CRITICALLY APPRAISED PAPER (CAP) 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 and Other Dementias, 30(3), 276 289. http://dx.doi.org/10.1177/1533317514545477 CLINICAL BOTTOM LINE Older adults with dementia living in assisted living (AL) facilities often experience a decrease in functional status and an increase in behavioral and emotional problems. They may require additional care outside of AL facilities. AL residents suffer from depression, behavioral symptoms such as agitation, and a lack of motivation to engage in physical activity and activities of daily living (ADLs). Nonpharmacological interventions, such as pet-assisted living (PAL), are grounded in the self-efficacy model to motivate AL residents to improve their functional status and emotional and behavioral symptoms. Similar studies have also shown the benefits of the presence of animals to help elderly patients get more engaged in activities and to help improve their overall health. The study indicates that the PAL intervention can effectively address dementia-related problems among AL residents. As an emerging practice area in occupational therapy, this intervention can be used in conjunction with standard occupational therapy to help patients get more involved in working on their therapy goals. The occupational therapist can assess a patient s performance of ADLs, fine motor skills, range of motion, and social skills by observing the patient brush the dog s fur, put a collar on the dog, throw a ball, or give commands. In addition, occupational therapists can use the evidence of this study to educate staff members, patients, and patients families on the advantages of the PAL intervention to promote health and engagement in meaningful occupations, especially when patients refuse to participate in regular therapy sessions. Some limitations include a small sample size, restriction of the type of facilities available, and more women were enrolled than men. Because this was a pilot study, further research is needed before the results can be generalized to the larger population. 1
RESEARCH OBJECTIVE(S) Determine the utility of the PAL intervention for AL residents with mild to moderate cognitive impairment to improve their overall physical, emotional, and behavioral functions DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Randomized controlled trial PARTICIPANT SELECTION How were participants recruited and selected to participate? All participants were recruited from seven AL residences in suburban areas of Maryland, and an AL staff member selected the participants on the basis of the inclusion and exclusion criteria. Inclusion criteria: Mild to moderate cognitive impairment (according to a Mini-Mental State Exam score ranging from 8 to 23) Age = 55 years or older Length of stay in AL = 6 months or longer English speaking Prior interest in or experience with dogs Exclusion criteria: Fear of or allergies to dogs A physical illness, such as asthma, that can worsen with proximity to a dog Receiving hospice care PARTICIPANT CHARACTERISTICS N= 40 #/ % Male: 11/(27.5%) #/ % Female: 29/(72.5%) Ethnicity: White: 37 Non-White: 2 Disease/disability diagnosis: Hypertension, heart disease, heart failure, dementia, depression, anxiety, and agitation INTERVENTION AND CONTROL GROUPS 2
Group 1: Intervention group: PAL group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? An interventionist engaged each AL resident with the Cardigan Welsh corgi therapy dog during each session. Some skills that were taught included the following: ADLs feeding the dog, brushing the dog s teeth; range of motion throwing a ball, grooming the dog; small motor skills adjusting a collar, hand feeding a treat; sequencing events opening a bag of treats and then giving it to the dog; and social skills talking to the dog or giving commands (p. 279). 22 The group living room area in AL facilities in suburban communities in Maryland The PAL interventionist, who was a nurse practitioner, or someone familiar with working with the geriatric population Twice per week for 60 90 minutes each session 12 weeks Group 2: Control group: Reminiscing group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? The reminiscing group participants received an attentional control intervention and were taught similar skills, such as social skills talking to the researcher and other residents and small motor skills picking up pictures to show the other group members (p. 279). To facilitate communication skills, the interventionist used prompts related to the AL residence to encourage conversation among the residents. 18 The group living room or dining room area in AL facilities in suburban communities in Maryland An interventionist, who was a nurse practitioner, or someone familiar with working with the geriatric population Twice per week for 60 90 minutes each session 12 weeks INTERVENTION BIASES 3
Contamination: NO Explanation: The control (reminiscing) group had the same schedule as the PAL group, so the control group did not have the chance to inadvertently receive the intervention. Co-intervention: Timing of intervention: NR Site of intervention: Explanation: Both groups were taking antipsychotic medications or antidepressant medications over the course of the study, so this could have influenced the slight reduction of depression in the PAL intervention group. Explanation: Within a 3-month time period, the results indicated improvements with the PAL intervention. However, further studies with longer time periods are needed to assess the duration and effectiveness of the PAL intervention after the 3-month period. Explanation: Across all the participating AL facilities, both groups received the intervention in a group living room, but the control group also received the intervention in the dining room area. Because the intervention was not administered at the same location, the differences between the size and layout of each AL facility could have influenced the overall results of the study. Use of different therapists to provide intervention: NO Explanation: The interventionist, who is a nurse practitioner, was consistent throughout the study. Baseline equality: Explanation: Both groups had equal baseline characteristics and outcome measures. MEASURES AND OUTCOMES Measure 1: Mini-Mental State Examination Mini-Mental State Examination Cognitive function 4
Is the measure reliable (as reported in the article)? (as reported in the article)? Measure 2: Barthel Index Is the measure reliable as reported in the article? as reported in the article? Not Reported Not Reported Pretest for inclusion criteria Barthel Index Physical function Not Reported Not Reported Pretest and posttest Measure 3: Cohen Mansfield Agitation Inventory Is the measure reliable as reported in the article? as reported in the article? Cohen Mansfield Agitation Inventory Behavioral function Not Reported Not Reported Pretest and posttest Measure 4: Cornell Scale for Depression in Dementia Cornell Scale for Depression in Dementia Emotional function 5
Is the measure reliable as reported in the article? as reported in the article? Not Reported Not Reported Pretest and posttest Measure 5: Apathy Evaluation Scale Is the measure reliable as reported in the article? as reported in the article? Seven-item Apathy Evaluation Scale Emotional function: apathy symptoms Not Reported Not Reported Pretest and posttest MEASUREMENT BIASES Were the evaluators blind to treatment status? Was there recall or memory bias? NO Other measurement biases: N/A Explanation: The assessments were completed by a nurse observer who was not a part of the intervention and was blind to treatment status. Explanation: None of the measurements used required participants to recall past events, because AL residents experienced mild to moderate cognitive impairment. RESULTS List key findings based on study objectives: 6
In terms of energy expenditure over time, the change was not statistically significant in either intervention, but physical activity slightly increased for the PAL intervention, whereas it decreased for the reminiscing group. Additionally, the Barthel Index indicated in stratified linear models that ADLs increased over the course of the study for the PAL intervention (p =.073) but not for the reminiscing intervention (p =.466). According to the same statistical model, the PAL group experienced a significant reduction in depression (p =.013) compared with the reminiscing group (p =.723). Last, for behavioral functioning, changes in agitation were not statistically significant for either group (PAL: p=.423; reminiscing: p=.865) (p. 284). Behavioral functioning only decreased slightly for the PAL intervention, whereas behavioral functioning remained stagnant for the reminiscing intervention over the course of the study. Was this study adequately powered (large enough to show a difference)? NO Explanation: This study consisted a total of 40 participants from the 82 who were potentially eligible. Because it was a small sample size, the researchers noted that further studies with larger samples are needed to determine the effectiveness of the PAL intervention. Were the analysis methods appropriate? Explanation: The authors explained the appropriateness of using linear mixed models to analyze interclass correlations of various outcomes and both interventions. They also used different tests to determine the differences between the outcomes and categorizations of the participants in each intervention group pre- and postintervention. Were statistics appropriately reported (in written or table format)? Explanation: Was participant dropout less than 20% in total sample and balanced between groups? Explanation: What are the overall study limitations? 7
The study only consisted of participants who had prior experience or interest (p. 286) in dogs, which might have influenced the participants positive reactions to the intervention. In addition, there were a limited number and type of facilities (p. 286) available, and it was difficult to recruit participants with a wide range of dementia types. A total of five outcomes were also measured that might have displayed significant changes that could have been due to chance. Last, this study was based on a small sample size, which might have influenced the positive outcomes of the PAL intervention. CONCLUSIONS State the authors conclusions related to the research objectives. The authors of this pilot study suggested that the PAL intervention can be beneficial for improving physical, emotional, and behavioral functions among AL residents with dementia. The improvements from before to after the PAL intervention in each outcome measure support the authors hypothesis. The PAL intervention also used a self-efficacy approach that can help long-term care residents overcome motivational challenges to engage in physical activities. However, further studies with larger sample sizes and longer time periods are needed to determine the effectiveness of the PAL intervention on each of those outcomes for this population. This work is based on the evidence-based literature review completed by Michelle Tan, OTS, and Ashley Halle OTD, OTR/L, faculty advisor, University of Southern California. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8