting things done during day is important to him/her
2.27
2.73
0.460
.265
Has initiative
2.81
3.0
0.190
.317
Has motivation
3.0
3.18
0.180
.480
1-not characteristic at all
*
Structured AAI sessions facilitated by CTRS may decrease some
symptoms of apathy related to socialization and improve engagement.
Discussion
Some response varies by dose
and familiarity with the particular animal.
While equine sessions showed more significant increases during later
sessions, after the participants gained more familiarity with the horses,
canine sessions and social control more consistently yielded
engagement, coherence, and frequency social response. AAI is being
used frequently with older adults (Porter et al, 2020). CTRS with specific
training in AAI modalities can promote engagement, coherence, and
improved socialization of LTC residents with dementia. Assessment of
the residents’ needs for engagement and lifelong preferences with
particular animals is particularly important in choice of the animal and
individualization of the session to meet particular resident needs.
On the overall apathy scale, as seen in Table 1, the participants became
more apathetic (p<.05) over the six-weeks in “low effort” (p = .039) and “
needs help” (p = .015). However, they significantly improved
in the area of “friends” (p =.013) and “intensity” (p =.053). While not
significant, means in interest, excitement, and motivation improved.
Scale 1-4
*
*
Findings
Variable
Overall, the program with canine, equine, and control decreased
apathy scores in social items but increased apathy in ADLS items.
Canine-assisted showed more stable participant duration,
attentiveness, and coherence than equine. Participants started the
equine sessions with lower engagement improved over the sessions.
Because the same protocol (grooming, leading, feeding) was used,
the differences probably relate to the type of animal. When compared
to the control, the equine and canine sessions pre-and post EPASS
scores were lower. However, difference scores from pre-and-post
comparison were lowest in social control and highest in equine. While
the equine sessions showed the most improvement, canine and social
control showed steady engagement. The differences in familiarity and
size of the animals may make a difference in the participants initial
reaction to animal-assisted interventions. Limitations: Residents
opportunity to go on a regular community outing, variability in health,
and disease progression may have impacted results. Further research
is needed to better understand how preference and early experience
shapes engagement with animals in late life for a person with
dementia.
*
Figure 2 Comparison of Pre and Post EPASS Scores for each Equine Session
*
By 2050, dementia is projected to affect over 115.4 million people
globally (World Health Organization, 2018). Currently, over 50% of
long-term residents have dementia (US Census Bureau, 2014). One of
the most common neuropsychiatric symptoms in dementia is apathy
(Selbæk, Engedal, & Bergh, 2013). Since no conclusive evidence
exists for pharmacological approaches (Harrison, Aerts, & Brodaty,
2016) and some may have negative side effects, non-pharmacologic
approaches are suggested (Brodaty & Arasaratnam, 2012). Limited
research exists on animal-assisted interventions (AAI) effectiveness in
decreasing apathy or increasing engagement. AAI has been shown to
enhance well-being in older adults in LTC (Friedman, Thomas &
Chung, 2015; Huff-Mercer, 2015). No known research measures older
adult response to multi-species animal-assisted therapy. This study
compared RT using canine, equine, and control to understand the
effectiveness on apathy, heart rate variability (HRV), and engagement.
Discussion
*
Britton, A., Singh-Manoux, A., Hnatkova, K., Malik, M., Marmot, M.G., & Shipley, M. (2008). The association between
heart rate variability and cognitive impairment in middle-aged men and women: The Whitehall II Cohort Study
Neuroepidemiology, 31(2), 115-121.
Brodaty, H. & Arasaratnam, C. (2012). Meta-analysis of nonpharmacological interventions for neuropsychiatric
symptoms of dementia. American Journal of Psychiatry. 169:946–953.
Friedmann, E., Thomas, S.A, & Chung, S.Y. (2015). Evaluation of a pet-assisted living intervention for improving
functional status in assisted living residents with mild to moderate cognitive impairment : A pilot study.
American Journal of Alzheimer’s Disease & Other Dementias. 30(3), 276-289.
Harrison, F., Aerts, L., Broadaty, H. (2016). Apathy in dementia: Systematic review of recent evidence on
pharmacological treatments. Current Psychiatry Reports, 18(11):103.
HeartMath Institute (2020). Emwavepro t www.heartmath.org.
Huff-Mercer, A.K. (2015). Animal-Assisted Therapy and Application to Older Adults in Long Term Care. Journal of Arts
and Humanities, 4(5), 16-27.
Marin R.S., Biedrzycki, R.C., Firingiogullari, S. (1991). Reliability and validity of the Apathy Evaluation Scale.
Psychiatric Research 38:143–162.
Nelson, R., Humes, S., Borgstrom, K., Crew, A., Crumbie, V., Gimbel, J. & Park, K. (2014). The Engagement in
Preferred ActivieS Scale (EPASS). Technical Report. Retrieved from author.
Porter, H., Hawkins, B.L., & Kemeny, B. (2020). ATRA Competencies in RT Practice. ATRA: Reston, Va.
Selbæk, G., Engedal, K., Bergh, S. (2013). The prevalence and course of neuropsychiatric symptoms in nursing
home patients with dementia: a systematic review. Journal of American Medical Director Association.14:161–9.
U.S. Census Bureau (2014). Fast Stats.https://www.cdc.gov/nchs/fastats/alzheimers.htm.
World Health Organization. (2018). Dementia: A public health priority. World Health Organization; Geneva
Switzerland.
Acknowledgements
4-a lot characteristic
1 Comparison of Pre and Post EPASS Scores for each Control (Social ) Session
Storm Harbor Equestrian Center
Slippery Rock University Faculty-Student Research Grant
Elizabeth Kemeny Ph.D., CTRS, Deborah Hutchins Ed. D., CTRS, Courtney Gramlich, CTRS, Emily Jones, Hope Gettemy, Megan Hutchman, Deborah Walton
Recreational Therapy, Slippery Rock University
Measures
Findings
Apathy (withdrawal from social engagement) was measured before and
after the entire program using the Dementia Interview and Rating
Scale(Strauss & Sperry, 2002). Four distinct outcomes were measured
using previously reliability and validity-tested measures: Engagement in
Preferred Activities Scale (EPASS) (Nelson et al., 2014), an observational
measure, measured the 1) duration, 2) attentiveness, and 3) positive
attitude, and 4) Heart rate variability, a measure of coherence, was
measured using the Emwave pro (Heart Math Institute, 2018). Frequency
of in-person observations of targeted social behaviors were recorded
during each session.
As seen in Figure 1, participants started and ended the canine session with a
high engagement. In Figure 2, significant improvement (p < .05) can be seen
in equine sessions 3 and 4 with duration, attitude, and attentiveness and in
the control for session 2 with duration and 5 with attitude. Mean difference
scores vary in range: 1) for canine, range is -4 to 7.5 with average mean diff
score of 3.46; 2) for equine, range is -8 to 12.7 with average mean difference
score of 3.76; and 3) for control range is -4 to 12.2 with average mean diff
score of 1.89. Participants displayed a higher frequency of all targeted social
behaviors with canine than equine in every incidence but two. The
participants’ average HRV showed lower average coherence during equineinteraction than dog-interaction or control.
Background
Research Question
Which type of animal-assisted intervention is the most effective in
improving the social and engagement responsiveness of an older
adult with dementia?
Methods
Following IRB/IACUC approval, in five two-hour sessions, 10
volunteer participants with dementia from two LTC facilities were
randomly assigned to the order in which each resident received every
intervention per session (AAI with dog, AAI with horse, and control
(social group). Informant-reported apathy, using the Apathy Evaluation
Scale (Marin, Biedrzycki, Firingiogullari, 1991) was collected before
and after the entire five-week period. During each session,
Engagement in Preferred Activities Scale (EPASS) (Nelson et al.,
2014), targeted observed AAI social responses, and heart rate
variability (HRV) Emwave pro, which is impacted by dementia (Britton,
2008; HeartMath Institute, 2020).
Participants
Five participants were recruited through flyers, word-of-mouth, and
LTC that serve older adults with dementia. Participation in the
research was voluntary. Inclusion criteria were age 60 and above,
with a diagnosis of dementia or related disorder. Exclusion criteria are
anxiety or fearfulness of dogs or horses. An IRB/IACUC approved
protocol assured protection of human and animal subjects.
Procedures
To promote fidelity, the same CTRS dog-handler and the same CTRS
PATH instructor incorporated grooming, walking and interaction with the
dog or horse during every session for the same amount of time. The
control, a social group, was facilitated under the supervision of a CTRS.
Analysis
Observational data and heart rate variability was analyzed through
charting, visual inspection, and interpretation of the data. Experimental
control is demonstrated by a consistent level and/or trend difference
,
between the conditions (Wolery, Dunlap, & Ledford, 2011).
The Wilcoxon
Rank Sum Test, was used to compare 1) apathy index before and after
the entire protocol; and 2) the engagement (duration, attention, attitude)
before and after each canine, equine, and control sessions.
Implications /Significance to Recreational Therapy
*
Figure 1 Comparison of Pre and Post EPASS Scores for each Canine Session
*
**
**
**
**
Table 1
Comparison of Apathy Evaluation Scale Before and After Intervention Period
References
Pre
Baseline
Post
Baseline
Mean
Difference
Interested in things
3.360
3.450
0.090
Wilcoxon
Value
* if <.05
.739
Gets things done during day
Gets important things started on his/her own
2.730
2.90
2.550
2.09
-0.180
-0.810
.527
.066
Interested in having new experiences
2.82
3.90
1.080
.102
Interested in new things
Puts little effort into anything
Approaches life with intensity
2.81
1.73
2.27
2.54
2.45
2.91
-0.270
0.720
0.640
.334
.039*
.053
Seeing a job through to end is important to him/her
2.81
2.36
-0.450
.197
Spends time on things that interest him/her
3.63
3.63
0.000
1.00
Someone has to tell him/her what to do each day
2.45
3.45
1.000
.015*
Less concerned about problems than she/he should be
3.09
3.27
0.180
.414
Has friends
3.00
3.36
0.270
.157
Getting together with friends is important to him/her
1.91
2.91
1.000
.013*
When something good happens, he/she gets excited
3.34
3.45
0.110
.527
Has an accurate understanding of her/his problems
1.81
2.45
0.640
.102
Getting things done during day is important to him/her
2.27
2.73
0.460
.265
Has initiative
2.81
3.0
0.190
.317
Has motivation
3.0
3.18
0.180
.480
1-not characteristic at all
*
Structured AAI sessions facilitated by CTRS may decrease some
symptoms of apathy related to socialization and improve engagement.
Discussion
Some response varies by dose
and familiarity with the particular animal.
While equine sessions showed more significant increases during later
sessions, after the participants gained more familiarity with the horses,
canine sessions and social control more consistently yielded
engagement, coherence, and frequency social response. AAI is being
used frequently with older adults (Porter et al, 2020). CTRS with specific
training in AAI modalities can promote engagement, coherence, and
improved socialization of LTC residents with dementia. Assessment of
the residents’ needs for engagement and lifelong preferences with
particular animals is particularly important in choice of the animal and
individualization of the session to meet particular resident needs.
On the overall apathy scale, as seen in Table 1, the participants became
more apathetic (p<.05) over the six-weeks in “low effort” (p = .039) and “
needs help” (p = .015). However, they significantly improved
in the area of “friends” (p =.013) and “intensity” (p =.053). While not
significant, means in interest, excitement, and motivation improved.
Scale 1-4
*
*
Findings
Variable
Overall, the program with canine, equine, and control decreased
apathy scores in social items but increased apathy in ADLS items.
Canine-assisted showed more stable participant duration,
attentiveness, and coherence than equine. Participants started the
equine sessions with lower engagement improved over the sessions.
Because the same protocol (grooming, leading, feeding) was used,
the differences probably relate to the type of animal. When compared
to the control, the equine and canine sessions pre-and post EPASS
scores were lower. However, difference scores from pre-and-post
comparison were lowest in social control and highest in equine. While
the equine sessions showed the most improvement, canine and social
control showed steady engagement. The differences in familiarity and
size of the animals may make a difference in the participants initial
reaction to animal-assisted interventions. Limitations: Residents
opportunity to go on a regular community outing, variability in health,
and disease progression may have impacted results. Further research
is needed to better understand how preference and early experience
shapes engagement with animals in late life for a person with
dementia.
*
Figure 2 Comparison of Pre and Post EPASS Scores for each Equine Session
*
By 2050, dementia is projected to affect over 115.4 million people
globally (World Health Organization, 2018). Currently, over 50% of
long-term residents have dementia (US Census Bureau, 2014). One of
the most common neuropsychiatric symptoms in dementia is apathy
(Selbæk, Engedal, & Bergh, 2013). Since no conclusive evidence
exists for pharmacological approaches (Harrison, Aerts, & Brodaty,
2016) and some may have negative side effects, non-pharmacologic
approaches are suggested (Brodaty & Arasaratnam, 2012). Limited
research exists on animal-assisted interventions (AAI) effectiveness in
decreasing apathy or increasing engagement. AAI has been shown to
enhance well-being in older adults in LTC (Friedman, Thomas &
Chung, 2015; Huff-Mercer, 2015). No known research measures older
adult response to multi-species animal-assisted therapy. This study
compared RT using canine, equine, and control to understand the
effectiveness on apathy, heart rate variability (HRV), and engagement.
Discussion
*
Britton, A., Singh-Manoux, A., Hnatkova, K., Malik, M., Marmot, M.G., & Shipley, M. (2008). The association between
heart rate variability and cognitive impairment in middle-aged men and women: The Whitehall II Cohort Study
Neuroepidemiology, 31(2), 115-121.
Brodaty, H. & Arasaratnam, C. (2012). Meta-analysis of nonpharmacological interventions for neuropsychiatric
symptoms of dementia. American Journal of Psychiatry. 169:946–953.
Friedmann, E., Thomas, S.A, & Chung, S.Y. (2015). Evaluation of a pet-assisted living intervention for improving
functional status in assisted living residents with mild to moderate cognitive impairment : A pilot study.
American Journal of Alzheimer’s Disease & Other Dementias. 30(3), 276-289.
Harrison, F., Aerts, L., Broadaty, H. (2016). Apathy in dementia: Systematic review of recent evidence on
pharmacological treatments. Current Psychiatry Reports, 18(11):103.
HeartMath Institute (2020). Emwavepro t www.heartmath.org.
Huff-Mercer, A.K. (2015). Animal-Assisted Therapy and Application to Older Adults in Long Term Care. Journal of Arts
and Humanities, 4(5), 16-27.
Marin R.S., Biedrzycki, R.C., Firingiogullari, S. (1991). Reliability and validity of the Apathy Evaluation Scale.
Psychiatric Research 38:143–162.
Nelson, R., Humes, S., Borgstrom, K., Crew, A., Crumbie, V., Gimbel, J. & Park, K. (2014). The Engagement in
Preferred ActivieS Scale (EPASS). Technical Report. Retrieved from author.
Porter, H., Hawkins, B.L., & Kemeny, B. (2020). ATRA Competencies in RT Practice. ATRA: Reston, Va.
Selbæk, G., Engedal, K., Bergh, S. (2013). The prevalence and course of neuropsychiatric symptoms in nursing
home patients with dementia: a systematic review. Journal of American Medical Director Association.14:161–9.
U.S. Census Bureau (2014). Fast Stats.https://www.cdc.gov/nchs/fastats/alzheimers.htm.
World Health Organization. (2018). Dementia: A public health priority. World Health Organization; Geneva
Switzerland.
Acknowledgements
4-a lot characteristic
1 Comparison of Pre and Post EPASS Scores for each Control (Social ) Session
Storm Harbor Equestrian Center
Slippery Rock University Faculty-Student Research Grant