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Puppies & Poppy - The Impact of Animal-Assisted Therapy on Nursing Home Residents
Ariel Ligowski
Liberty University

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Abstract
In hospitals, nursing homes, schools, and even private practices, animal-assisted therapy is
becoming increasingly popular. A concern of care in nursing home residents with cognitive
impairment is how to decrease agitated behaviors and increase their socialization. Similarly, for
the general care of nursing home residents, a concern is how to decrease levels of apathy,
depression, and loneliness, increase expended energy, physical activity, activities of daily living,
subjective well-being, and of course socialization. Regardless of cognitive impairment, it was
found that regular interventions with a therapy dog, typically in a small group but also one-on-
one, in fact decreased apathy, depression, and loneliness, while increasing activity, subjective
well-being, and socialization. The benefits are optimized if in the late afternoon, among a small
group of people, and without a maximal level of noise. The benefits are predicted to be even
better for individuals that are able to walk the dogs on interventions. The implications for this
are to regularly integrate animal-assisted therapy into the care plans at assisted-living homes, and
to utilize evidence-based practice to treat the psychological well-being of the residents with the
therapy dogs.
Puppies & Poppy: The Impact of Animal-Assisted Therapy on Nursing Home Residents

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“Man’s best friend” is not a concept new to American culture. Therefore, it is no surprise
that animal-assisted therapy is growing rapidly in popularity. Animal-assisted therapy is utilizing
therapy dogs in visits, in small group settings or one-on-one, to allegedly improve the
psychological well-being of the intervention recipients. Animal-assisted therapy is commonly
provided for hospital patients, trauma victims, and nursing home residents. Keeping in mind the
loneliness that can unfortunately pair with the nursing home experience, the implications of
animal-assisted therapy are exciting: would the presence of a therapy dog eradicate the ways
assisted living can inhibit socialization? Does it have any bearing on loneliness or levels of
depression? As review of the literature suggests that implementing animal-assisted therapy in
the care of nursing home residents, regardless of cognitive impairment, will decrease agitation
and increase activity, social behavior, and subjective well-being.
A crucial factor of a nursing home resident’s care is the resident’s engagement. A
sedentary, disengaged lifestyle is not appropriate for the physical, emotional, spiritual, or mental
health of any individual, let alone an institutionalized older adult. Older adults placed in nursing
homes have to adjust to a separation from their regular social life and a lack of independence,
while often dealing with cognitive impairment simultaneously. Cohen-Mansfield, Thein,
Dakheel-Ali, and Marx (2010) developed a framework titled the Comprehensive Process Model
of Engagement; it asserts that a combination of added stimuli, individual differences,
environment, and social interactions affect engagement. This study particularly focused on the
impact of setting and environmental characteristics on engagement. 193 residents of seven
Maryland nursing homes were selected as participants, all of them diagnosed with dementia.
Individuals with a comorbid diagnosis of bipolar disorder or schizophrenia, who have no

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dexterity in either hand, who were unable to be seated in a chair or wheelchair, who were under
the age of sixty, and who were either in hospice or were short-stay nursing home residents were
excluded from the experiment. Beginning the study, Cohen-Mansfield et. al expected that
engagement would decrease or be less effective after 2 p.m. due to the rumored effect of
“sundowning” in individuals with dementia. Sundowning is the supposed increase in agitated
behaviors as the day progresses, particularly in the late afternoon onward. Surprisingly, they
found engagement was most effective after 2 p.m., perhaps because of prolonged grogginess in
the morning. They also found that the optimal environment for engaging older adults, regardless
of cognitive impairment, is preceded by a modeling of the subjective activity, and contains a
moderate level of noise and a limited number of people in the room at once (approximately four
to nine). A resident with cognitive impairment simply needs more repetition in his/her modeling
presentation than a typical older adult. An example of this would be having a minimally
crowded common room that is not overly noisy, and modeling for the guests where the games
are, where to lay them out, how to play them, and how to put them back. That way the older
adults are more likely to come into the common room and pull out a game and play, as opposed
to looking out a window. For an individual with cognitive impairment, a nursing home aide
might go through this presentation multiple times, and remind them if they are sitting in the
common room disengaged. In light of their findings, Cohen-Mansfield et. al encourages nursing
homes to find ways to implement modeling presentations into their care plans; additionally, they
encourage a focus on behavioral and environmental interventions, as opposed to pharmacological
ones.

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Agitated behaviors are symptomatic of dementia, and affect more than 90% of nursing
home residents (Richeson 2003). Therefore, it is one of the biggest issues in nursing home care.
In this study, Richeson felt that therapeutic recreation animal-assisted therapy intervention can
decrease agitated behaviors in individuals with dementia, subsequently increasing their social
interactions. They conducted a nine-week pilot study in two New England nursing homes with
therapeutic recreation programs already in place. The animal-assisted therapy (AAT)
intervention consisted of a small group in an isolated room for a half hour in the late afternoon
Monday through Friday. Scheduled in the late afternoon with a small group and minimal to
moderate noise creates an optimal engaging environment for older adults, as per the findings of
Cohen-Mansfield et. al (2010). The small group is then introduced to each other and gets to
freely interact with the therapy dog - playing with it, brushing it, and talking to its handler, the
staff, and one another, often reminiscing on past pets. The staff noted that the intervention
created an atmosphere of excitement and camaraderie, and the residents appeared alert and
responsive throughout. After each intervention, the residents were assessed using a model for
understanding the behaviors of individuals with dementia, called Need-Driven Dementia-
Compromised Behavior Model. At the end of their study, the researchers accepted their research
hypothesis, finding that the participants’ agitated behaviors decreased and their social
interactions increased. This supports the hypothesis that animal assisted therapy decreases
agitation and increases social behavior in older adults. Another study, conducted by Friedmann
et. al (2014) examined whether the intervention of AAT would increase physical activity and
decrease depression, agitation, and apathy in assisted living residents with cognitive impairment.
Friedmann et. al utilized a randomized trial with repeated measures, looking at the effect of dog

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intervention on emotional, behavioral, and physical function of assisted living residents with
mild-moderate dementia over a three month period. The residents lived in a small family-style
home, comprised of seven to fourteen people per facility. The AAT intervention consisted of
60-90 minute sessions with the therapy dog twice a week for three months. The interventionist
engaged each resident in dog-related activities, additionally allowing the residents to freely
engage with the dog, as with the study conducted by Richeson (2003). The use of a modeling
presentation by the interventionist, paired with a small group setting utilizes the findings by
Cohen-Mansfield et. al (2010) for an optimal engaging environment for older adults.
Eventually, they found that in comparison to the control group, there was a significant increase in
physical, emotional, and behavioral function in assisted living residents with cognitive
impairment and/or dementia. They also found that the residents receiving the AAT intervention
expended more energy than the control group. While it is not significant, it also surely worth
noting that there was an increase found in activities in daily living, in comparison to the control
group. Finding an increase in energy expended and activities of daily living coincides with the
findings by Richeson (2003), who also saw an increase in activity in persons of dementia
receiving AAT interventions. The implications of Friedmann et. al’s study (2014) are that
nursing homes should utilize AAT interventions to engage residents and promote self-efficacy in
ways the residents might not otherwise engage in (for example, they might not choose to be
physically active unless they were interacting with the dog). Friedmann et. al noted that they
predict the impact of AAT intervention to be even better for individuals able to walk, as they
would be able to walk the dog. This study supports the hypothesis that AAT would increase
activity and social behavior.

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An obvious concern with nursing home residents is loneliness and subjective well-being.
The ailments that placed the older adults in an assisted living home disrupt their social life
anyway, while being institutionalized can alter it completely. With the progression of adulthood,
onset of certain diseases, abrupt change in lifestyle, and loss of certain independences, subjective
well-being and overall satisfaction in life is a definite concern in geriatric care. With this in
mind, Vrbanac et. al (2013) conducted a study with twenty nursing home residents, ages 73-88
receiving AAT interventions over the course of six months. They explored the possibility of
whether dog companionship as a form of AAT reduces perception of loneliness in older adults at
nursing home facilities. At the conclusion of the study, Vrbanac et. al (2013) found that animal
care can improve emotional and psychological well-being of nursing home residents. The
reported levels of loneliness in participants’ reduced by the end of the six-month period of AAT
interventions. This supports the findings in Friedmann et. al (2014) that AAT interventions
decrease levels of depression. There was also an observed increase in socialization. As the study
progressed, the residents would arrive early to the intervention, engage in more free
communication, and stay even after the therapy dog had left. As with the previous sources, the
study conducted by Vrbanac et. al (2013) shows a strong relationship between AAT interventions
and the socialization of the resident. Finally, Richeson and McCullough (2003) studied 37
nursing home residents with no cognitive impairment in a four-week study to measure the impact
of AAT interventions on subjective well-being. The purpose of the study was to attempt to
integrate AAT interventions as evidence-based practice by using them strategically to increase
the psychological well-being of older adults. Many nursing homes have AAT as part of geriatric
recreational therapy practice, however, they don’t have specific techniques to target

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psychological well-being or track it post-intervention. For this experiment, there were three
groups: a control group, that was still involved in general recreation therapy; the AAT
intervention group, that would visit with a therapy dog for 10-15 minutes one-on-one; and the
student visitor group, that would visit with a student visitor for 10-15 minutes one-on-one.
Subjective well-being was measured by three scales: positive affect, negative affect, and
satisfaction with life. Their findings showed an overall statistically significant increase in
satisfaction with life. There was a significant increase in the reported feelings “interested” and
“excited” in the AAT group as compared to other groups. There was a significant increase in the
reported feelings “enthusiastic”, “attentive”, “interested”, and “inspired” in the AAT group in
comparison to the control group, but not in comparison to the student visitor group (2003). The
implications of this are that, as said by Richeson (2003), AAT intervention creates an atmosphere
of excitement and camaraderie. Furthermore, as there is a discovered positive relationship
between AAT and subjective well-being, nursing homes should modify their geriatric recreation
therapy to utilize AAT interventions as evidence-based practice to treat the psychological well-
being of residents.
As anticipated, implementing AAT in the care of nursing home residents provides a host
of benefits. It decreases agitated behaviors, reported loneliness, apathy, and levels of depression.
It also increases physical activity, socialization, and subjective well-being. The intervention of
the therapy dogs bonds residents together, summons pleasant memories of their past, and overall
creates an environment of excitement and camaraderie. Most importantly, these benefits and
decreases in undesirable attitudes are seen in individuals with and without cognitive impairment.
It would not only be beneficial for all nursing homes to include this in their care plans, but to

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utilize evidence-based practice with AAT to target and treat psychological well-being. Whether
it is with a therapy dog or a game of chess, engagement can be achieved with any older adult
with a modeling presentation and an environment that is mildly crowded and minimally noisy.
Nursing homes are not always known for optimal care, which is unfortunate and is perhaps due
to lack of evidence-based practice. There is a well-established body of research for care of our
older adults, and teaming up with man’s best friend is an excellent way to start.

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References
Cohen-Mansfield, J., Thein, K., Dakheel-Ali, M., & Marx, M.S. (2010). Engaging nursing
home residents with dementia in activities: The effects of modeling, presentation order,
time of day, and setting characteristics. Aging Mental Health, 14(4), 471-480. doi:
10.1080/13607860903586102
Friedmann, E., Galik, E., Thomas, S. A., & Hall, P.S. (2014). 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 and Other Dementias, 30(2).
Richeson, N. E. (2003). Effects of animal-assisted therapy on agitated behaviors and social
interactions of older adults with dementia. American Journal of Alzheimer’s Disease
and Other Dementias, 18, 353-358.
Richeson, N. E., & McCullough W. T. (2003). A therapeutic recreation intervention using
animal-assisted therapy: Effects on the subjective well-being of older adults. Annual
in Therapeutic Recreation, 12, 1-6.
Vrbanac, Z., Zecevic, I., Ljubic, M., Belic, M., Damir, S., Brkljaca-Bottlgoro, N., . . . Zubcic, D.
(2013). Animal-assisted therapy and perception of loneliness in geriatric nursing home
residents. Collegium Antropologium, 37(3), 973-976.