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The Effects of a Therapy Dog on the Blood
Pressure and Heart Rate of Older Residents in a Nursing Home
Linda Handlin, Anne Nilsson, Lena Lidfors, Maria Petersson & Kerstin Uvnäs- Moberg
To cite this article: Linda Handlin, Anne Nilsson, Lena Lidfors, Maria Petersson & Kerstin Uvnäs- Moberg (2018) The Effects of a Therapy Dog on the Blood Pressure and Heart Rate of Older Residents in a Nursing Home, Anthrozoös, 31:5, 567-576, DOI: 10.1080/08927936.2018.1505268 To link to this article: https://doi.org/10.1080/08927936.2018.1505268
© 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group ISAZ
Published online: 19 Sep 2018.
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aNthROZOöS VOlUmE 31, ISSUE 5 REPRINtS aVaIlaBlE PhOtOCOPYING
PP. 567–576 DIRECtlY FROm PERmIttED
thE PUBlIShERS BY lICENSE ONlY
Address for correspondence:
Linda Handlin, University of Skövde, School of Health and Education, P.O. Box 408, 541 28 Skövde, Sweden.
E-mail: linda.handlin@his.se
567anthrozoös DOI: 10.1080/08927936.2018.1505268
The Effects of a Therapy Dog on the Blood Pressure and Heart Rate of Older
Residents in a Nursing Home
linda Handlin
*#, Anne nilsson
†#, lena lidfors
†, Maria Petersson
‡, and kerstin Uvnäs-Moberg
†*School of Health and Education, University of Skövde, Sweden
†Department of Animal Environment and Health, Swedish University of Agricultural Sciences, Skara, Sweden
‡Department of Molecular Medicine and Surgery, Endocrine and Diabetes Unit, Karolinska Institutet, Sweden
#Both authors contributed equally to this work.
ABSTRACT the aim of the present project was to investigate whether repeated visits by a therapy dog to nursing homes might affect the older res- idents’ systolic blood pressure and heart rate. a secondary aim was to investigate and compare effects (differences in responses) in older people with high and normal systolic blood pressure. the project consisted of two con- secutive studies; the dog study (two researchers and a therapy dog with a handler visited the residents at three nursing homes, n = 13), and the control study (the two researchers alone visited the residents at three different nurs- ing homes, n = 13). the studies were divided into three periods; period 1 (weeks 1–2), period 2 (weeks 3–4), and period 3 (weeks 5–6) and included two visits per week. the dog and her handler visited during periods 2 and 3 in the dog study. Participants’ heart rate and blood pressure were measured at 0 and 20 minutes at each visit. the data were analyzed using Friedman’s two- way analysis of Variance by Rank with post-hoc analysis using Wilcoxon signed-rank tests with a Bonferroni correction, and also with the mann- Whitney U test for independent samples. In the dog study, participants’ heart rate decreased significantly (p = 0.006) from period 1 to period 3. Participants with an initial systolic blood pressure ≥ 130 mmhg had a significant decrease in both systolic blood pressure (p = 0.009) and heart rate (p = 0.009). In the control study, participants’ heart rate and systolic blood pressure did not change significantly. the participants in the dog study had a significantly lower systolic blood pressure during period 3 (p = 0.016) compared with those in the control study. In conclusion, repeated visits by a therapy dog–handler team decreased the older adults’ heart rate, and for those with high initial systolic
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blood pressure, blood pressure also decreased. In addition, systolic blood pressure decreased significantly in the dog group when compared with the control group.
keywords: heart rate, human –animal interaction, older adults, systolic blood pressure, therapy dog
Owning a dog is sometimes associated with positive cardiovascular effects. For example, dog owners have significantly lower blood pressure and stress reactivity than those who do not have a dog (allen, 2003; allen, Blascovich, & mendes, 2002;
allen, Shykoff, & Izzo, 2001; Friedman et al., 1983, 2013), and dog owners who have had a cardiac infarction show an increased chance of survival (Friedmann, Katcher, lynch, & thomas, 1980; Friedmann & thomas, 1995). Dogs have also been shown to reduce owners’ stress reactions when they perform stressful tasks (allen, Blascovich, & mendes, 2002).these types of effects are seen not only in response to the relationship between an owner and their own dog; similar effects may also be induced by unknown dogs, for example, by trained therapy dogs, which together with their handlers serve as assistants in health care. the use of ther- apy dogs has, for example, been shown to decrease cortisol levels and blood pressure, to r - educe anxiety and pain, as well as to improve mood and social abilities in people (Barker &
Wolen, 2008; Beetz, Julius, turner, & Kotrschal, 2012; Cole, Gawlinski, Steers, & Kotlerman, 2007; marcus, 2012; marcus et al., 2012, 2013).
the effects of therapy dogs may be mediated by the interaction between them and humans. Physical closeness to a dog, and in particular the stroking of a dog, increases social interaction and lowers levels of anxiety in humans (Kotrschal & Ortbauer, 2003). In addition, short-term sensory interaction between humans and dogs causes a reduction in blood pressure, heart rate, plasma levels of adrenaline, noradrenaline, and cortisol (Beetz, Julius, turner, & Kotrschal, 2012; handlin et al., 2011; Klaus, 1998; Odendaal & meintjes, 2003). In contrast, levels of oxytocin are increased during human-dog interaction (handlin et al., 2011; miller et al., 2009; Odendaal & meintjes, 2003). Oxytocin, which is produced in the hypothalamus and released into the circulation from the posterior pituitary and into the brain from oxytocin-containing fibers, stimulates various types of social interactive behaviors, and reduces stress levels and anxiety (Uvnas-moberg, 1998a, b).
Older people living in nursing homes often display cardiovascular problems such as hypertension (i.e., systolic blood pressure ≥ 130 mmhg) and therefore they are often treated with antihypertensive drugs. In addition, they often suffer from a number of other illnesses for which they usually receive multiple pharmacological treatments. Such polypharmacy may increase the risk of unstable blood pressure, dizziness, and falls in older adults. Falls often give rise to fractures leading to hospital care, with consequent increased morbidity and mortality (the National Board of health and Welfare, 2016). For the above reasons there is a need for the development of alternative treatments to improve the cardiovascu- lar health and wellbeing of older adults living in nursing homes (lucenteforte et al., 2017;
Weiss et al., 2017).
the aim of the present project was to investigate whether repeated visits by a therapy dog to older residents in nursing homes might influence their systolic blood pressure and heart rate. these parameters were selected as they are indicators of older adults’ cardiovascular health and/or stress levels. a secondary aim was to investigate if there were differences in responses to the dog visits for the participants with high systolic blood pressure, when compared with normotensive participants.
❖
Methods
the project consisted of two consecutive studies: the dog study and the control study.
In the dog study, a therapy dog with her handler and two researchers visited the residents of three nursing homes. In the control study, only the two researchers visited the residents of three different nursing homes. the six nursing homes selected for the project were all similar regarding size and age and health profile of the residents. the nursing homes were all located in the county of Skaraborg, in the southwestern part of Sweden. there was no previous experience of therapy dogs in the selected nursing homes.
Participants
Five participants were recruited from each nursing home. the dog study included 13 women (range: 75–100 years, mean age: 89 years, SD: 7.8 years) and two men (range: 80 years, mean age: 80 years, SD: 0). the control study included 11 women (range: 78–91 years, mean age: 82 years, SD: 3.9) and four men (range: 81–85 years, mean age: 83 years, SD: 1.8). Due to long-term illness, two participants in the dog study and two in the control study only took part occasionally and were therefore excluded from the study.
Both the dog and control groups were further divided into two subgroups, based on the participants’ initial systolic blood pressure; those with initial systolic blood pressure ≥ 130 mmhg (Dog study: 6 individuals; range: 130–154 mm/hg, mean: 142.5 mmhg, SD: 23.1 mmhg. Control study: 6 individuals; range: 131–156 mmhg, mean: 139 mmhg, SD: 9.6 mmhg) and those with initial systolic blood pressure < 130 mmhg (Dog study: 7 individuals;
range: 107–127 mm/hg, mean: 117 mmhg, SD: 11.6 mmhg. Control study: 7 individuals;
range: 106–128 mmhg, mean; 118 mmhg, SD: 8.3 mmhg).
the recruited participants fulfilled the following inclusion criteria; they were Swedish speak- ing and were able to participate in a simple conversation, make their own decisions, and understand information and instructions. this was evaluated by the head nurse at each nurs- ing home. In addition, the participants could not have a medical diagnose of dementia. Some of the participants received pharmacological treatments, for example, for high blood pressure, anxiety, sleeping problems, and pain. all participants were in need of assistance to be able to walk or were sitting in wheelchairs.
the experimental procedure was approved by the local ethics committee in Gothenburg, Sweden (ref. no 669-10 and 553-12). Before the experiment started, the participants, as well as their relatives, were informed about the study and given the opportunity to ask questions. the residents were informed that they could end their participation in the study at any time without affecting the care they received. the resident or a relative (in those cases where the participant was unable to write) signed a written consent for participation in the study.
Study Design and Data Collection
Both the dog study and the control study were divided into three periods: period 1 (weeks 1–2): where only the researchers (two females) visited the nursing homes; period 2 (weeks 3–4); and period 3 (weeks 5–6). Each nursing home received two visits each week, one in the morning and one in the afternoon. the therapy dog, her handler, and the researchers visited the nursing homes together in the dog study, but only the researchers visited the nursing homes in the control study. the researchers did not initiate conversations with the participants but did answer questions posed by them. the researchers spent the time between measurements sitting in their chairs without interacting with the residents.
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the visits took place in the day rooms of the nursing homes, where the participants sat in their own wheelchairs or in other suitable chairs next to each other in a semi-circle. When the dog was present, a water bowl and some toys for the dog were also brought in.
the participants’ blood pressure and heart rate were measured during each visit using an automatic blood pressure and heart rate gauge (type 6050 3V/2W Braun, Braun aG Kronberg.
Germany. accuracy: +/–3 mm hg (cuff pressure), +/–5% of reading (pulse rate)). two meas- urements were performed during each visit: at the start (0 min) and after 20 minutes. the same researchers performed all data collection.
Therapy Dog
the same therapy dog and handler performed all group visits. the dog was a privately owned 2-year-old female labradoodle, which was trained to work with older residents in nursing homes. Both the dog and the dog handler had been trained for one year at “Vårdhundskolan”
in Uppsala, Sweden. the experimental procedure was approved by the animal ethics com- mittee in Uppsala, Sweden (ref.no. 283/10) and the use of a privately owned therapy dog was approved by the Swedish Board of agriculture (ref.no. D31-12610/10).
Therapy Dog Intervention
at the beginning of each visit, the dog greeted each participant by either placing her head in the person’s lap and/or by letting the person stroke her. the dog and her handler were present during the entire visit and the dog spent an equal amount of time with each participant. all par- ticipants interacted with the dog, but in different ways according to their individual capabilities.
the participants talked to and/or engaged in physical activity with the dog, including stroking her and playing with her by throwing a ball or another toy that she fetched. Where physical issues prevented the participants from touching the dog, she was placed on a chair close to the participant, allowing him/her to reach out and stroke the animal.
Control Intervention
No therapy dog was present during the control intervention. the researchers visited the nurs- ing homes and collected the data as described above. During the control intervention, the researchers did not initiate conversations with the participants but answered any questions.
the researchers spent the time between measurements sitting in their chairs without interacting with the residents.
Statistical Analysis
Statistical calculations were performed using the IBm Statistical Package for the Social Sciences (SPSS Version 22.0; armonk, NY, USa). the studies were divided into three periods; period 1 (weeks 1–2), period 2 (weeks 3–4), and period 3 (weeks 5–6). For these periods, mean values were calculated based on the recordings performed at 0 and 20 minutes during the four sep- arate visits in each period (in total, mean of 8 measurements/period). mean values were created both for the values obtained at 0 and 20 minutes combined, as well as separately.
Since the number of participants was relatively small and none of the variables were nor- mally distributed, non-parametric statistical tests were used. Friedman’s two-way analysis of Variance by Rank was used to test for differences over time within the two studies. Post-hoc analysis was conducted with the Wilcoxon signed-rank test. Due to multiple testing, a Bonferroni correction was performed, resulting in a significance level of p < 0.025, and a tendency level of p ≤ 0.050. the mann-Whitney U test for independent samples was used to test for differences between the two studies.
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Results
Changes Over Time
the analyses of changes over time were based on the mean of values obtained during periods 1–3. mean values were based on the recordings performed at 0 and 20 minutes during the four separate visits in each period. Comparisons were made over time and between periods in the dog and the control studies.
Dog Study
heart rate decreased significantly over the entire study (2(2)= 10.308, p = 0.006). Significant decreases were also noted between periods 1 and 2 (Z = –2,412, p = 0.016) and between periods 1 and 3 (Z = –2,657, p = 0.008) (Figure 1a). Systolic blood pressure did not decrease significantly during the entire study (Figure 1b).
Figure 1. Mean values (± SD) from four visits during periods 1, 2, and 3, respectively for heart rate (a) and systolic blood pressure (b) for the participants in the dog study (n = 13) and in the control study (n = 13). Each of these values represents the mean of the recordings obtained at 0 and 20 minutes. *p < 0.025 in the dog study. a = significant difference in systolic blood pressure between the dog study and the control study during period 3.
(a)
(b)
Participants in the Dog Study with an Initial Blood Pressure ≥ 130 mm Hg For the participants with an initial systolic blood pressure ≥ 130 mmhg, heart rate and systolic blood pressure decreased significantly during the study (2(2) = 9.333, p = 0.009 and
2(2)= 9.333, p = 0.009, respectively) (Figures 2a and 2b). For the participants with an initial systolic blood pressure < 130 mmhg, there were no changes in either systolic blood pressure or heart rate during the study.
Control Study
Participants’ heart rate and systolic blood pressure did not change significantly during the study (Figure 1). When analyzing the participants with an initial systolic blood pressure ≥ 130 mmhg and the participants with an initial systolic blood pressure <130 mmhg separately, no changes were observed for heart rate or systolic blood pressure in either of the groups.
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Figure 2. Mean values (± SD) from four visits during periods 1, 2, and 3, respectively for heart rate (a) and systolic blood pressure (b) for the participants in the dog study for those with initial systolic blood pressure ≥ 130mmHg (n = 6), those with initial systolic blood pressure <
130mmHg (n = 7) and all participants in the dog study (n = 13) (for standard deviations for all participants, see Figure 1). Each of these values represents the mean of the recordings obtained at 0 and 20 minutes. *p < 0.025.
(a)
(b)
≥
≥
Changes between 0 and 20 Minutes, during the Visits within Periods 2 and 3 Within period 2, no changes were observed from 0 to 20 minutes, for either heart rate or sys- tolic blood pressure in the dog study or the control study. Within period 3, heart rate decreased significantly from 0 to 20 minutes, during the visits in the dog study (Z = – 2.551, p = 0.011) (Figure 3), but not in the control study. Systolic blood pressure did not change between 0 to 20 minutes for the participants in either the dog study or the control study.
Comparison between the Dog Study and the Control Study
the analysis of systolic blood pressure and heart rate were based on mean values obtained during periods 1–3 (mean values were based on the recordings performed at 0 and 20 min- utes during the four separate visits in each period). Comparisons were made between the dog and control studies for each period. In addition, the initial values of heart rate and systolic blood pressure were compared and no differences were found between the dog and control studies. When comparing the mean values for the three different periods between the dog study and the control study, no significant differences in heart rate were found during any of the periods (Figure 1a). the participants in the dog study had a significantly lower systolic blood pressure in period 3 compared with the participants in the control study (2(1)= 5.781, p= 0.016) (Figure 1b).
Discussion
In the present study, we showed that repeated visits by a therapy dog decreased the older adults’ heart rate. For the residents with an initial systolic blood pressure ≥ 130 mmhg, both heart rate and blood pressure decreased over time. In addition, when the dog and the con- trol studies were compared, systolic blood pressure was significantly decreased in the dog study but not in the control study. these results are in line with several other studies demon- strating that interaction with dogs is associated with positive cardiovascular and/or stress reducing effects (see, for example, Friedmann & tsai, 2006). however, our project is, to the best of our knowledge, the first one to show that visits from a therapy dog may induce positive cardiovascular effects in older adults.
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Figure 3. Mean (± SD) heart rate recorded at 0 and 20 minutes in periods 1–3 for the participants in the dog study (n = 13). *p < 0.025.
the results demonstrated that heart rate decreased in the participants who experienced the dog visits, and for the participants with initial systolic blood pressures ≥ 130 mmhg, systolic blood pressure also decreased significantly. heart rate decreased significantly in the presence of the dog during period 3, which is indicative of an immediate response, perhaps an anxiolytic- like effect induced by the dog. thus, visits by therapy dogs may result in both reduced stress levels that might last between the visits, as well as have an acute effect during the visit (as reflected by the decrease in heart rate during the visits in period 3).
the therapy dog used in the present study had been trained to work with older adults.
During each visit, the dog approached the participants, putting her head on their lap and mak- ing eye contact. after this “invitation” by the dog, the participants started to interact with and stroke the dog. It is important to note that the dog handler played an important role in guiding the interaction between the dog and the participant, and sometimes the handler talked to the participants and even touched them. therefore, it might be more appropriate to consider the dog–handler team, and activities associated with them, as the cause of the effects observed on the older adults, and not the dog alone.
We can only speculate on the mechanism underlying the observed decreases of systolic blood pressure and heart rate during the visits by the therapy dog–handler team. We propose that these effects are mediated by changes in the activity of the autonomic nervous system, leading to a decreased sympathetic tone. a possible mechanism behind that might be a release of oxytocin in the adults in response to the interaction with the dog–handler team. as mentioned in the introduction, oxytocin increases during human–dog interaction (handlin et al., 2011; miller et al., 2009; Odendaal & meintjes, 2003). the release of endogenous oxytocin has been shown to induce anti-stress like effects: blood pressure and cortisol levels decrease, and anxiolytic-like effects are induced (light, Grewen, & amico, 2005; Uvnäs-moberg, 1998a, b;
Uvnäs-moberg, handlin, & Petersson, 2015). Some of these effects are caused by an increase in activity of alpha 2-adrenoreceptors in response to oxytocin; for example, in areas of the brain and brainstem that are of central importance for the control of the autonomic nervous system and cardiovascular regulation (Petersson, Diaz-Cabiale, angel Narvaez, Fuxe, &
Uvnäs-moberg, 2005; Petersson, Uvnäs-moberg, Erhardt, & Engberg, 1998).
high blood pressure is a common disorder and its prevalence increases with age (Ferdinand
& Nasser, 2017). hypertension is linked to an enhanced risk of developing serious cardiovas- cular diseases such as stroke and heart infarction and should be treated. In addition to lifestyle changes, pharmaceutical treatments such as beta blockers, aCE-inhibitors, angiotensin receptor 2 blockers, and diuretics are often used to normalize blood pressure. these treat- ments are most often well tolerated, but can sometimes cause problems. In fact, older people often receive a multitude of drugs, including anxiolytics, analgesics, sedatives, hypnotics, and anti-hypertensive drugs. together these drugs might lead to hypotension and vertigo, and as a consequence older adults may fall and receive fractures, leading to expensive hospital care and increased morbidity and mortality (lucenteforte et al., 2017; Weiss et al., 2017).
Limitations
We acknowledge that the number of participants in our study was small, that the study was not randomized, and that the dog and control parts of the study were not run in parallel. although this would have been desirable, it was not possible for practical and logistical reasons. We wanted the nursing homes to be as similar as possible and within the same region. thus, it was not pos- sible to find the requested number of participants that also fulfilled the criteria of the present proj-
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ect for the two groups at the same time. Despite this, we managed to perform a unique project in which the data are based on a substantial amount of measurements. the participants partic- ipated in the study for 6 weeks and met the investigational team, with or without the dog and her handler twice each week. In fact, each value used for statistical calculations was based on 24 recordings, which allowed us to see significant changes and differences over time within the dog group, and also between the dog and control groups.
a detailed health profile of each participant was not available. In Sweden it is a custom to live at home as long as possible with the help and support from the health-care system. When peo- ple cannot cope at home they will move or be transferred to a home for older adults, which most often occurs when they are in their eighties or nineties (the National Board of health and Welfare, 2016), suggesting that the participants of this study had a relatively similar health profile.
Conclusion
Repeated visits by a therapy dog–handler team decreased older adults’ heart rate and blood pressure over time. the decrease over time in systolic blood pressure was only found for the older adults with systolic blood pressure ≥ 130 mmhg. In addition, systolic blood pressure was significantly lower in the dog study, compared with the controls. these findings suggest that visits by a therapy dog–handler team might constitute an effective non-medical treat- ment for elevated blood pressure and heart rate in older adults. this type of treatment may in the future be used to treat, to prevent, or to delay the development of cardiovascular dis- ease in older people. It may also promote health in a more general sense and decrease use of pharmaceutical drugs, which might be associated with undesirable side effects.
Acknowledgements
We thank the participants and their relatives, the staff at the nursing homes, and the therapy dog and her handler for participating in this study. this study was supported by the Knowledge foundation (2009/0209), Vinnova and Skaraborg Institute for Research and Development (12/1032).
Conflicts of interest No potential conflict of interest.
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