RESEARCH OBJECTIVE(S) To examine the effects of AAT on agitation and depression among nursing home residents with dementia

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1 CRITICALLY APPRAISED PAPER (CAP) Majic, T., Gutzmann, H., Heinz, A., Lang, U. E., & Rapp, M. A. (2013). Animal-assisted therapy and agitation and depression in nursing home residents with dementia: A matched case-control trial. American Journal of Geriatric Psychiatry, 21(11), CLINICAL BOTTOM LINE: The older adult population constitutes a large portion of occupational therapy s practice realm. One intervention that has been applied to this specific population is animal-assisted therapy (AAT); however, limited research has been done on this subject. This Level II matched case-control study collected data from eight nursing homes in Germany to analyze AAT s effects on behavioral and psychological symptoms of dementia (i.e., agitation, aggression, and depression) in older nursing home residents receiving standard care and therapy. Results showed that in the intervention group, there was no statistically significant difference in pretest to posttest scores on the Cohen Mansfield Agitation Inventory (CMAI) and Dementia Mood Assessment Scale (DMAS), which indicates stability in the severity of agitation and depressive symptoms. In the control group, scores significantly increased on the CMAI and DMAS. These results indicate that AAT seemed to have an impact on stabilizing nursing home residents behavioral and psychological symptoms of dementia. Because this study implemented AAT for a total of 10 weeks, with sessions lasting up to 45 min once a week, therapists interested in using AAT might find it beneficial to start with this timeline. Further research still needs to be done, however, to verify AAT s middle- and long-term effects on nursing home residents with dementia. RESEARCH OBJECTIVE(S) To examine the effects of AAT on agitation and depression among nursing home residents with dementia DESIGN TYPE AND LEVEL OF EVIDENCE: Level II: Matched case-control SAMPLE SELECTION Participants were recruited from eight nursing homes in Germany. Written consent was obtained from participants and caregivers holding power of attorney. There was no mention of randomization during allocation of nursing homes. 1

2 Inclusion Criteria Nursing home residents had to meet the following criteria: score less than 25 on the Mini- Mental State Examination (MMSE), which indicates a cognitive impairment; fulfill the criteria for a diagnosis of dementia according to the DSM IV; have been cognitively impaired for less than 6 months; and have a clinically significant cognitive impairment. Exclusion Criteria Participants were excluded from the sample if they were diagnosed with another relevant Axis I disorder (delirium, schizophrenia, bipolar disorder) or a terminal somatic illness, as defined by a clinical examination and history taking. SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 75 #/ (%) Male 16/(29.6%) #/ (%) Female 38/(70.4%) Ethnicity NR Disease/disability diagnosis Dementia INTERVENTION(S) AND CONTROL GROUPS Group 1: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? The control group consisted of participants receiving the same care and therapies before the onset of the study. This care included pharmacologic and nonpharmacologic treatment, ergotherapy, massage, and physiotherapy. 27 Nursing home in Germany NR NR Group 2: Intervention group Brief description of the intervention 10 weeks The intervention group received their previous care and therapy as well as AAT from two border collies who were educated therapy dogs. The intervention was conducted at the same time and day each week and followed a standardized beginning and ending. The 2

3 sessions began with an introduction of the dog to the participant by the dog therapy guide. The participant was urged to talk to the dog, and then he or she had physical contact with the dog through stroking and petting. After the physical contact, the participants were allowed to have free interactions with the dog. The session ended with the dog therapy guide speaking to the participant. How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? 27 Nursing home in Germany Dog therapy guide Once a week for up to 45 min 10 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: YES NO Co-intervention: Timing: Site: YES NO Although both groups continued with their previous care and therapy, the researchers did not specifically state what therapies each participant received. Participants in the AAT group might have been receiving more outside therapies in addition to the AAT, which could have skewed the results. The authors failed to mention how nursing homes were selected. Use of different therapists to provide intervention: YES Both dog guides were close in age, were female, had the same 3

4 NO level of education, and had a close relationship with the dog. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? MMSE Participants cognitive impairment YES NR YES NR Within 4 weeks before study implementation and 4 weeks after completion Measure 2: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Measure 3: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? CMAI Agitation symptoms Within 4 weeks before study implementation and 4 weeks after completion DMAS Depressive symptoms YES NR YES NR Within 4 weeks before study implementation and 4 weeks after completion Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. 4

5 The researchers mentioned that the trained raters (i.e., medical students and physicians) were blind to participants treatment allocation. Recall or memory bias. Check yes, no, or NR, and if yes, explain. YES NO Others (list and explain): RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported Paired t tests were used for calculating differences between symptom scores preintervention and postintervention. Repeated-measures analysis of covariance was used to analyze the difference in treatment group effects preintervention and postintervention. Preintervention and postintervention scores from the CMAI and DMAS were classified as dependent variables; treatment groups were classified as between-subjects factors; and age, gender, pretest MMSE sum score, and matched-pair denominators were classified as covariates. The statistically significant pretest difference in depression between the two treatment groups determined this analysis design. Repeated-measures analysis of variance found that the Treatment Groups Time effect was significant for symptoms of agitation (p <.05) and depression (p <.001) during treatment. The researchers found that participants who received AAT showed no significant changes in CMAI (p =.81) and DMAS (p =.069) scores. The control group showed a significant increase in CMAI (p <.001) and DMAS (p <.001) scores. Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. 5

6 Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. Was the percent/number of subjects/participants who dropped out of the study reported? Limitations: What are the overall study limitations? Participants were allocated from only a few nursing homes in Germany, which thus limits the study s external validity. CONCLUSIONS State the authors conclusions related to the research objectives. This study found that nursing home residents diagnosed with dementia had stable symptoms of agitation, aggression, and depression over a 10-week period when AAT was combined with standard care. Among nursing home residents diagnosed with dementia, symptoms of agitation, aggression, and depression increased over a 10-week period when residents only received standard care. This indicates that AAT seems to have helped residents avoid developing more severe symptoms. Difference in cognitive decline was not statistically significant between the two treatment groups, which indicates that AAT can be a promising option for treatment of some behavioral and psychological symptoms of dementia. This work is based on the evidence-based literature review completed by Kelsey Peterson, OTS, and Myka Winder, OTD, OTR/L, Faculty Advisor, University of Southern California. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: 6