What are the effects of animals on the health and wellbeing of residents in care homes? A systematic review of the qualitative and quantitative evidence

The number of older adults needing long-term care worldwide is on the increase. In the UK, in 2011 291,000 people aged 65 and over were living in care homes in England and Wales [1] and by 2020 this has risen to > 360,000 [2]. In the USA, latest estimates place over 1.3 million older adults living in long-term care [3] and similar rises are being seen throughout Europe [4]. In addition, people living with dementia comprise a large proportion of the resident population of care homes [5, 6]. Moving from independent living to residential/nursing care is a key transition in an older person’s life and can significantly affect an individual’s quality of life [7, 8]. A recent systematic review by Gardiner et al. suggested that as many as 61% of older people living in long-term care may be moderately lonely and around 35% may be severely lonely [9]. The recent restrictions on family visits and group activities as a result of COVID-19 infection measures has further highlighted the issue of social isolation and loneliness for those living in long-term care [10, 11].

A home-like environment is important to residents [12], and the presence of animals or pets may contribute to a feeling of less institutionalised living [13]. Companion animals and pet/animal-assisted therapy may provide people with access to different forms of social contact, as well as providing opportunities for sensory experiences and meaningful engagement. The systematic use of animals or pets in the context of therapy for the purpose of improved health and wellbeing is often referred to as animal-assisted intervention (AAI). AAI can encompass animal-assisted activities (AAAs), focussing on the motivational, educational and/or recreational benefits of animals or animal-assisted therapies (AATs), which tend to be more structured, goal orientated and planned and often led by a trained therapist [14]. Although AAA and AAT have separate definitions, there is often overlap between them in practice and studies do not always differentiate between them [15]. There may also be opportunity for human animal interaction from less organised activities in this setting, such as live-in pets and domestic animals kept by the home itself.

There has been a number of systematic reviews over the past 10 years assessing the impact of AAI on the health and wellbeing of older people in general [16‐18]. Some have focused specifically on people living with dementia or cognitive impairment [19, 20] or have limited the review to dog specific AAIs [21‐23]. The majority of reviews have had mixed findings and focused on quantitative outcomes. None to date have brought together qualitative and quantitative evidence relating to AAI specific to older adults living in long-term care. This review aims to create a state-of-knowledge synthesis on the impact of animal-human interaction on care home residents and care home staff. In particular we sought to answer:

Our review used best practice methods of evidence synthesis [24] and was developed in consultation with three relevant professionals (a care home owner, a care home manager, and a veterinarian) who formed our Expert Advisory Group (EAG). A full protocol outlining the methods of this systematic review which followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [25] was registered with International Prospective Register of Systematic Reviews (PROSPERO) CRD42017058201.

From the initial searches and update searches, 391 articles were selected for full-text review, resulting in 35 included full text articles. With an additional 5 articles found through supplementary searching, 40 articles (reporting on 34 studies) met the inclusion criteria (see PRISMA diagram in Fig. 1 for reasons for exclusion). The 34 studies included 16 qualitative studies and 18 randomised trials.

This is the first mixed methods systematic review to examine the experiences and effects of pets and animals in older adult residential care settings. A strength of the review is the rich qualitative findings which identified five themes around experiences and meanings of resident-animal interaction in care homes. Engaging with animals had positive effects on the health and wellbeing of residents by providing opportunities for residents to interact with ‘living beings’, to reminisce and share stories, to care for a living creature, have respite, and engage their senses. The conceptual model (see Fig. 2), generated from the process of drawing the qualitative and quantitative evidence together, depicts the resident-animal interaction at the centre, with identity as the global theme that draws the other themes together, and offers an overarching interpretative framework for understanding the health and wellbeing benefits of animal interactions for care home residents. In this section the discussion focusses firstly, on the significance of the relationship between animals and residents; secondly, on how residents maintain identity by living with, and caring for, their pet, reminiscing, participating in meaningful activities with animals, and through the sensory and embodied experiences with the animals; and thirdly, on the importance of care homes adopting a person-centred care approach to resident-animal interactions.

At the core of the conceptual model was the underpinning theme of the animal as a ‘living being’, and the kinship or connectedness that this meant to individual residents. Within human-animal interaction research, there is an implicit assumption that it is ‘something unusual, specific, or even unique about animals’ that brings about change [77]. In our conceptual model, the human-like quality of the animal underpinned the experiences of how pets and animals connected with the residents. Residents’ descriptions of animals as ‘almost human’ may be explained as anthropomorphism which is the “…attribution of human mental states (thoughts, feelings, motivations and beliefs) to non-human animals” ([78], p.437). Although regarded by some as ‘undesirable’, ([79], p.141)Beetz argues that it is the basis for understanding how humans relate to and communicate with animals and build social relationships with them. Residents, and particularly those who were living with their pets in the care homes, spoke about their relationships with their pets in terms of kinship [80], and how they received social and emotional support from their pets. Residents could interpret animal gestures such as a ‘paw on a cheek’ as a sign of emotional support and describe it in similar terms to that of human support. Their evaluations of the animal’s behaviour – often regarded as superior to that of humans – influenced the degree to which residents were attached to their pet. Arguably, relationships with animals were valued because animals were similar to humans and also because they were not [80]. The emotional bonds with their pets were of even greater significance to residents when they felt alone and apart from family and friends, and could even substitute for lost relationships (e.g. with a spouse). Thus, the support and positive social relationships residents experienced with their pets contributed to their wellbeing.

The residents benefitting from this social and emotional support were most likely to be those with a long-term relationship with their own pets and who were living with them in the care home. However, having a relationship with visiting animals was important for some residents too and familiarity could be achieved when the same animals returned on each visit, on a regular schedule over a sustained period of time [40]. Residents indicated that having the animals recognise them enhanced the pleasure they experienced, so regularity and continuity in animal visits is important to ensure that wellbeing benefits are delivered. Interestingly, in these relationships between humans and animals, the animal can be seen as an active participant with its behaviour and responsiveness shaping the relationship with the human [80]. This challenges those studies where the animal has been treated as the “…uniform variable that either is present or absent, as if all [animals] were equivalent, regardless of species, breed, temperament or behaviour” ([78], p.444). According to Serpell et al. (2017), acknowledging the individual characteristics of animals participating in interventions should be an important part of accounting for heterogeneity in RCTs and increasing their methodological rigour [77].

The presence of animals helped residents maintain continuity of self, particularly important as moving to, and living in, a care home can mean that residents experience changes and losses that impacts their identity and wellbeing [81]. For example, residents may experience loss of self-care ability, loss of control or autonomy, loss of meaningful connections [44], and loss of domesticity [46]. In this context, being able to keep their pet in the care home seemed to “…take on increased significance and meaning” for residents ([4], p.9), perhaps by helping residents to maintain a connection between their former life and current one in the care home [44, 82]. However, with many care homes not able to take on animals, some residents were forced to part with their companion animal, which Fox and Ray suggest is akin to the loss of a family member, having a detrimental impact on their health and wellbeing [76]. Residents’ descriptions of their pets as family indicates ‘connectedness and belonging’ and arguably, pets offered emotional support, comfort and security to such an extent that they provided residents with a sense of ‘ontological security’ [80]. That some residents were able to continue caring for their pets and fulfil their caring responsibilities was important, not only for maintaining a degree of autonomy or agency [36] but also for maintaining the identity of ‘pet owner’. Arguably, personal pets are part of the identities of residents in a way that communal and visiting animals could never be and to some extent, resident disinterest in visiting animals may have been recognition that the animal was ‘not theirs’ to which they could link their identity.

However, there is evidence to suggest that visiting and communal animals did enable some residents to reconnect with their former lives through reminiscence and storytelling, and through caring activities. Interestingly, some residents spoke of how important the visiting animals were to them in terms of ‘belonging to something’ [52]. Where residents were involved in the everyday caring routines for communal animals, they were ‘doing’ meaningful activities which may have been a way of linking with former routines and replacing the loss of other responsibilities [81]. For some, such activities could be described as ‘identity work’ [83], and meaningful activities have been identified as supporting personhood for residents with dementia by enabling them “to continue to be who they are” ([84], p.12). In some cases, there was an assumption that for residents to find interacting with the animal meaningful, they had to have experience of animals in the past, but this was not always the case [39, 48], which fits with Strick et al.’s assertion that ‘meaningful occupation’ can also support an ‘evolving and changing identity’ [85].

The importance of touch in resident encounters with animals, and the pleasure and comfort derived from touch, particularly for those residents with dementia, highlights how it can enhance the wellbeing of care home residents. In care settings, residents can experience ‘touch deprivation’ [86], in that they are more likely to receive instrumental, task-oriented touch associated with the routine tasks of caring, than caring touch for ‘reassurance or comfort’ ([87], p.543). Touch in the context of carers providing daily assistance with washing, dressing, eating and walking has been described as ‘bodywork’ [88]. That residents enjoyed the animals’ ‘snuggles’ and ‘cuddles’ suggest that such physical interactions restored an ‘element of touch’ to their lives ([46], p.115), and may even have acted as a “substitute for the lack of affectionate human touch” ([89], p.10). For some residents with dementia, cuddling and petting the animals enabled them to connect to the present and be aware of the animal and its body. In that moment, residents could engage in conversation, show awareness of, and respond to, the situation and express care for the animal through an “embodied knowledge of how to take care” ([90], p.329). This resonates with the concept of embodied selfhood [91] and how people with dementia use non-verbal behaviour to engage with, and connect to, the world.

The physical contact with an animal could also enable residents to connect with ‘life past’ and evoke ‘dormant’ memories and feelings which could bring sadness as well as joy [47]. Swall et al. draws on embodiment to explain how physical contact with animals could stimulate memory:

“To feel, see and hear the dog reveals feelings and expressions from a ‘whole’ human being, allowing them to connect with…memories earlier in life when they were younger and before they contracted AD [Alzheimer’s Disease]. Their existence and awareness might be due to the sense of being a ‘whole’ human being with the dog felt through their senses, which in turn connects with inner feelings and memories that they reveal when the dog is close”. ([47], p.89).

Downs argues that embodiment is important for understanding ‘continuity of self’ in dementia and the embodied nature of the human-animal interaction enabled residents living with dementia to express something of their identity [92]. There is increasing recognition that the body and embodiment are central to living with dementia with implication for care practices which, according to Downs ([92], p.368), should be “…person-centred in the sense of affirming personhood and sense of self.” Providing opportunities for residents with dementia to interact with animals is potentially a person-centred approach to strengthen a sense of self-identity [49].

A person-centred approach to care is about staff recognising each resident in the care home as a unique individual with likes and dislikes, understanding his/her life story, and appreciating the resident’s preferences in order to offer activities that match his/her interests and capacities [93, 94]. The overwhelming view of the staff in Fossey & Lawrence’s ([37], p.250) study was that involving animals should be “…facilitated to ensure resident’s’ choices and preferences were respected,” yet the evidence suggests that in practice, the attitudes of staff towards animals were likely to determine whether they were considered as part of person-centred care. Additionally, the willingness of care home managers to support resident pets or visiting animals was a critical factor. These findings are supported by Buist et al.’s research on the implementation of green care farm characteristics in long-term care settings which found that staff flexibility and ability to deliver person-centred care, management commitment and vision, and flexible approaches to risk and safety facilitated change and innovation [95]. Notably, Fossey & Lawrence ([37], p.322) observed that staff often presented health and safety concerns as “a default response that negated the need to consider the topic further.” The extent to which health and safety risks were experienced as a perceived or actual barrier is also likely to be closely related to a care home’s approach to person-centred care. According to Ettelt et al.’s typology of care home approaches, in the task-oriented, risk averse care homes, person-centred care happened at the ‘periphery’, with managers highlighting the tension between person-centred care and risk management [96]. For Fox & Ray ([76], p.212), risk reduction is paramount when residents are viewed as a “homogenous vulnerable group requiring protection from harm” and, in the words of Freedman et al. ([38], p.1976), that is because “risk reduction is valued above identity.”

Person-centred care should be an important influence when developing a policy for resident and visiting animals [97]. Given that the evidence suggests that interacting with animals is more than simply an activity that residents do and is important for ‘who they are’ [38], care homes should think carefully about the animal interactions that best match individual residents’ needs and respect individual choice and autonomy. Arguably, the presence of resident pets and communal animals offered residents the possibility of spontaneous interactions on their own terms, whereas interactions with visiting animals were more likely to be structured and time-bounded. While these visits were a highlight for some, they were, for others, ‘another activity’ that had been organised for them by management [52]. This reinforces how a sense of agency was important for some residents and where possible care homes should aim to facilitate participation in animal visits as a ‘meaningful choice’ for residents. Visits from therapy animals for residents with dementia tended to be structured, as in one study where dog visits were prescribed with each referral made by a nurse, and individualised for each resident with a specific purpose such as increase alertness or decrease anxiety [47‐49]. The dog handlers indicated that by knowing the residents they aimed to tailor each visit to the individual and respond to the residents’ emotions and feelings. The importance of ‘learning to read the residents’ signals’ was observed by one dog handler [39], and demonstrated that the dog handlers sought to support residents with dementia to exercise agency [98]. The challenge for care home staff is how best to balance supporting residents with dementia to exercise agency and motivate them to engage with animal therapy [85].

Previous systematic reviews of animals in the residential care setting have identified the promise of animal-assisted interventions but have largely focussed on quantifiable outcomes and have focussed on specific populations. Whilst most highlight the lack of rigorous studies, the reviews suggest there is weak evidence that targeted animal -assisted therapies might be effective for older adults with dementia in improving social functioning [15, 18, 19], depression [20, 23] and agitation [16, 20, 99]. Borgi et al. (2018) reviewed the evidence of dog-assisted interventions on older adults with depression, including those in care homes [21]. Despite considerable heterogeneity amongst the studies, the authors concluded that dog assisted interventions of at least four weeks or more, had beneficial effects on depressive symptoms for those living in the community as well as those in residential care, and for those with cognitive impairment of any level, in line with findings from previous reviews [23, 100], and further supported by Jain et al. (2019) [22]. The review by Jain et al., included four qualitative studies, from which the authors drew three themes: dogs visiting the home served as ‘transitional objects’ supplementing otherwise missing interaction, dogs were ‘therapeutic’ in creating a good moment and reducing stress, and lastly the importance of the care home environment in facilitating the most out of dog-assisted interventions [22]. However, there is a recognised dearth of qualitative reviews on the experience of pets and animals in this setting [22, 101]. It seems intuitive that we need to understand the value of pets and animals to residents in long-term care before we try to assess if they are ‘effective’. The qualitative synthesis and conceptual model from our review brings new insight into this area.

A strength of this review is that it followed best practice guidelines for both quantitative and qualitative syntheses and was informed by stakeholders. We searched widely for relevant literature and did not limit by date or language. It is also the first systematic review to bring together qualitative and qualitative evidence on human-animal interactions in the long-term care setting: being inclusive of all type of animal interactions, from resident animals and pets through to structured therapeutic visits. It highlights the value of qualitative research in capturing the richness, diversity and similarities in resident experiences of animal interactions. Six of the included papers were drawn from two studies [47‐52] and Table 2 shows that these papers made similar contributions to the thematic synthesis, apart from one [50].

The potential for animals to elicit negative responses from residents received little attention in the studies. The benefits of animals for residents in long-term care has “almost universal acceptance” ([102], p.151) with the public eager to consume the ‘feel-good’ stories published by the mass media [103]. However, this may present researchers with a ‘double-edged sword’ ([77], p.7), in that a ready audience for their findings may exert a subtle pressure to report positive findings and overlook the”…need to document what might seem the obvious” ([102], p.151). Whilst there were examples of residents becoming over attached or possessive with the animals, and others simply disinterested, the focus was more on the potential benefits. Future research should address this need to document some of the resident-specific challenges of introducing animals into long-term care settings.

The potential discrepancies observed across the qualitative and quantitative syntheses may in part be due to the appropriateness and sensitivity of the outcome measures being used in the trials which may not reflect the value or impact that are important to the participants. They also may be a reflection that the sample sizes in the trial evidence were too small to detect meaningful differences.

There also is a possibility that the difference is explained by the wide and diverse nature of the human-animal interactions that have been explored and assessed across studies to date. The type of animal, the nature of the interaction (individual vs communal, therapy vs activity), and the personality and history of the resident, inevitably leads to a heterogeneity of experience and impact which is difficult to capture and unlikely to be uniform. This is acknowledged, to some extent, in the conceptual model (Fig. 2) which proposes that the experiences and impacts of the human-animal interaction are nuanced by the type of animal interaction which may vary and change across time. Arguably, more research attention should focus on understanding the strengths and limitations of the different types of human-animal interactions themselves.

There was little in the studies about how living in, or visiting, care homes impacted the health and wellbeing of the animals. There is a paucity of research on the possible ill-effects of human interaction on animals [103] and the dominant utilitarian approach in research focuses on ‘what can animals do for us?’ ([75], p.39). Staff raised the welfare of resident pets and the potential for neglect [37] but did not discuss any other aspects of animal wellbeing. Gorman ([104], p.318) counsels against assuming that animals do not receive any benefits from their encounters with humans in a care setting, by arguing that it “…gives rise to the view of animals as passive and lacking agency, simply receiving human action.” He believes that human-animal relations have the potential to be ‘reciprocally beneficial’. The potential for animals being active partners within the relationship and receiving benefit is likely to vary according to the type of animal and its role in the care setting and in this review, some animals were pets belonging to individuals living in the care homes, others were communal animals and part of the care home environment, and others were visiting with either volunteers or trained animal handlers. Arguably, the chickens in the HENPOWER project were less likely to have a mutually beneficial relationship with residents in that they were part of the homes’ outdoor spaces and residents were less likely to interact with the chickens themselves [104]. Understanding more about the experience of animals is essential to ensure that they too have opportunities to mutually benefit from interacting with care home residents. There was also very little in the studies that considered the perceptions and experiences of family members, and only a few studies examined the experiences and perspectives of the volunteers [46] and the dog handlers [39, 48, 50].

The review is limited by the quality of the included quantitative studies. In particular, many of the randomised trials were small, and of short duration, with little or no follow-up. In addition, for the majority of the trials both the residents and researchers were aware of group allocation. Another limitation of the quantitative evidence is the appropriateness of outcome measures, which may not reflect the value or impact that are important to the participants. The qualitative research included in the review was generally of higher quality.

This systematic review demonstrates that animals can significantly impact the health and wellbeing of some care home residents. Residents had meaningful relationships with pets, resident and visiting animals, which were experienced as embodied and emotionally supportive, and from which they derived pleasure and comfort. Interacting with animals offered residents a way to maintain a sense of self in the care homes, and with support, residents with dementia could also express their identities. Facilitating residents to interact with animals as part of person-centred care may also help residents to feel ‘at home’ in the care home, which, according to Cooney, [93] is associated with ‘continuity’, ‘preserving personal identity’, ‘belonging’ and ‘being active and working.’ How care homes facilitate the human-animal interaction, whether it is pets living in the home with their owners or communal animals, or animals as visitors—designated as ‘activity’ or ‘therapy’, the critical factor is that residents’ agency is recognised and respected. Where animals are not a viable option for care homes, robotic animals that mimic ‘living’ animals and respond to human touch, might be a viable alternative [33]. Any care homes considering resident or visiting pets and animals should have an animal policy in place, as recommended by the UK animal charity Blue Cross [105], and establish connections with local vet services. In conclusion, care homes should consider carefully how to encourage human-animal interactions as it will impact the daily functioning and wellbeing of those living, working and visiting long-term care environments.