**7. How can a dog assisted therapy be beneficial for therapy in Alzheimer patients?**

It may cause decreased agitation, improvement in the mood, and increased communication with the surrounding: Alzheimer patients may experience different clinical symptoms at different disease stages. Generally as the disease is progressed, they isolate themselves from their surroundings, family members, friends, healthcare personnel; they become quieter and less mobile. In this stage, an accompanying therapy dog may even become the only commu‐ nication bridge to continue the interaction with their surroundings. Sometimes patients may end up the silence on a dog's touch or behaviors; they may smile, talk a few words, and even they may be involved more with their surroundings.

Indoor and outdoor safety problems are most commonly encountered problems in some patients. With the accompanying well-trained dog, the patient can feel more secure. Since the dog can estimate behaviors of the patient, it may warn the patient and his /her relatives and/or healthcare personnel before and/or during the behaviors. A guiding dog may prevent the patient, who would like to leave his/her surrounding (home or nursery home) without informing anybody, from many dangers he/she would be confronted with. When the patient come to the top of the ladder, the dog may inform the patient about his/her position, how he/ she should act or what he/she should do next by barking or behaving differently non-verbally without agitating the patient. It may protect the patient while crossing the street. The dog guiding a patient, who will forget the way home or the address of his/her home, can lead the patient home safely and in good health.

Aquarium assisted therapy studies have revealed that eating habits of Alzheimer patients are improved by feeding fish. Moreover aquarium assisted activities improve hand skills as well as they increase socialization of patients. Various mood disorders like nervousness, agitation, unhappiness, very quietness, and loneliness may be observed in subjects with dementia, who live in nursery homes. Aquariums at nursery homes may attract attention of subjects in these crowded environments, they may provide relaxation and happiness for them as well as they may help people live in more humane environments by decreasing work load and stress also for relatives of patients and healthcare personnel. Aquariums may help all individuals to share the same environment with the underwater creatures.

AAT is especially effective in elderly subjects with cognitive disorders like Alzheimer disease. Patients with dementia usually experience various degrees of agitation mainly in the evening. This situation, known as "sundowning", is not only stressful for patients, but can also be challenging for the healthcare personnel. Even touching an animal may decrease anxiety during challenging evening hours, and increase calmness/well-being feelings.

As displayed on Table 5, AAT especially dog therapies can be used successively as a preventive and interventional method in patients with Alzheimers' disease and dementia. Also, recent studies have shown that AAT may be beneficial to improve for various psychiatric diseases including Alzheimer, dementia, depression, anxiety, addiction, schizophrenia, autism

Dog therapy Comparing to the control group,

scores.

the 4 weeks.

weeks.

improvements as below was observed in the pet group: Decreasing of depression symptoms at 50% level and increasing 4.5 times in mini mental

Significantly decreasing of problem behaviors at the end of

Over 16 week period, it was observed that patients had needed less nutritional

Since 2th weeks, nutritional intake behavior increased significantly and this increase kept on during 6

supplements than baseline. Finally, authors indicated that dog therapy can provide health care cost savings (personal communication).

It was observed that man who were attached to dogs scored better psychological health than men who had no pets. While, women less than 40 years old attached to cats were scored better some psychological health than women same aged and had no pets, women aged 40 to 59 years attached to dogs scored worse of life satisfaction and depression than women in the same age and had no pets.

**Results Study design**

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Methodological Study (6 weeks)

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315

Methodological study (4 weeks)

Methodological study (Follow-up) (6 weeks)

Case-control study

**Pet therapy model**

Resident dog therapy in a special care unit

Aquarium therapy used for improving nutrition intake behaviors

Man and women contacted with pets regular (dog or cat)

spectrum disorder. [74]- [79]

**Authors Patients or**

*Moretti F, et al.*

*McCabe BW, et al. 2002*

*Edwards NE and Beck AM, et al. 2002*

*Fritz CL, et al. 1996*

*2011*

**study group**

Over 84 age patients with dementia, depression and psychosis Pet group (n=10) Control group (n=11)

Patients with Alzheimer in a special care unit

62 patients with Alzheimer living a special care unit

244 caregivers working with Alzheimer patients in Northern California. 124 caregivers contact with pets. 120 caregivers didn't contact with pets included into the control group.

It has been observed that responses have been achieved in patients with advanced dementia by animal assisted therapies. Some patients with dementia may develop better and easier commu‐ nications with animals when compared with humans. A pet can listen to a patient with demen‐ tia without judging. In guiding dog visits in AAT program, dogs may allow patients to come nearto themandplaywiththem.Ithas beenreportedthatdog assistedtherapiesmayhelpthese exercises to be happier and more motivating experiences in patients, who are recommended to take a walk. These patients are also reported to have improved life quality, and socialization desires when compared with patients, who have not kept or lived with animals.

A therapy dog provides the Alzheimer patient a unique communication and love bonding, which can be re-shaped according to the target whichever animal assisted therapy is required, and various physical, mental and social health benefits can be achieved. Fish, cat, dog, horse or tortoise may present human benefits, which we cannot presume for Alzheimer patients, and by supporting patients' treatment compliances, they provide that patient relatives and healthcare personnel serve under more positive conditions. To provide the most benefit from AAT or AAA, in especially dog therapies, "resident" or "visiting" models can be used together for patients with dementia and Alzheimer´s disease. [14], [15], [18] It is not clearly explored which therapy model more useful than the other one. [9] In another review written by Williams and Jenkins reported that animal visitings to nursing-care units can provide various benefits including relaxation, improving of apathy and decreasing in agitation, aggression behavior and blood pressure for both patients and their caregivers, relatives. [18] According to the Churchill et al., a therapy dog can reduce some agitation behaviors of Alzheimer patients with especially sundown syndrome, and also help increasing social behaviors and calm down. [16]

Studies shown that environmental factors or changes in Alzheimer's disease special care units can be effect on patients' behavioral health outcomes including aggression, resident agitation, social withdrawal, depression, psychotic problems. [69], [70] That is why, treatment proce‐ dures should be planned and managed considering a balanced combination of pharmacologic, behavioral and environmental options in order to improve health, behavior and quality of life of patients with Alzheimer's disease. [70] It is important that physicians who are playing a key role in recognizing problems and arranging suitable treatment for their patients should consider alternative treatment options based on social and recreational interventions including meditation, validation therapy, reality orientation, reminiscence therapy, sensory interven‐ tions (therapeutic touch and massage therapy, aromatherapy, music therapy, dance therapy, light therapy, multisensory stimulation therapy), social contact (animal-assisted therapy, simulated presence therapy), exercise, art therapy and Montessori-based activities. [71], [72] In addition, most of the AAT studies have been focused on dog, cat and other small animal activities. It is not well-known that animal assisted therapies with farm animals may have positive effects on self-efficacy and coping ability among psychiatric patients. [73]

As displayed on Table 5, AAT especially dog therapies can be used successively as a preventive and interventional method in patients with Alzheimers' disease and dementia. Also, recent studies have shown that AAT may be beneficial to improve for various psychiatric diseases including Alzheimer, dementia, depression, anxiety, addiction, schizophrenia, autism spectrum disorder. [74]- [79]

AAT is especially effective in elderly subjects with cognitive disorders like Alzheimer disease. Patients with dementia usually experience various degrees of agitation mainly in the evening. This situation, known as "sundowning", is not only stressful for patients, but can also be challenging for the healthcare personnel. Even touching an animal may decrease anxiety

It has been observed that responses have been achieved in patients with advanced dementia by animal assisted therapies. Some patients with dementia may develop better and easier commu‐ nications with animals when compared with humans. A pet can listen to a patient with demen‐ tia without judging. In guiding dog visits in AAT program, dogs may allow patients to come nearto themandplaywiththem.Ithas beenreportedthatdogassistedtherapiesmayhelpthese exercises to be happier and more motivating experiences in patients, who are recommended to take a walk. These patients are also reported to have improved life quality, and socialization

A therapy dog provides the Alzheimer patient a unique communication and love bonding, which can be re-shaped according to the target whichever animal assisted therapy is required, and various physical, mental and social health benefits can be achieved. Fish, cat, dog, horse or tortoise may present human benefits, which we cannot presume for Alzheimer patients, and by supporting patients' treatment compliances, they provide that patient relatives and healthcare personnel serve under more positive conditions. To provide the most benefit from AAT or AAA, in especially dog therapies, "resident" or "visiting" models can be used together for patients with dementia and Alzheimer´s disease. [14], [15], [18] It is not clearly explored which therapy model more useful than the other one. [9] In another review written by Williams and Jenkins reported that animal visitings to nursing-care units can provide various benefits including relaxation, improving of apathy and decreasing in agitation, aggression behavior and blood pressure for both patients and their caregivers, relatives. [18] According to the Churchill et al., a therapy dog can reduce some agitation behaviors of Alzheimer patients with especially sundown syndrome, and also help increasing social behaviors and calm down. [16]

Studies shown that environmental factors or changes in Alzheimer's disease special care units can be effect on patients' behavioral health outcomes including aggression, resident agitation, social withdrawal, depression, psychotic problems. [69], [70] That is why, treatment proce‐ dures should be planned and managed considering a balanced combination of pharmacologic, behavioral and environmental options in order to improve health, behavior and quality of life of patients with Alzheimer's disease. [70] It is important that physicians who are playing a key role in recognizing problems and arranging suitable treatment for their patients should consider alternative treatment options based on social and recreational interventions including meditation, validation therapy, reality orientation, reminiscence therapy, sensory interven‐ tions (therapeutic touch and massage therapy, aromatherapy, music therapy, dance therapy, light therapy, multisensory stimulation therapy), social contact (animal-assisted therapy, simulated presence therapy), exercise, art therapy and Montessori-based activities. [71], [72] In addition, most of the AAT studies have been focused on dog, cat and other small animal activities. It is not well-known that animal assisted therapies with farm animals may have

positive effects on self-efficacy and coping ability among psychiatric patients. [73]

during challenging evening hours, and increase calmness/well-being feelings.

314 Understanding Alzheimer's Disease

desires when compared with patients, who have not kept or lived with animals.



in AAT applications can be classified under five headings as social, psychological, training, physical and motivational. Moreover, what we expect from all applications in a patient with Alzheimer´s disease are mainly physiological improvements, better focusing on environment, enabling physical contact, interaction with surroundings, improvements in nutritional behaviors, socialization, acceptance, motivation, increased physical activity, stress, decreased mood disorders like depression, and agitation, enjoying, and decreased feeling of loneliness.

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In USA, 60% of the population has at least one pet at home. Patients and animals participating in AAT require special care for prevention of zoonotic diseases, hypersensitivity reactions and injuries during visits. Therefore, the maximum benefit obtained from this therapy method depends on the multidisciplinary team work of a veterinarian specialist, a veterinarian public health specialist, a medical doctor, and an experienced therapist. [49], [80] Animal assisted therapy performed at treatment centers should always be performed following by a structured program, under the recommended guides, and targeted at the objectives of the program. [49] Hamsworth and Pizer reported after they investigated studies, which evaluated interactions with animals, and risk factors for zoonosis in immunocomprimised children, and guidelines that information obtained from specialists were not adequately evidence-based. Keeping an animal is beneficial for prevention and development of emotional and physical health.

Minimization of risks in such applications depends upon a careful planning with multidis‐ ciplinary approaches, written protocols, personnel training, documentation, and investiga‐ tions. Veterinarian public health practices, which will be performed in this field, are important sources to keep risks endangering human and animal health at minimum levels. Especially veterinarians should choose the appropriate animal for therapy of each patient group according to temperament and behaviors of animals, perform the care for each animal, work for prevention of zoonotic diseases, and suggest an appropriate interaction model for the therapy. [32] Infection controlling policies and regulations should be obeyed in treatment and prevention of zoonotic diseases, so that animal assisted therapies will be more widespread. If measures for risk prevention are taken, then AAT applications can be

In studies, where risk analyses have been performed, people interacting with pets have been observed to have benefits for their health. It has been reported from regions, where risks were not significantly high, controlled environmental conditions are provided especially in Europe and North America, potential benefits are reported in treatments with animals kept at home or at hospitals. Guidelines have been developed to limit infection risk during applications and

In addition to guidelines used during treatments, supportive units have also been established. Animal Assisted Crisis Response (AACR) unit is one of these. This unit provides services in how to struggle with the impending crises for assigned healthcare personnel, consultants and

**8. Risks of AAT and Their managements**

However, guidelines are also required to conduct treatments. [81]

performed safely. [82], [83]

to perform safe treatments. [84]- [86]

**Table 5.** Animal Assisted Therapy Studies in patients with Alzheimer´s disease and other dementia

According to the literature, number of studies recommending animal assisted therapies in clinical and social medicine practices in elderly people with dementia, Alzheimer´s disease, ability losses, mental health problems and conduct disorders, cognitive problems, physical and functional health problems have been increased rapidly. [1-3], [63] Targeted acquisitions in AAT applications can be classified under five headings as social, psychological, training, physical and motivational. Moreover, what we expect from all applications in a patient with Alzheimer´s disease are mainly physiological improvements, better focusing on environment, enabling physical contact, interaction with surroundings, improvements in nutritional behaviors, socialization, acceptance, motivation, increased physical activity, stress, decreased mood disorders like depression, and agitation, enjoying, and decreased feeling of loneliness.
