Feature ArticleEffect of animal-assisted activity on balance and quality of life in home-dwelling persons with dementia
Introduction
A World Health Organization (WHO) report on aging and health, published in 2015 (WHOe), suggests there should be a shift in focus from diseases and morbidity to functional ability,1 and therefore future studies of aging should be more specific when defining healthy aging and, in addition to describing patterns of morbidity and mortality, it is advisable to look at physical and cognitive function.1, 2 Functional ability is the key for living good independent lives throughout the life course and obtaining a high quality of life (QoL).1
For many older people an independent life means living in their own place of residence. In Norway, about half of the total population of persons with dementia (PWDs) live in their own homes.3 People's ability to live at home as long as possible is a political goal in Norway and considered a human right.4, 5 Part of reaching the political goal is the development of day-care centers for PWDs. Day-care centers have been described as offering respite care, with main aim to provide meaningful activities for home-dwelling PWDs.6
One type of activity that can be provided at day-care centers is animal-assisted interventions (AAIs), and these have become widely used among older people and especially dementia patients, as shown in several reviews.7, 8, 9, 10 An AAI is defined as ‘a goal oriented and structured intervention that intentionally includes or incorporates animals in health, education and human service for the purpose of therapeutic gains in humans.’11 Animal-assisted activities (AAAs) are one type of AAI and include, for example, dogs and their handlers who visit for ‘meet-and-greet’ activities.11 Most studies of AAIs have focused on the interventions' impacts on social outcomes,12, 13, 14, 15 behavioral and psychological outcomes,16, 17, 18, 19, 20 and physiological outcomes,21, 22, 23 many of which are regarded as risk factors associated with falls. However, there are fewer studies of the effect of AAIs on performance-based physical outcomes and the results from these studies are inconsistent.19, 24
Balance is a central function in most activities of daily living25 and is associated with QoL.26 It has been shown that levels of physical activity decline with increasing age27 and therefore in order to prevent falls it is important for people to maintain their physical performance as they age, particularly their strength and balance.28 Complex interventions targeting several risk factors related to falls have been considered most effective for reducing the risk of falls and are therefore recommended.29, 30 A model by Horak suggests that effective rehabilitation of balance requires an understanding of the many systems underlying postural control such as cognitive processing (attention and learning), biomechanical restraints (strength and limits of stability), sensory strategies, movement strategies, orientation in space, and control of dynamics.31
As stated by WHO, independent living and PWDs' QoL should be in focus. QoL has been a subject of great interest in assessments of the outcomes of medical and social interventions, and the need to improve PWDs' QoL is increasingly acknowledged.32 QoL is a multidimensional concept, which in older adults includes behavioral competence, the objective environment, psychological well-being, and perceived QoL.33 QoL among elderly PWDs is often diminished34 due to several factors such as low cognitive function, major depression, lack of social activities, impaired mobility, and low performance in activities of daily living.26, 35, 36, 37 It is documented that older people consider good functioning to be of higher importance than the prevention of diseases,38 and PWDs with higher physical capabilities, such as strength and balance, have scored higher on QoL.26 Further, a study demonstrated that AAA had a positive effect on the QoL of PWDs living in nursing homes,20 but it is not known whether the effect would be the same among home-dwelling PWDs.
Based on previous research on AAIs and PWDs' need for meaningful activities,39 research on the effect of AAIs on the physical outcome ‘balance’ would be of great interest. Moreover, there has been a lack of research on the effect of AAIs in home-dwelling PWDs in general.
The main aim of the study on which this article is based was therefore to examine whether, in the context of in home-dwelling PWDs attending day-care centers, AAAs would have an effect on factors related to the risk of fall accidents, with balance and QoL as main outcomes.
Section snippets
Design
The study was conducted as a prospective and cluster-randomized multicentre trial with a follow-up study. The project is registered in ClinicalTials.gov, a service of the USA's National Institutes of Health (identifier: NCT02008630).
A total of 16 adapted day-care centers for home-dwelling PWDs in the Norwegian counties of Østfold, Vestfold, Oslo, and Akershus were recruited to the project. After recruitment, each day-care center was randomized, by computerized random numbers at Uni Helse in
Results
The group characteristics of the participants are listed in Table 1. In the control group, 60.5% were women, and the mean age was 81.7 years. In the AAA group, 51.2% were women, and the mean age was 84.0 years. The majority of participants in both groups reported that they enjoyed contact with animals. About half of the participants had mild dementia (CDR 1), and almost half were assessed as having moderate dementia (CDR 2). Only 1 participant in the control group and 4 participants in the AAA
Discussion
The results showed that AAA had a statistically significant and clinically positive effect on balance measured by the BBS for participants in the intervention group compared to the control group from pre-test (T0) to post-test (T1), but not from pre-test to follow-up (T2). No effect was found on QoL. However, a strong favorable association with QUALID was found, with a tendency toward statistical significance in the subgroup of participants with a clinical improvement on the BBS.
One explanation
Conclusion
The results of the study indicate that AAA might have useful clinical implications by leading to improvements in balance and thereby preventing risks of falls. However, in our study, AAA in a group setting did not affect the QoL of the study population.
Acknowledgments
The authors want to thank: Dog handlers and their dogs, cooperating partners, institutions, health workers and participants.
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Cited by (0)
Financing: The project is funded by grant nr. 217516 from the Oslofjordfondet and RFF Hovedstaden, NMBU and Cooperating partners (The Norwegian Centre of Anthrozoology, Buskerud and Vestfold University College, Centre for Development of Institutional and Home Care Services in Vestfold, Nøtterøy municipality). Cooperating partners supported the project with internal financing.