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Resident Dog in the Alzheimer's Special Care Unit
Barbara W. McCabe, Mara M. Baun, Denise Speich and Sangeeta Agrawal The online version of this article can be found at: can be found at:
Western Journal of Nursing Research
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Western Journal of Nursing Research,2002,24(6),684-696
Western Journal of Nursing ResearchOctober 2002, Vol. 24, No. 6 Resident Dog in the Alzheimer’s
Special Care Unit
Behavioral disturbances are a common feature of Alzheimer’s disease (AD). Prior studies havedemonstrated a significant reduction in agitation behaviors during short-term exposure to a dogon an Alzheimer’s special care unit (SCU) for persons with AD. The purpose of this studywas todetermine the effect over time of a resident dog on problem behaviors of persons with AD in anSCU. A within-participants repeated-measures design was used for this study. The NursingHome Behavior Problem Scale was used to document behaviors (on days and evenings) 1 weekbefore and 4 weeks after placement of the dog. Participants on the dayshift exhibited signifi-cantlyfewer problem behaviors across the 4 weeks of the study(F[1, 80] = 7.69, p < .05). No sig-nificant change in behaviors occurred on the evening shift. The findings support the long-termtherapeutic effects of dogs for persons residing in Alzheimer’s SCUs. The purpose of this study was to determine the effect of the introduction of a resident dog on problem behaviors of persons diagnosed with Alzheimer’s(AD) or related disorders who reside in an AD special care unit (SCU). A sec-ondary purpose was to compare the variation in use of pharmacologicalagents to treat problem behaviors before the introduction of the resident dogto the unit and for the first 4 weeks after the introduction of the resident dog.
Issues and Interventions for Persons With AD
AD is a progressive neurodegenerative disorder characterized by impair- ment in a wide spectrum of cognitive abilities including memory, language, Barbara W. McCabe, Ph.D., R.N.C.S., Associate Professor, University of NebraskaMedical Center, College of Nursing; Mara M. Baun, D.N.Sc., F.A.A.N., Lee & Joseph D.
Jamail Distinguished Professor, University of Texas at Houston School of Nursing;Denise Speich, M.S.N., A.P.R.N., Consultants in Gastroenterology; Sangeeta Agrawal,M.S., Data Analyst, University of Nebraska Medical Center, College of Nursing.
DOI: 10.1177/019394502236641 2002 Sage Publications mood, judgment, and social behaviors. The Alzheimer’s Association (1998)estimates that there are 4 million persons with AD, and by 2050 there will be14 million persons with this disorder (Alzheimer’s Association, 1998). Adefinitive diagnosis of AD can only be made through brain autopsy at thistime. Although the causes of AD are unknown, pathophysiologic changesthat occur in the brain result in a progressive decline in cognitive function-ing. Although there is no established treatment to permanently reverse orstop the changes associated with AD, the use of cholinesterase inhibitorssuch as Aricept (donepezil), Exelon (rivastigmine), and Reminyl(galantamine) have been demonstrated to slow down and, in some cases,temporarily reverse cognitive decline. Successful pharmacological manage-ment of cognitive decline and function in persons with AD is currently lim-ited (Keltner & Folkes, 1997). Until researchers definitively establish theunderlying pathophysiology of this disease, the goal remains that of effec-tively managing the associated symptomatic behaviors.
Behavior disorders are a common feature in dementia and become more problematic as the disease progresses. Symptoms include agitation, aggres-sion, delusions, hallucinations, sleep problems, wandering, incontinence,and vocalizations (Stoppe, Brandt, & Staedt, 1999). Behavioral disturbancesare usually more problematic than cognitive difficulties for caregivers andare often the reasons for institutionalization. Behavioral problems can bemanaged with environmental modification, alterations in caregiving, andpharmacotherapy (Sloane, 1998). Certain behavioral disturbances, such ashallucinations, anxiety, and depression can be treated effectively with anti-psychotic, mood-stabilizing, and antidepressant medications (Kumar,Durai, & Jobe, 1998), but given the risk-benefit of most psychotropic drugsused in older persons with dementia, the effectiveness of nonpharma-cological strategies is deserving of systematic study (Keltner & Folkes,1997). One approach that is designed to be responsive to the specific needsof persons with AD are SCUs (Sand, Yeaworth, & McCabe, 1992). SCUsprovide activity-based interventions and behavioral management for ADresidents who may be difficult to manage in a nonspecialized facility. Thera-peutic environments are created that use a variety of techniques to promoteindependence, decrease the use of chemical agents and physical restraints,and improve the quality of life for these residents (Alzheimer’s Disease andRelated Disorders Association of Eastern Massachusetts, 1999). The designof SCUs stresses the role of environmental factors on the behavior of per-sons with AD. Attention is directed to lighting, colors, and noise that caninfluence the behavior of SCU residents. SCUs provide settings that aresecure, comforting, and nonthreatening. They offer a familiar frame of reference, lessen confusion, and offer freedom of movement within an unre-stricted space (Teresi, 2000).
Another aspect of the environment receiving increased attention is the use of companion animals in the clinical setting. Animals have long been apart of programs to help people. As early as the 17th century, the health ben-efits of animals were recognized. The idea that human interaction with com-panion animals can result in psychological and physiological benefits isreceiving increased attention by health professionals (Willis, 1997). Petsprovide affection and companionship regardless of one’s cognitive or physi-cal abilities (Kongable, Buckwalter, & Stolley, 1989).
Several studies have demonstrated that interactions with animals have positively influenced people in a variety of settings, such as home (Fritz,Farver, Kass, & Hart, 1995), psychiatric (Walsh, Merten, Verlander, & Pol-lard, 1995; Zisselman, Rovner, Schmuely, & Ferrie, 1996), and nursingfacilities (Darrah, 1996; Fick, 1993). Physical benefits of association withanimals include decreased blood pressure and heart rate and increasedperipheral skin temperature (Baun, Bergstrom, Langston, & Thoma, 1984;Oetting, Baun, Bergstrom, & Langston, 1985). Psychological benefitsinclude relaxation, reality orientation, self-worth and companionship (Fine,2000). Long-term associations of companion animals with community-residing persons with AD have been linked with fewer episodes of verbalaggression and anxiety compared with those not having a companion animal(Fritz et al., 1995). Persons with AD who were attached to their pets hadfewer reported mood disorders (Fritz, Farver, Hart, & Kass, 1996). In astudy conducted on an AD SCU, the presence of a therapy dog increased thetotal number of socialization behaviors of persons with AD during one-on-one interactions (Batson, McCabe, Baun, & Wilson, 1998). The presence ofa visiting dog showed increased social behaviors in persons with AD resid-ing on an SCU (Kongable et al., 1989; Kongable, Stolley, & Buckwalter,1990).
Although pet therapy is becoming increasingly popular in a variety of set- tings, most research has addressed only the short-term effects of pet therapyusing a visiting pet, usually a dog. One of the few studies that addressed thelong-term effects of pet therapy was conducted in prisons where small farmanimals were used. Data demonstrated that inmates became less violent, hadfewer conflicts, required fewer medications, and showed more acceptablebehaviors (Greenberg, 1996). A recent study by Churchill, Safaoui,McCabe, and Baun (1999) on an AD SCU reported a decrease in agitationand improved socialization in AD residents during sundown hours when adog visited. The study reported here builds on the study by Churchill et al.
(1999) by focusing on the extent to which changes in problem behaviors aresustained for 1 month after the introduction of a resident dog to an AD SCU.
This study examined the effect of the introduction of a resident dog on prob-lem behaviors of persons with AD who reside in an SCU and compared theuse of pharmacological agents to treat behavioral problems before and 1month after the introduction of the resident dog on the SCU.
A within-participants repeated-measures design was used in this study.
Facility staff members used the Nursing Home Behavior Problem Scale(NHBPS) (Ray, Taylor, Lichenstein, & Meador, 1992) to document prob-lem behaviors before the introduction of the dog and weekly for 4 weeks fol-lowing placement of the dog on the unit. Medications used for problembehaviors were also recorded during the same time frame. The data analyzedwere part of a clinical improvement project designed by the staff on the unitwhere this project was conducted. One of the investigators had a facultypractice appointment at this facility thus making it possible to accessrecorded data. The Institutional Review Boards of both the medical centerwhere the investigators were employed and the institution where this studywas conducted approved the study. It was not necessary to get approval fromthe Institutional Animal Care and Use Committee of the investigators’employment institution because the decision to place a resident dog on theSCU was an independent decision made by the facility staff prior to theimplementation of this study.
Eligibility criteria included a probable diagnosis of AD or a related dis- ease and residence on an AD SCU. Records of both men and women werereviewed for reports of agitation or aggression behaviors recorded on theNHBPS by the primary caregivers of the SCU residents as well as the admin-istration of pharmacological agents to treat mood and behavioral problems.
The study site was a 22-bed SCU of an urban extended health care facility in a midwestern state. The philosophy of the unit was consistent with criteriadeveloped by the Alzheimer’s Association (1992) and published in Guide-lines for Dignity. All aspects of care provided on this unit were designed to promote functional capacity and dignity of the residents. Residents on theunit were free to move about the unit at will. The unit included both privateand semiprivate rooms. A common area on the unit was used as the diningroom as well as the area for planned unit activities. In the common area,there was an aquarium with tropical fish, a pair of caged budgies, and a vari-ety of nontoxic houseplants. Incorporating plants and animal life in a long-term care setting is consistent with the Eden Alternative model of caredesigned to “deinstitutionalize” the nursing home environment (Thomas,1994, 1996). A social model of care was emphasized in daily interactionsbetween staff members and residents. Staff education and research utiliza-tion relevant to the care of persons with AD was emphasized. In addition, thestaff had prior experience with research studies designed to measureresponses of the residents to visitor dogs on the unit. Visiting animals, mostof which were dogs, were frequently present on the unit.
Measurement Tools
The measurement tools used in the study included a demographic profile, a medication review form, and the NHBPS. The demographic profile col-lected information about participant age, gender, medications, and length ofstay on the SCU. The medication review form was used to examine the med-ical record for information about the total number of mood-and behavior-altering medications, category of medication, dose, frequency, and whetherthe medication was prescribed as routine or as needed (PRN).
The NHBPS was used to measure the level of problem behaviors. The NHBPS was developed to measure the specific disruptive behavior prob-lems that occur in a nursing home setting and may result in use ofantipsychotic drugs or physical restraints. The scale consists of 29 items.
There are 6 subscales: uncooperative or aggressive behaviors, irrational orrestless behaviors, sleep problems, annoying behaviors, inappropriatebehaviors, and dangerous behaviors. The scale was designed to be com-pleted by nurses and nursing assistants who are familiar with the resident.
The rater is asked to report the frequency of each behavior in the past 3 days,using a 5-point frequency of occurrence scale (0 = never to 4 = always). Theoverall score is calculated as the sum of the individual items; larger scoresindicate a greater level of behavioral problems. A 3-to 5-minute time frameper resident is needed to complete the scale. The scale interrater reliabilitywas measured by the Pearson correlation coefficient, with interrater correlations of approximately .8 (Ray et al., 1992). The instrument has highconvergent validity; the correlation with the widely used Nurse OrientedScale for Inpatient Evaluation (NOSIE) was –.747 and that with the CohenMansfield Agitation Inventory (CMAI) was .911 (Ray et al., 1992).
Therapy Dog
The therapy dog used for this study was a neutered male blue heeler. This adult dog was adopted by the participating facility from a local countyhumane society. The estimated age of the dog was 4 years. The dog wasevaluated and professionally trained for a period of 3 weeks in basic obedi-ence by a well-respected local trainer in the community where the facilitywas located. The dog was judged to have a docile personality and to be wellmannered. The dog was currently immunized and verified to be in goodhealth by a local veterinarian. Arrangements for the dog to live on the unitincluded identifying a staff member as well as a designated alternate whowould assume primary responsibility for the dog, developing criteria toassure proper health maintenance activities for the dog, developing criteriaas to when and where the dog could roam on the unit, and creating a livingspace for the dog adjacent to the unit. The dog had independent access to theenclosed outdoor courtyard from his living space. The dog was present onthe unit from morning to evening with the exception of mealtimes, when hewas confined to his living space adjacent to the unit. While on the SCU, thedog freely interacted with the residents in common areas of the SCU andspent time in individual resident rooms. It was not uncommon for the dog toaccompany staff members as they assisted residents with activities of dailyliving.
Data Collection Procedure
One investigator reviewed and transcribed entries from resident records pertaining to the NHBPS, administration of mood-altering drugs, andselected demographic information onto a data collection sheet. The primarycare staff nurse completed the NHBPS for each resident on the day (7 a.m. to3 p.m.) and evening (3 p.m. to 11 p.m.) shifts 1 week prior to the introductionof the resident dog and weekly for 4 weeks following the placement of thedog on the unit. The recorded data represented frequency of occurrence ofeach behavior within the past 3 days. Data were recorded on Tuesday thusrepresenting both weekend and weekday behavior patterns.
Data Analysis
To determine the effect of the introduction of a resident dog on problem behaviors of persons with AD who reside in an SCU AD unit, total scores onthe NHBPS were analyzed using within-patients repeated-measures ANOVA.
Descriptive statistics were used to identify changes in the frequency of useof mood-altering medications while the resident dog was present. A signifi-cance level of p < .05 was used for this study. Because of the small samplesize, additional analyses by gender, age, and length of stay on the unit werenot done.
The records of 22 residents (15 females and 7 males) were reviewed.
Twenty residents were Caucasian, 1 was Hispanic and 1 was African Ameri-can. Mean age was 83.7 years (range 68-96 years). Mean length of stay onthe SCU was 2.9 years (range 0.6-8 years). All participants had a diagnosisof AD or a related disorder.
A two-way within-participants repeated-measures ANOVA was con- ducted to evaluate whether there was a change in behavior problem scoreson the day and evening shifts over the 4-week period following the introduc-tion of a resident dog. The dependent variable was the NHBPS total score, ameasure of behavior problems. The two within-patients factors were theshift (time of day) with two levels (day and evening) and weeks with fivelevels (Week 1 through Week 5). Mauchly’s Test of Sphericity for the inter-action effect was found to be nonsignificant, χ2 (9) = 14.99, p > .05, thus sup-porting the assumption of sphericity. The univariate tests of within-partici-pants revealed a significant interaction between shift (time of day) andweek, F(4, 80) = 2.88, p < .05. The univariate tests for the overall main effectof week were found to be nonsignificant, F(4, 80) = 2.39, p > .05. Post hoctests were conducted and indicated a statistically significant effect, F(1, 80) =9.24, p < .01, for shift (time of day). The results indicate that there was a sus-tained decrease over 4 weeks in behavioral problems during the day shift ascompared to the evening shift. The results also indicate that overall thebehavior problems were significantly less in the evening shift as comparedto the day shift.
Figure 1: Mean behavior problem scales over time.
Subscales of the NHBPS
The data were also analyzed according to the 6 subscales of the NHBPS.
The most frequent types of behavior problems exhibited by the participantswere aggressive or uncooperative behaviors and irrational or restless behav-iors. The least frequently identified behaviors were dangerous behaviors.
Analysis of the subscale scores demonstrated a decrease in the mean scorefor each subscale of the NHBPS for the day shift. No substantial decrease inmean NHBPS subscale scores for the evening shift occurred.
Medication Use
The use of mood-and behavior-altering medications by the participating residents was reviewed. Five participants took no mood-or behavior-alter-ing medications. Ten participants took at least one medication for mood-andbehavior-altering indications, 5 participants took two medications, and 1participant took three medications. One resident’s record was not availablefor review of the medication history. The categories and the percentage ofprescribed medications relevant to the study are as follows: antidepressants Figure 2: Mean behavior problem subscores.
% Receiving
Mood Altering
Number of Mood Altering Drugs
Figure 3: Total mood altering drugs prescribed 22.7%, antipsychotics 50%, benzodiazapines 9.1%, and anxiolytics 18.2%.
These medications were prescribed for routine daily use; none was adminis-tered on a PRN basis. The dose and frequency of the scheduled medicationsremained constant throughout the study.
DISCUSSION
The presence of the resident dog decreased the occurrence of behavioral disturbances during daytime hours for the 1-month study period. There wasa statistically significant decrease in the mean score of behavioral problemsfrom Week 1 (pretest) to Week 2 (the 1st week after the introduction of theresident dog). There was a slight increase in behavior problem scores on theday shift the 3rd week of the study. Halloween festivities took place duringthis week and may account for the rise in behavioral problems. On Week 4 ofthe study, the behavioral problem scores fell again to a score even lower thanthe Week 2 mean score. Problem behaviors in Week 5 did, however,increase slightly but still remained less than the mean score of Week 2.
No significant differences in problem behavior scores were observed throughout the study on the evening shift. The lack of significant changes onthe evening shift warrants further study. Staffing patterns, unit characteris-tics, or unit routines during the evening hours may have influenced how theresidents responded to the dog in the evening.
Throughout the study, the mean behavioral scores for the evening shift were lower than the day shift scores. These findings are similar to the lowlevel of behavior problems during the sundown period noted by Churchillet al. (1999). Churchill et al. suggested that soothing background music aswell as use of mood-and behavior-altering drugs might have accounted forthe low level of behavior problems observed in study participants. Anotherpossible explanation of the low level of observed problem behaviors is thepresence of additional visitors and less staff on the evening shift. Behaviorproblems may have been less evident to the staff. The presence of more visi-tors and fewer staff members may have modified the milieu of the SCU in away that decreased behavior problems. On the evening shift, the actual timefor observation of behavior problems is shortened because some residentsretire to bed in the early evening hours. Early evening is typically when resi-dents interact with family and friends. In addition, there are fewer transientpeople (lab, laundry, nutrition) on the unit during the evening shift.
Although literature indicates that behavior problems increase during thesundown period, the low level of the problems observed in this study may reflect the fact that staff members may already have interventions and strate-gies in place to help decrease the severity of the sundown syndrome.
This study extended the work of Batson et al. (1998) and Churchill et al.
(1999). They examined the effects of the presence of a companion animaland found that the presence of the visiting companion dog had a calmingeffect on institutionalized residents with AD. Whereas those studies used acompanion animal in planned brief interactions with residents, this studyshowed the effectiveness of the use of a dog that resided in the SCU. Thebehavioral disturbances associated with AD residents were decreased innumber, and the changes were sustained for 1 month. No differences werenoted in the administration of pharmacological agents to treat mood andbehavioral problems. One of the characteristics of an SCU is the use ofnonmedication intervention. It is not unusual to see less medication usage.
Further studies are needed to explore the role of nonpharmacological inter-ventions that may effect the use of pharmacological agents.
Limitations
The study was limited to one setting with a small sample size. Results of this study are limited to generalizability to persons with AD or relateddementias that reside in the SCU who were a part of the study.
Implications
The main implication for practice is the potential value of the use of a res- ident dog as an adjunct to therapies designed to decrease the occurrence ofproblem behaviors displayed by persons with AD. Further research isneeded to examine other contributions of companion animals to the health ofpersons with AD. Additional studies should focus on the optimal use ofcompanion animals, such as how frequently the dog should “work” on theunit and what interactions with residents are more effective in decreasingbehavior problems. Reducing the occurrence of behavioral problems willimprove the quality of life of persons with AD or related dementia.
Findings indicate that a resident dog was effective in reducing the num- ber of problem behaviors by AD residents for the daytime hours but not dur-ing the evening hours. No significant changes were noted in the usage ofpharmacological agents to treat problem behaviors after the resident dogwas introduced.
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