Running head : EFFECT OF DOGS ON BEHAVIORAL SYMPTOMS OF DEMENTIA Dogs as an Intervention for Behavioral Symptoms of Older Adults with Dementia : A Systematic Review

The purpose of this systematic review was to determine if dogs are an effective occupational therapy intervention for reducing agitation and increasing social participation among older adults with symptoms of dementia by examining and rating the current published evidence. Studies were included if a dog was the primary intervention, and participants were at least 65 years of age with a diagnosis of dementia. Eleven studies were identified that met inclusion criteria. A majority of those studies found that the use of a dog reduced agitated behaviors and promoted social participation in older adults with dementia. While the variability in the methodology of the interventions in these studies make specific clinical recommendations difficult to determine, the current literature does suggest that animal assisted therapy would be an effective intervention strategy for occupational therapists working with clients in all stages of dementia. EFFECT OF DOGS ON BEHAVIORAL SYMPTOMS OF DEMENTIA 4 Dogs as an Intervention for Behavioral Symptoms of Older Adults with Dementia: A Systematic Review According to the U.S. Census Bureau (1995), the population of older adults in the United States has increased at a faster rate than any other age group. In the previous decade alone, the number of persons over the age of 65 has increased exponentially from 3 million to 33 million. This rate increase is predicted to continue such that by 2030 one in five individuals in this country will be over the age of 65 (United States Census Bureau, 1995). The Aging, Demographics, and Memory Study found that age to be of the most consistent predictors of dementia (Plassman et al., 2007), making it likely that there will be a parallel increase in dementia accompanying the increase in the older adult population. The same study estimates that there are currently 3.8 million Americans with some form of dementia. As the number of individuals affected by dementia continues to rise in the absence of a cure or preventative measures, exploring treatment options for these individuals becomes crucial for promoting the best possible care. Dementia is the term used to describe conditions, such as Alzheimer’s disease, which are characterized by cognitive degeneration that interferes with a person’s ability to meet life’s demands. In addition to the deterioration of cognitive functioning, later stages of dementia typically include behavioral changes. Agitation and reduced social participation are two common behavioral changes seen as a result of dementia that limit an individual’s ability to engage in meaningful activities. These limitations in occupation may result in a reduction in life roles, such as being a parent, spouse, or neighbor, their relationships with others, and quality of life (Doble, 2009). It is of great importance, therefore, to reduce behavioral symptoms and to EFFECT OF DOGS ON BEHAVIORAL SYMPTOMS OF DEMENTIA 5 support social participation in order to help the client maintain or restore engagement in meaningful activity. There are many approaches to reducing behavioral symptoms, the most common being medications, such as cholinesterase inhibitors and memantine (Cranwell-Bruce, 2010). These drugs are often accompanied by adverse side effects including nausea, dizziness, and confusion. In addition to medication, there are numerous non-pharmaceutical intervention strategies for addressing the behavioral symptoms of dementia. A review of alternative approaches to the behavioral symptoms of dementia conducted by Kong, Evans, and Guevara (2009) found that sensory interventions, such as aromatherapy and calming music, showed potential for reducing the agitated behavior of individuals with Alzheimer’s type dementia. One study found that the use of lavender aromatherapy significantly reduced agitated behaviors of individuals with behavioral and psychological symptoms of dementia, further supporting the potential efficacy of non-pharmacological interventions with this population (Fujii et al., 2008). Furthermore, nonpharmacological interventions, as compared to their prescription drug counterparts, have the additional advantage of being low risk and cost effective while having the potential to improve the client’s quality of life. Occupational therapists support individuals and families coping with dementia through a variety of non-pharmacological interventions including caregiver education, and environmental and task modification to enhance performance in activities of daily living (Doble, 2009). However, they may also address behavioral symptoms in order to support engagement in meaningful activities that support mental and physical wellness. As stated by the American Occupational Therapy Association (2010),“Interventions designed to enhance or restore wellbeing, occupational balance, and occupational engagement are critical components of the EFFECT OF DOGS ON BEHAVIORAL SYMPTOMS OF DEMENTIA 6 therapeutic process. ” Similarly, the Occupational Therapy Practice Framework (2008), which guides the profession, states that, “occupational therapy practitioners are concerned not only with occupations, but also the complexity of factors that empower and make possible clients’ engagement and participation in positive health-promoting occupations. ” If the behavioral changes associated with dementia interfere with an individual’s ability to engage in meaningful occupations, then it is within the scope of occupational therapy to address it. Background Occupational therapists work with clients with dementia and their caregivers in a variety of practice settings. Depending upon the stage of dementia, the severity of the symptoms, and the resources of the individual and their family, occupational therapists may provide interventions in the client’s home, the home of a family member, a skilled nursing facility, special care unit of a skilled nursing facility, or an adult day care program. Their caregivers are equally diverse in their relationship to the individual. Family members, including children and spouses, are often caregivers in this situation, but paraprofessionals and medical professionals also work with these clients. Thus, occupational therapists will assist clients, their families, and their caregivers in many settings each of which has their own set of environmental demands. Social participation. Social participation is an area of occupation defined by the Occupational Therapy Practice Framework (American Occupational Therapy Association, 2010) as patterns of behavior that are expected of an individual as they engage in activities in the community, and among family members, friends, and peers. This broad definition leaves room for interpretation with regard to what qualifies as social participation. In the most obvious sense, communicating with friends, family and community members in a contextually appropriate manner is social participation. However, social participation need not be limited to verbal EFFECT OF DOGS ON BEHAVIORAL SYMPTOMS OF DEMENTIA 7 communication with other people. People frequently communicate with one another using nonverbal forms of communication, such as gestures and facial expressions. Similarly, leaning towards another person and laughter can convey enjoyment between people. In addition to communication with other people, many behaviors indicative of social participation can occur to interactions between individuals and pets. For example, typical social behaviors of people interacting with dogs include talking, non-verbal expressions, and touching that engages the dog in a social way. In this review, social participation will include interaction between adults with dementia and other adults as well as therapy dogs. Social participation is a meaningful occupation that contributes to an individual’s wellbeing and quality of life in many ways. Interacting with others and the environment establishes and maintains roles and identities, which in turn provides a sense of purpose and autonomy. Social participation also promotes physical, mental and emotional health by engaging individuals in meaningful activity, strengthening coping ability during difficult life circumstances, and keeping individuals attuned to the present. The benefits of social participation become increasingly important to individuals as they age and lose some of the roles and occupations they once held. Amid the restrictions and losses imposed by age, relationships with others become crucial forms of reinforcement of identity, and interacting with the environment promotes a sense of purpose and autonomy (Doble, 2009). For individuals experiencing the progression of dementia in addition to the aging process, social participation becomes increasingly difficult and critical. The accelerated loss of occupations due to the effects of the dementia greatly reduces an individual’s sense of self and often results in the loss of relationships. The loss of verbal communication during the late stages of dementia further limits social participation for this population. Increasing social participation EFFECT OF DOGS ON BEHAVIORAL SYMPTOMS OF DEMENTIA 8 for adults with dementia is needed to reinforce their sense of personhood, support them in coping with the losses associated with dementia, and re-engage them in meaningful activities that will increase their quality of life (Schaber, 2011). Agitation. The progression of dementia leads not only to reduced levels of social participation, but also to inappropriate vocal or motor activity referred to as agitation (CohenMansfield & Billig, 1986). While the source of agitation is difficult to determine, limitations on one’s ability to perform tasks, increasing dependence upon others, disorientation, and loss of verbal communication are all changes associated with dementia that seem likely to induce frustration and anxiety. Agitation is one of the primary reasons that individuals with dementia move to long-term care facilities (Alzheim