Study by Nancy R. Gee (WALTHAM/Cornell), Erika Friedmann & Elizabeth Galik (University of Maryland) showing positive benefits of pet assisted living in older adults with mild to moderate dementia. Presented at Gerontological Society of America Annual Scientific Meeting November 2016.

1. Potential Health Benefits of Pets for
Older Adults: Findings from the Pet
Assisted Living (PAL) Study
Human-Animal Interaction and Healthy Aging Symposium
GSA Annual Scientific Meeting, Nov 16-20th, 2016
Nancy R. Gee1, Erika Friedmann2 & Elizabeth Galik2
1WALTHAM; 2University of Maryland
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DISCLOSURE(S)
• Research Support: [Friedmann - ISAZ/WALTHAM
Collaborative Research Award]
• Consultant: [Gee - WALTHAM]
• Discussion of Off-Label, Investigational, or
Experimental Drug Use: [None]

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Potential Health Benefits for Older Adults:
Findings from the Pet Assisted Living Study
• Nancy R. Gee, PhD
State University of New York,
Fredonia & WALTHAM
• Erika Friedmann, PhD
Beth Galik, PhD
University of Maryland
School of Nursing

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What is the Human-Animal Bond?
…a mutually beneficial and dynamic relationship between
people and other animals that is influenced by behaviours
that are essential to the health and well-being of both
Definition of the Human-Companion
Animal Bond (HCAB) taken from the
American Veterinary Medical Association
(AVMA) 2006

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An enduring and important relationship…
• 7.5 M cats
• 8.5 M dogsUK
• 60+ M cats
• 66+ M dogsEU
• 2/3 of all homes
include a petUS
• 7 M cats
• 6.4 M dogsCA
Pompeii Mosaic 79 AD
Ancient Cave Painting

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Plan for Part I…
• Theoretical basis of the bond
• Evidence related to the impact on older
adults of interacting with companion
animals
– Psychological
• Depression
• Anxiety
• Loneliness
• Social functioning
– Physical: Heart Health & Exercise
• Brief evaluation of the evidence
• Intervention Study Example
– Pet Assisted Living Study Methodology
– Results & Conclusions
• Part II – Dr. Mueller’s presentation will
focus on the impact of pet ownership

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Theoretical Basis of the Bond
• Neoteny (Beck & Katcher, 1999)
– Retention by adults of juvenile traits
– Selective breeding of domestic dog for
specific traits:
• Large eyes, rounded forehead, large
ears, shortened muzzle
• Biophilia hypothesis (Wilson, 1984)
– Instinctive bond between human
beings and other living systems.

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Theoretical Basis of the Bond
• Attachment Theory (Bowlby 1969, 1980)
– Human need to protect and be protected
– maintain close proximity to others in
order to better cope with the world.
• Social Support (Cohen & Wills, 1985)
– Perception and reality that one is cared
for, is part of a supportive social network
and has access to supportive resources
(e.g., companionship, nurturance.
– Serves a protective function from the
adverse effects of stressors.

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Theoretical Basis of Health Outcomes from
the Bond
• BioPsychoSocial - individual level (Engel, 1997, 1980)
– Disease outcomes result from a complex interaction of biological
factors (e.g., biochemical, genetic), psychological factors (e.g.,
personality, behavior) and social factors (e.g., culture, family).
• Social-Ecological Model – community/policy level (Brofenbrenner, 1979)
– Understanding of human development must be considered within
the context of the entire ecological system in which growth
occurs.
– Network of interactions among:
• Microsystem: interactions with immediate surroundings (e.g., family)
• Mesosystem: interactions among the systems (e.g., interactions
between church and neighborhood)
• Exosystem: social, political and economic conditions
• Macrosystem: cultural values, customs and laws

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The Evidence – intervention studies
• Emerging evidence indicates that for older adults
interacting with companion animals:
• Reduces:
– Depression
– Anxiety
– Loneliness
• Increases:
– Social Functioning
– Physical Health & Exercise

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Reducing Depression
• Cognitively unimpaired institutionalized older
adults (Colombo, et al 2006)
– N = 144 - randomly assigned to receive:
• Canary, plant, or nothing (control) for 3 months
– Depression and anxiety (measured by the Brief
Symptom Inventory)
• Canary group significant reduction relative to plant
and control groups
• Residents of aged care facilities – with dementia
(Travers, et al 2013)
– N = 55 RCT
– 11 week intervention (dog-assisted therapy vs
human therapist)
– Dog assisted intervention resulted in significant
improvements in:
• Depression scores
• Quality of life scores

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Reducing Depression
• AL residents (65 years and older) using wheelchairs or
walkers (LeRoux & Kemp, 2009)
– N = 16 randomly assigned:
• AAA (involving a dog) or Control (not defined)
– Dog group - significant decrease Pre to Post intervention on
depression as measured by the Beck Depression Inventory.
• AAA not significantly different from Control
• Pet therapy (6 weeks) was effective in reducing
depression among older patients with mental illness
(Moretti, et a., 2011)
– Pet therapy group N=10 vs Control group N=11
– Both groups improved from pre to post test
– 50% reduction in Geriatric Depression Scale (GDS) for pet
group

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Reducing Depression – Meta-Analyses
• AAA/AAT associated with fewer
depressive symptoms (Souter & Miller, 2007)
– Inclusion criteria: random assignment,
appropriate control/comparison
– 5 studies identified
– Aggregate effect size = medium and
significant
• Similar results (Virues-Ortega et al, 2012)
– AAT - moderately effective in reducing
depression (d = -.34)

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Reducing Anxiety
• AAA with Alzheimer’s patients in Daycare setting (Mossello, et al., 2011)
– Repeated measures design (2 week pre-intervention, 3 weeks plush
toy, and 3 weeks with dog)
– Dog intervention:
• Decrease in anxiety and sadness and an increase in physical activity
• Effects apparent immediately and 3 hours later
• Similar results with
– AAA in patients hospitalized with heart failure (Cole, et al., 2007)
– AAA in older adult residents of a long-term care facility (LeRoux & Kemp, 2009)

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Decreasing Loneliness
• AAT in long-term care facilities (Banks & Banks, 2002)
– N = 45 (15 – no AAT, 15 – AAT once/week, 15 – AAT three
times/week
– UCLA loneliness scale
– AAT significantly reduced loneliness scores in comparison to
the no AAT group.
• AAT: A 6 month dog companionship program -
interaction with a dog three times/week (Vrbanac, et al, 2013)
– N = 21 (pre-test/posttest)
– Used the short form of the UCLA loneliness scale
– Significant reduction in loneliness from pre to post-test.
– Most participants reported improved quality of life and mood,
and demonstrated increased physical activity and social
interaction.

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Improving Social Functioning
• AAA with dogs produced significantly higher interactions than
photographic interaction (both were higher than the control) among
older psychiatric patients (Haughie et al, 1992)
• AAT with Dementia patients (ABAB design) resulted in a
significantly increase in social behaviors and a corresponding
decrease agitated behaviors (Sellers, 2005)
• Dogs and dog related stimuli appear to get dementia patients to
engage/interact (Marx, et al, 2010)
– Puppy video, real dog, dog color activity were all equally good at
eliciting engagement behaviors.
• Meta-analysis (Virues-Ortega et al, 2012)
– AAT improved social functioning (pooled effect size = 1.06)
– Effects were larger in individuals with psychiatric conditions.

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Increasing Physical Health & Exercise
• AL residents who walked with a dog walked farther than when they
walked alone (Herbert & Greene, 2001)
• Parasympathetic neural activity as measured by HF Power values
of Heart Rate Variability (HRV) increased significantly for healthy
older adults when (Motooka et al, 2006):
– They were walking a dog compared to walking without the dog.
– They were home with the dog compared to when they were at their
home without the dog.
• Gait retraining following a stroke was improved by working with a
rehabilitation dog (Rondeau, et al, 2010).
– Walking speed significantly increased after training with the dog.
– Patients gait pattern improved and walking speed was faster with the
rehabilitation dog than when using a cane.

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Evaluation of existing evidence
Preponderance of evidence (not all)
• Lacks standardized measures
• Short term impact (lack of longitudinal
designs)
• Small sample sizes
• Animals/animal interaction not well
described
• Pet ownership history/involvement not
included

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Example Intervention Study
Pet Assisted Living Study – addresses concerns
• The functional status of older adults with dementia who
reside in assisted living facilities deteriorates quickly
– Often leads to movement to nursing homes
Purpose:
• Evaluate the use of structured activities with a dog to
prevent deterioration in function in AL residents with
dementia

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PAL Design
Participants: Assisted Living Residents with mild to moderate dementia
Inclusion Criteria
• Mild to moderate cognitive impairment (MMSE score > 11)
• Age > 55 years
• Anticipated LOS >= 6 months
• English speaking
• Prior experience with or interest in interacting with a dog
Exclusion Criteria
• Known allergies to dogs
• Known fear of dogs
• Physical illness exacerbated in the presence of furry animals
• Expected survival < 6 months (hospice care)

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PAL Design
• Recruited from 7 Facilities
Recruitment
• Informed Consent from LAR
• Assent from Residents
Random Assignment of Facilities to Interventions
• Dog Activities (4 facilities)
• Reminiscing (3 facilities)
Intervention
• 60-90 min sessions 2 X per week for 12 weeks

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PAL Design
PAL (dog) Intervention
Skills taught/reinforced:
• ADLs – feeding the dog, brushing the dog’s teeth, walking the dog,
dressing the dog in a bandana, brushing the dog’s hair;
• range of motion – throwing a ball, grooming the dog,
• small motor skills – attaching a leash, adjusting a collar,
• hand feeding a treat, petting the dog;
• sequencing events –opening a container of treats and then giving
the dog a treat;
• social skills – talking to the dog, talking about the dog to another
person, giving the dog commands, petting the dog;
• large motor skills – taking the dog for a walk, teaching the dog to
walk on the leash, teaching/practicing commands.

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PAL Design
Reminiscing Intervention
• Attentional control intervention – equal amount of attention from the
interventionist and on the same schedule as the PAL intervention
Skills taught/reinforced:
• Social skills – talking to the researcher and other residents;
• Small motor skills – picking up pictures and showing them to others
Both PAL and Reminiscing interventions:
• Conducted in group living room environment
• Each participant was encouraged to interact

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PAL Design
Functional Assessments
• 0, 4, 8, 12 weeks
Behavioral Function
• Agitation (Cohen-Mansfield Agitation Inventory)
Emotional Function
• Apathy (Apathy Evaluation Scale)
• Depression (Cornell Scale for Depression in Dementia)
Physical Function
• Activities of Daily Living (Barthel)
• Physical movement (actigraph)

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Participants
• Ages 56 to 95 years (M=81, SD=9.1)
• Education 7- 20 years (M=13, SD=7.2)
• Male 28%
• Minority 5%
• Married 20%
• Diagnosed dementia 65%
• PAL N=22; Reminiscing N= 18
• No significant differences in demographics between the two groups

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Results
• Emotional Function: Depression
(lower is better)
Months after Start of Study
0 1 2 3
Depression
4
5
6
7
8
9
10
11
Dog Group (n = 22)
Reminiscing Group (n=18)
Initial 3 Months Initial 3 Months
PercentDepressed
0
20
40
60
80
Reminiscing n = 18
Dog n=22
Depression Major Depression
p = .065
p = .030
(Interaction p < .05)

27. Months after Start of Study
0 1 2 3
ActivitykCals
10
20
30
40
50
60
70
80
90
Dog Group (n = 22)
Reminiscing Group (n=18)
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Results
• Physical Function: Physical Activity
K Cals per 24 hours (Ms & SEMs)
(Interaction NS)

28. Months after Start of Study
0 1 2 3
BarthelScore
50
55
60
65
70
75
80
85
Dog Group (n = 22)
Reminiscing Group (n=18)
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Results
• Physical Function: Activities of Daily Living
(higher is better)
(Interaction p < .10)

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Behavioral Results

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Correlations
• Looking at the dog - not correlated with other behaviors
• Touching - correlated with talking to the dog
• Treating - correlated with talking to and touching the dog
• Brushing - correlated with talking to, touching, and treating the dog
• Walking with the dog - correlated with treating the dog

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Correlations
Between average activities, baseline MMSE score,
change in physical activity and change in depression

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General Conclusions
• Evidence that the PAL program may
be effective for preserving/enhancing
function in residents of Assisted Living
with mild to moderate dementia
• Considerable variability in function
and in responses of residents
• Require further study to evaluate the
duration of the effect
• Require further study to evaluate
predictors of effectiveness for each
type of function

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Conclusions – Behavioral Analysis
• Participation in behaviors with the dog differed between
participants, and between sessions
• Engagement in behaviors with the dog was linked to a
to 12 week improvement in depression and physical
activity
• Cognitive status did not predict behavior or improvement
in depression or physical activity
• Touching the dog was not related to improvement
• Assessment of behaviors during interventions may
enable evaluation of behaviors that predict target
outcomes and personalization of activities for outcomes
and individuals

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Funded by
ISAZ/WALTHAM®
Collaborative Research Award