7KNIM110: Animal-Assisted Therapy for Dementia - Systematic Review

This systematic review examines the effectiveness of animal-assisted therapy (AAT) in improving depression and agitation in elderly individuals with dementia. The review follows a structured methodology, including a PICO (Population, Intervention, Comparison, Outcome) framework to define the research question and inclusion/exclusion criteria. The search strategy encompassed databases like Medline, PsycINFO, and Embase, with studies from 2000 to 2019 included. The review synthesizes findings from two studies (Moretti et al., 2011; Olsen et al., 2016) that met the inclusion criteria, analyzing their methodologies, interventions, and outcomes. Key findings suggest that AAT can positively impact depressive symptoms, cognitive function, and the overall quality of life for dementia patients. The report critically appraises the included studies using the NICE checklist, considering factors like population representation, allocation methods, and outcome measures. The discussion highlights the potential of AAT as a non-pharmacological approach to manage neuropsychiatric symptoms in dementia. The conclusion emphasizes the need for further research, especially long-term studies with larger sample sizes, to fully understand the benefits of AAT for this vulnerable population.

Systematic review study
Does animal-assisted therapy help improve depression and agitation in the elderly with
dementia?
University
Unit
Name
Tutor

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Title
Does animal-assisted therapy help improve depression and agitation in the elderly with
dementia?
Background
Animal-assisted therapy (AAT) has often been used as an alternative therapeutically form of
treatment. It involves interventions which encompass treatment involving animal subjects,
with an aim of improving patient status in terms of social, emotional and cognitive aspects.
Studies have indicated that animals are useful for motivational and educational effects for
participants (Menna et al., 2016 pp. 242). Research studies have documented the immense
benefits of Animal-assisted Therapies through subjective assessment data such as improving
blood pressure and social aspects. Neuropsychiatric symptoms on cognitively impaired
nursing subjects have a high incidence of agitation and depression signifying common
symptoms among the elderly (Friedmann et al., 2015 pp. 277).
The choice of PICO question for this review based on the following key PICO elements;
Question elements Population Intervention Comparison Outcome
Elderly Animal-assisted
therapy
- Improved mental
health
Precise question Does animal-assisted therapy help improve depression and agitation in the elderly
with dementia?
Effective approaches to be used in answering the PICO question above entail Meta-analysis
of the related data which used randomized controlled trials in their methodology. This offers
level I of evidence. Further, search on randomized controlled studies assessing on the effect
of animal-assisted therapies is able to offer level II of evidence to assess the relationship on
the improvement of animal-assisted therapies on dementia persons in alleviating depression
and agitation. Other study designs best to answer the relevant PICO question entail the use of
quasi-experimental controlled studies designs which offer level III evidence. Scoping search
yielded 695 studies conducted between in the last 20 years relating to the topic.

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Method
The methodology employed in the systematic review involved the use of NICE checklist to
review the information sought. The checklist offers an instrumental basis for assessing the
population of focus which describes the source, representation of the population and
eligibility factors. Further allocation methods were employed in the study. Focus on
allocation treatment of the subjects, blinding for comparisons, adequacy of intervention and
comparison and comparisons with other similar groups. Lastly, the NICE guidelines checklist
offered an incisive way analysis, outcomes measures summaries of the studies which were
crucial in this phase. The search database employed includes Medline, Pyshco INFO, and
Embase. The search included studies between 2000 and 2019. The inclusion criteria for the
articles searched entailed those that pertained the elderly over the age of 65 years and have
been institutionalized over the last 2 months and have been affected by mental illness. Mental
health, in this case, referred to as vascular dementia, secondary dementia, agitation, such as
mood disorder, psychotic disorders.
The search entailed the use of keywords in combination with Boolean operators. The
keywords used in the search entailed; ‘and', ‘or' and ‘not'.
The following table shows the application of the methodology Boolean search methods;
Facet
analysis
Population Intervention Comparison Outcome
Index Elderly Animal-assisted
therapy
- Mental health
Geriatric
Or
Old age
Or
Older
Or
Senior
Animal activity
Or
Pet-assisted activity
Pet therapy
Or
Human-animal
interaction
Or
Therapeutic recreation
Mental illness
And
Cognitive impairment
And
Illness perception
And
Psychological health
And
Psychological illness
And
dementia
Alzheimer
The participant’s description was extracted such as age and sex. Further diagnosis factors
such as the depression states and other descriptive factors being sought by the studies. Further
details of the intervention such as the program session were considered with keen interests,
this was employed as a measure of standardization. The outcomes and conclusion of the

697 articles were obtained
from search database
0 articles sourced from
different databases
500 articles remained after duplicates removal
2 articles met the inclusion
criteria match and thus included
in the systematic review
697 articles remained to be
subjected on the inclusion
criteria set
695 articles did not meet the set
criteria for inclusion, hence
removed
Inclusion criteria
Elderly above 65 years
Institutionalized atleast 2
months
Having mental disease
and agitation
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studies were extracted with information on the type of assessments and summary available.
Findings of the search
The search entailed yield 697 studios ranging from different designs protocol. The designs
included in the search process included the use of randomized controlled studies, descriptive
studies, correlational studies, and quasi-experimental studies and meta-analysis. The elderly
population of the elderly above the age of 65 years were included in the study.
The search yielded and synthesis two studies which are essential in this review. The studies
were chosen Moretti et al., (2011) and Olsen et al., (2016) were chosen for the purpose of this
study. The flow chart was applied in the screening process to identify the two studies;

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The two studies Moretti et al., (2011) and Olsen et al., (2016), met the inclusion criteria for
the study. The table below was used to analyze this section so as to ensure that the effective
inclusion of the selected studies was met.
Article
author
Study design Sample size Intervention Comparison
group
settings outcome
Moretti et
al., (2011
Quasi-
experimental
design with pet
group and
control group
20 subjects Pet group
activity 90 mini
once a week.
Pet group
played with the
animals while
the control
group allowed
into a nursing
home but not
allowed to
interact with
the
animals
10 patients-pet
group
10 patients-
control group
Nursing
home
Per therapy
efficient in
lowering
depressive
symptoms
and
improving
cognitive
function of
dementia
PICO Population
Elderly above
65 years
Intervention
Playing with
vet animals
for 90 minutes
Comparison
Control group
visiting nursing
home without
any play with
vet animals
Outcome
Improved
cognitive
function and
lowered
depressive
states
Olsen et
al., (2016),
Prospective,
cluster
randomized
trial
58
participants
recruited
30 minutes
session with
animal assisted
activities twice
weekly for 12
weeks
Did not receive
any treatment
activity.
10 Nursing
homes
Observed
significant
effect on
positive
symptoms of
depression
and quality of
life among
dementia
patients
PICO Population Intervention Comparison Outcome
The elderly
aged over 65
years and
above
Exercise
activity over
30 min for 12
weeks on
animal-
assisted
No activity
group
Improved
mental health
state

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activity
Critical appraisal
The NICE appraisal tools are crucial in the Assesment of these studies. The study Moretti et
al., (2011) has used the elderly population representing the population among nursing homes
in Italy representing the general nursing home set population. The selected population is the
elderly living wealthy area of Italy hence not a representative of the entire elderly population,
however, they represent the population of the elderly in the wealthy area.
The treatment of groups was based on an international manual on International Statistical
Classification of Diseases and Related Health Problems, 10th Revision-ICD-10 (Hellman et
al., 2018). The allocation retirement of the subjects was not blinded but rather using a
selection process based on socio-demographic and clinical assessments. Further, the study
used both the local GP and four dog educators and psychologist experts. The investigator
groping them into groups was blinded during the allocation of the treatment process. Finally,
the study accounted for all subjects with all the subjects accounted for.
The study assessed the relationship between the two groups on t-test. The two groups were
not standardized before treatment. The results showed an internal validity due to adjustment
of instruments for data collection. The size was quite small hence power effect could be
lower. The effect of size was not determined however the general methods were appropriate.
The study results could not be generalized due to various flaws identified in the analysis and
the overall methodology process.
The study by Olsen et al., (2016), employed the elderly population aged 65 years and above
living in Norway in a prospective cluster random assessment. The subjects were randomized
to home nursing units into either the control or treatment group. The subjects were
voluntarily selected themselves based on facilities available from three counties of
Norwegian, thus showing some biases in the sense it did not represent the entire 90 eligible
nursing homes, thus the subjects population could not be generalized.
The subjects were standardized and grouped into different groups among various units and
respective dig handlers. The groups received the same intervention treatment process, with

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similarities in both groups and follow up was done for the subjects. The study accounted for
all the participants in the process. The setting of the study was similar to that of UK practice
and used intervention specialist and subjects monitories. The outcomes of the study were
standardized with an appropriate methodology. Further missing data was able to be
standardized. The results depicted unbiasedness as sufficient details were offered. Effect sizes
were not measured with no follow-ups.
The outcome of the study could not be generalized due to identified flaws in the study as the
recruitment process of the nursing homes might have been subject to biases based on the
preference of self-selection. Further, the study could not authoritatively state cause and effect
on the symptoms of dementia.
Synthesis of results
The study by Moretti et al., (2011), evaluated the effects of pet therapy on cognitive
functionality, mood and perceived quality among the elderly inpatients. The findings yielded
an improved score of pet therapy on the depressive symptoms and cognitive function of long
term residents having a mental illness. Based on a geriatric depression scale, the treatment
group was able to have a decrease of 50% with an increase in mental assessment mean score
by 4.5(P=0.060). The findings showed an improved state of improved depression state among
dementia older persons.
Moreover, the focus of study analyzed by Olsen et al., (2016) involved on the neuro
psychotic symptoms of cognitively impaired nursing home residents with high depression
state and agitation symptoms. Treatment of animal-assisted activities showed a significant
improvement in the depression state of the subjects compared to the control group at follow-
up. The outcome of this study shows indicated the there is an effect on the animal-based
therapies in improving patient outcomes in dementia state among the older persons. However,
the stud could not conclusively attribute improved depression state, the findings revealed a
significant relationship compared to the control group.
Other similar studies have shown that animal-assisted therapy has been shown to have an
effective treatment for mental and behavioral factors such as depression and addictions.
Animal-assisted therapies to entail intervention geared at animal participation an integral part
to improve outcomes of the patients. This informs the interaction of diverse activities which
are crucial in improving psychiatric conditions and cognitive conditions such as dementia

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(Lundqvist et al., 2017).
Discussion
Literature studies have shown that Neuro psychotic prevalence in cognitive impairment is
very high in various nursing homes. Various studies have investigated the role of animal-
assisted therapy on symptoms and agitation in nursing homes residents (Majic et al., 2013).
Animal-assisted therapy has been shown to have significant positive effects on improving
psychiatric disorders however focus on depression and agitation is not well understood
(Kamioka et al., 2014 pp. 372-375).
A stud my Majic et al (2013), in a randomized controlled study found out that animal-assisted
therapies have a significant effect on the progression of neuro psychotic symptoms, findings
similar to our systematic review. In view of the absence of nonepharmacogenic and psychotic
options available for treatment of psychological symptoms of dementia, animal-assisted
therapies offer the safes approach therapeutically mechanism to manage dementia effects
among the elderly.
Conclusion
The beneficial effect of animal-assisted therapy has a significant effect on the
neuropsychology state of patients diagnosed with dementia especially the elderly. The
findings from this systematic analysis reveal that positive association is linked to an
improved outcome (Travers et al., 2013). The study findings reveal that the efficacy level of
the therapy as indicated tend to improve the level of dementia facing the elderly. Animal-
assisted therapy tends to improve the level of depression and agitation in the elderly with
dementia (Nordgren & Engström, 2014). More studies need to test the long term effects of
the therapy and to use a bigger number of subjects so as to assess in a more standard way as
the studies in this review were subject to methodological shortcomings. However, despite
this, its findings were in tandem with other studies conducted on the subject. Nevertheless,
none of these studies could have a significant assessment of the efficacy level to ascertain
with confidence in the efficacy of the assisted therapies for elderly persons facing dementia.

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References
Friedmann, E., Galik, E., Thomas, S. A., Hall, P. S., Chung, S. Y., & McCune, S. 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.
Hellman, J.B., Lim, M.C., Leung, K.Y., Blount, C.M. and Yiu, G., 2018. The impact of
conversion to International Classification of Diseases, 10th revision (ICD-10) on an academic
ophthalmology practice. Clinical ophthalmology (Auckland, NZ), 12, p.949.
Kamioka, H., Okada, S., Tsutani, K., Park, H., Okuizumi, H., Handa, S., ... & Honda, T.
2014. Effectiveness of animal-assisted therapy: A systematic review of randomized
controlled trials. Complementary therapies in medicine, 22(2), 371-390.
Lundqvist, M., Carlsson, P., Sjödahl, R., Theodorsson, E., & Levin, L. Å. 2017. Patient
benefit of dog-assisted interventions in health care: a systematic review. BMC complementary
and alternative medicine, 17(1), 358.
Majić, 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. The American Journal of Geriatric Psychiatry, 21(11), 1052-1059.
Menna, L. F., Santaniello, A., Gerardi, F., Di Maggio, A., & Milan, G. 2016. Evaluation of
the efficacy of animal‐assisted therapy based on the reality orientation therapy protocol in
Alzheimer's disease patients: a pilot study. Psychogeriatrics, 16(4), 240-246.
Moretti, F., De Ronchi, D., Bernabei, V., Marchetti, L., Ferrari, B., Forlani, C., Negretti, F.,
Sacchetti, C. and Atti, A.R., 2011. Pet therapy in elderly patients with mental illness.
Psychogeriatrics, 11(2), pp.125-129.
Nordgren, L., & Engström, G. 2014. Effects of dog-assisted intervention on behavioural and
psychological symptoms of dementia. Nursing older people, 26(3).
Olsen, C., Pedersen, I., Bergland, A., Enders‐Slegers, M. J., Patil, G., & Ihlebæk, C. 2016.
Effect of animal‐assisted interventions on depression, agitation and quality of life in nursing

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home residents suffering from cognitive impairment or dementia: a cluster randomized
controlled trial. International journal of geriatric psychiatry, 31(12), 1312-1321.
Travers, C., Perkins, J., Rand, J., Bartlett, H., & Morton, J. 2013. An evaluation of dog-
assisted therapy for residents of aged care facilities with dementia. Anthrozoös, 26(2), 213-
225.

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Appendix
 Tell student to upload the search results inform of a capture image which gave
rise to excelll file uploaded in this task and copy paste here