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Use of social commitment robots in the care of elderly people with dementia: A literature review

      Abstract

      Globally, the population of elderly people is rising with an increasing number of people living with dementias. This trend is coupled with a prevailing need for compassionate caretakers. A key challenge in dementia care is to assist the person to sustain communication and connection to family, caregivers and the environment. The use of social commitment robots in the care of people with dementia has intriguing possibilities to address some of these care needs. This paper discusses the literature on the use of social commitment robots in the care of elderly people with dementia; the contributions to care that social commitment robots potentially can make and the cautions around their use. Future directions for programs of research are identified to further the development of the evidence-based knowledge in this area.

      Keywords

      1. Introduction

      Statistics reported by the World Health Organization and Alzheimer's International indicate that by 2050 the number of people with dementia will globally increase by three times affecting 115.4 million people [
      • World Health Organization and Alzheimer's Disease International
      Dementia: a public health priority.
      ,
      • Alzheimer Society of Canada
      Rising tide: the impact of dementia on Canadian society.
      ]. In Canada, dementia is the leading cause of disability of Canadians over the age of 65 with significant economic costs expected to rise to $153 billion dollars by 2038 [
      • Alzheimer Society of Canada
      Rising tide: the impact of dementia on Canadian society.
      ]. Similar issues exist in other countries such as Japan and the United States, where the increasing aging demographic and declining traditional caregiver demographic have driven the search for innovative dementia care strategies [
      • World Health Organization and Alzheimer's Disease International
      Dementia: a public health priority.
      ,
      • Alzheimer Society of Canada
      Rising tide: the impact of dementia on Canadian society.
      ,
      • Broekens J.
      • Heerink M.
      • Rosendal H.
      Assistive robots in elderly care: a review.
      ,
      • Kimura R.
      • Miura H.
      • Murata A.
      • Yokoyama A.
      • Naganuma M.
      Consideration of physiological effect of robot assisted activity on dementia elderly by electroencephalogram (EEG): estimation of positive effect of RAA by neuroactivity diagram.
      ,
      • Kramer S.C.
      • Friedmann E.
      • Bernstein P.L.
      Comparison of the effect of human interaction, animal-assisted therapy, and AIBO-assisted therapy on long-term care residents with dementia.
      ].
      The anticipated prevalence and the economic impact of dementia care is significant, nevertheless, few countries have a national agenda for its treatment or management [
      • World Health Organization and Alzheimer's Disease International
      Dementia: a public health priority.
      ,
      • Alzheimer Society of Canada
      Rising tide: the impact of dementia on Canadian society.
      ,
      • Broekens J.
      • Heerink M.
      • Rosendal H.
      Assistive robots in elderly care: a review.
      ,
      • Kimura R.
      • Miura H.
      • Murata A.
      • Yokoyama A.
      • Naganuma M.
      Consideration of physiological effect of robot assisted activity on dementia elderly by electroencephalogram (EEG): estimation of positive effect of RAA by neuroactivity diagram.
      ,
      • Kramer S.C.
      • Friedmann E.
      • Bernstein P.L.
      Comparison of the effect of human interaction, animal-assisted therapy, and AIBO-assisted therapy on long-term care residents with dementia.
      ]. There is a pressing need for innovative research that will enhance quality care for people with dementia, decrease caregiver burden and reduce care costs [
      • Alzheimer Society of Canada
      Rising tide: the impact of dementia on Canadian society.
      ]. Research in the area of social robots is in the initial stages of determining if the use of social robotics can assist the elderly living with dementia to improve affect and decrease agitation as well as provide companionship and enrich social interaction and quality of life [
      • Broekens J.
      • Heerink M.
      • Rosendal H.
      Assistive robots in elderly care: a review.
      ]. The objectives of this paper are: to review the literature on social commitment robots and determine their efficacy within the elderly population living with dementia; and to determine future directions for this emerging area of research.

      2. Dementia

      Dementia is a progressive disease that erodes the person's ability to meaningfully communicate and interact, and impairs judgment, memory and affect regulation. Caregivers experience a considerable amount of stress in caring for a loved one with dementia. In addition to physical care, the inability to communicate is stressful not only for the person with the dementia, but also for professional caregivers and family members [
      • World Health Organization and Alzheimer's Disease International
      Dementia: a public health priority.
      ,
      • Alzheimer Society of Canada
      Rising tide: the impact of dementia on Canadian society.
      ]. Family members’ communication with the person with dementia may be problematic and cause significant burden and subjective distress impacting on the family members’ health. Social interaction and interactive communication are recognized helpful strategies to maintain the abilities of people with dementia and improve their quality of life. Social commitment robots are designed to promote therapeutic interactions through communication and social interaction. The therapeutic use of the robots attempts to reach out to people affected by dementia and may provide an alternative mode of engagement with this population [
      • Roger K.
      • Guse L.
      • Mordoch E.
      • Osterreicher A
      Social commitment robots and dementia.
      ,
      • Feil-Seifer D.
      • Mataric M.J.
      Socially assistive robotics.
      ].

      3. Search strategy

      For this review, the search focused on the use of social commitment robots for dementia patients in long term care. Literature searches for this review were conducted in March, April and May 2012 using databases: PubMed, CINHAL, Ageline, Embase, Scopus, EI Engineering Village, PsychINFO, Cochrane Library, Web of Science, and Google Scholar. Subject headings, from the databases’ thesaurus, and free text words (i.e. words from title, abstract or keywords) were used in the search strategies. Thesaurus terms included: robotics, robots, “artificial intelligence”, dementia, “Alzheimer's disease”, “long term care”, “nursing homes”, aged, geriatrics, “residential facilities”. Free text words included in the search strategies (* denotes truncation): robot*, “socially interactive robot*”, “sociable robot*”, “social robot*”, “social human-robot”, “human interactive robot*”, “social commitment robot*”, “social assistive robot*”, “therapeutic robot*”, “mental commitment robot*”, “care robot*”, robotherapy, “affective robot*”, geriatric*, “long term care”, nursing home*, residential, institutional*, dementia, alzheimer*, “cognitively impaired”, “mental health”. No limits were made for date or language and a hand search of reference lists was also conducted. Ninety-nine articles were identified as potentially relevant citations based on the search criteria. These 99 citations were reviewed to determine (1) that the sample was totally or partially comprised people with dementia; (2) that the robot was for therapeutic/social purposes; (3) if a research study and published in a peer reviewed journal, and (4) only English language articles were selected. While a paucity of rigorous scientific studies exists (see Table 1), a considerable volume of Institute of Electronic and Electronics Engineers (IEEE) conference proceedings articles were identified. The journal and proceedings publications from Takanori Shibata and Kazuyosi Wada are notable in number. Dr. Shibata, an engineer, created the well-known tabletop robot, Paro and with Dr. Wada, they have conducted longitudinal studies on this social commitment robot in Japan since 2003. As proceedings publications appear to be influential in the discussion on robot use with the elderly who have dementia, select conference proceedings are included in the literature review (see Table 2). Based on these selection criteria a total of 21; 10 journal articles and 11 proceedings citations are included in this review.
      Table 1Journal articles.
      Study ID

      Country
      DesignInterventionStudy populationDurationCore outcomes
      Campbell
      • Campbell A.
      Dementia care: could animal robots benefit residents?.


      Nursing Home, United Kingdom
      Two observational case studies, robotic cat and robotic dogRobotic cat, Simmy; robotic dog, biscuit; length of time not statedn = 5; 4 female, 1 male; various stages of dementiaTwo single sessionsCase study 1: one resident showed interest and interacted with the cat. Three with advanced dementia and little language did not engage with cat. Case study 2: one male resident spoke when the author interacted with the robotic dog
      Kanoh et al.
      • Kanoh M.
      • Oida Y.
      • Nomura Y.
      • et al.
      Examination of practicability of communication robot-assisted activity program for elderly people.


      Long-term care facility, Japan
      Videotaped observation of staff member and robot assisted activity with residents; focus group interview with residentsYORISOI Ifbot; 16 minn = 10; 75–88 years; 2 males, 8 females; MMSE range of 20–29 (24.1 ± 3.0)Single sessionResidents responded positively to activities; focus group indicated enjoyment, acceptance of the robot, need for a staff member to be present, and problems communicating with the robot
      Marx et al.
      • Marx M.
      • Cohen-Mansfield J.
      • Regier N.G.
      • Dakheel-Ali M.
      • Srihari A.
      • Thein K.
      The impact of different dog-related stimuli on engagement of persons with dementia.


      Nursing home, United States
      Direct observation of engagement of residents with a variety of stimuli to measure refusal, acceptance and duration of interaction for a maximum of 15 minPuppy video, a dog-coloring activity, a plush dog, three real dogs (small, medium and large-sized) and a robotic dogN = 56 (44 female, 12 male); 61–101 years; MMSE range from 0 to 21 (9.1 + 6.2)Single session with each stimuliResidents similarly engaged with (talked to) real dogs, puppy video, plush dog and robotic dog with less interest in dog-coloring activity; engagement was longest with the puppy video followed by the real dogs, the robotic dog, plush dog and dog-coloring activity; preference among dogs was for the large dog
      Kramer et al.
      • Kramer S.C.
      • Friedmann E.
      • Bernstein P.L.
      Comparison of the effect of human interaction, animal-assisted therapy, and AIBO-assisted therapy on long-term care residents with dementia.


      Nursing home, United States
      Robotic dog with a visitor compared to a real dog with same visitor and same visitor alone. Behavioral observation; sessions were videotapedRobotic dog, AIBO with a visitor; 3 min. Real dog with same visitor; 3 min. Same visitor alone; 3 min. Each resident had one session per weekn = 17 female with dementia3 weeksAll three conditions stimulated increased socially interactive behavior in the residents. Interaction between a dementia resident with a robotic dog was not only similar to those with a live dog, but in some cases was even more effective. AIBO induced longer looks and more resident-initiated conversation than the live dog and provided a positive source of social interaction
      Wada et al.
      • Wada K.
      • Shibata T.
      • Musha T.
      • Kimura S.
      Robot therapy for elders affected by dementia.


      Dementia treatment clinic, Japan
      Pre and post-test EEG to measure brain activity; and post-test questionnaire on subjects’ impressions of ParoTwo robotic seals, Paro; 20 minn = 14; 62–90 years; 4 males, 10 females; MMSE average: 16.6 ± 2.9Single sessionn = 7 showed EEG improvement; n = 4 females who showed EEG improvement had the highest positive impression of Paro
      Wada and Shibata
      • Wada K.
      • Shibata T.
      Social and physiological influences of robot therapy in a care house.


      Nursing home, Japan
      Videotaped observation of residents prior, during and after introduction of Paro into two communal areas; pre and post measure were self-reported assessment of social ties and urinalysis (17-KS-S and 17-OHCS measured stress recovery); two case studiesTwo robotic seals, Paro; 830–1800n = 12; 67–89 years; 1 male, 11 females; MMSE ranged from 15 to 291 monthVideotapes indicated interaction increased in one of the two areas; social network analysis (n = 9) indicated increased social network density; urinalysis (n = 9) indicated improved stress recovery; two case studies indicated increased interactions with Paro and others
      Wada et al.
      • Wada K.
      • Shibata T.
      • Saito T.
      • Tanie K.
      Robot assisted activity at a health service facility for the aged for ten weeks: an interim report of a long-term experiment.


      Nursing home, Japan
      Pre and post-test Face Scale measures for subjects interacting with robotic seal; anecdotal comments from nursing staffTwo robotic seals, Paro; 60 min × 2 days × 4 weeksn = 14 females;77–98 years; HDS-R indicated no dementia to slightly high degree10 weeksFace scales (n = 10) indicated those with slight dementia and slightly high dementia selected improved faces; staff indicated that Paro entertained and stimulated more interaction and positive facial expressions
      Libin et al.
      • Libin A.
      • Cohen-Mansfield J.
      Therapeutic robocat for nursing home residents with dementia: preliminary inquiry.


      Nursing home, United States
      Two randomized sessions with a robotic cat and with a plush toy cat. Assessments: ABMI; Lawton's MBS and 5 point Likert-type scale used for engagement of subject2 × 10 min sessions with robotic cat, NeCoRo and plush toy catn = 9 female; age range: 83–98; mean score of 5.4 GDS22 daysThe study found that both types of cats held subjects’ interest, with the robotic cat also producing increase in pleasure. Results demonstrate that residents with severe dementia can be engaged in interactions with a robotic animal
      Tamura et al.
      • Tamura T.
      • Yonemitsu S.
      • Itoh A.
      • et al.
      Is an entertainment robot useful in the care of elderly people with severe dementia?.


      Geriatric health care facility, Japan
      Videotaped observations of therapist directed interactions with a toy dog and robotic dog (with and without clothes) measuring: no interest, watching, talking, clapping hands, touching, and caringToy dog and robotic dog, AIBO; 5 minn = 13; average age of 84; 1 male, 12 females; average GBS score: 66 ± 21.8 points4 daysVideotaped analysis indicated that both the toy dog and AIBO increased resident activity; some residents had difficulty relating to AIBO without clothes but identified dressed AIBO as either a dog or baby
      DCM, Dementia Care Mapping; MMSE, Mini Mental Status Examination; SMMSE, Standardized Mini Mental Status Examination; EEG, Electroencephalogram; HDS-R, Hasegawa Dementia Scale-Revised; NPI, Neuropsychiatric Inventory; GDS1, Geriatric Dementia Scale; GDS2, Global Deterioration Scale; 17-KS-S-17, Ketosteriod sulfate; 17-OHCS-17, Hydroxycorticosteriods; POMS, Profile of Moods State; GBS, Gottfries–Brane–Steen Scale; ABMI, Agitated Behaviors Mapping Instrument; Lawton's MBS, Lawton's Modified Behavior Stream.
      Table 2Proceedings.
      Study ID

      Country
      DesignInterventionStudy populationDurationCore outcomes
      Inoue et al.
      • Inoue K.
      • Wada K.
      • Uehara R.
      How effective is robot therapy? PARO and people with dementia.


      Day Care Centre, Japan
      Pre and post-test single group interacting with robotic seal using DCM measures of well-being and ill-beingRobotic seal, Paro; 30 minn = 5; 70–89 years; 1 male, 4 females; intermediate to severe dementiaSingle sessionDCM well-being score improved for 4 females
      Kimura et al.
      • Kimura R.
      • Miura H.
      • Murata A.
      • Yokoyama A.
      • Naganuma M.
      Consideration of physiological effect of robot assisted activity on dementia elderly by electroencephalogram (EEG): estimation of positive effect of RAA by neuroactivity diagram.


      Nursing Home, Japan
      Pre and post-test EEG measures for group comparisons between residents with autonomous or remote controlled robotic dog, and between residents and young subjectsRobotic dog, AIBO; two 30 min sessionsn = 14; 60–97 years; HDS-R range of 0–29; n = 6 young subjects (21–22 years)1 monthResidents with autonomous and remote controlled robotic dog showed improved neuroactivity; neuroactivity of young subjects decreased after robotic dog session
      Wada et al.
      • Wada K.
      • Ikeda Y.
      • Inuoe K.
      • Uehara R.
      Development and preliminary evaluation of a caregiver's manual for robot therapy using the therapeutic seal robot Paro.


      Setting not specified, Japan
      Pre and post-test of two subjects interacting with robotic seal using measures of smiles/laughter; intervention is use of a caregiver manual1. Robotic seal, Paro; 30 min

      2. Caregiver manual, 30 min

      3. Robotic seal, Paro; 30 min
      n = 2; 81, 82 years; female; “had symptoms of dementia”2 sessions of 8 daysSmiles/laughter increased for one subject
      Gelderblom et al.
      • Gelderblom G.J.
      • Bemelmans R.
      • Spierts N.
      • Jonker P.
      • de Witte L.
      Development of PARO interventions for dementia patients in Dutch psycho-geriatric care.


      Three dementia care institutions, Netherlands
      Interviewing staff to develop interventions (goals, target groups and environments) involving robotic seal, Paro for subsequent RCTNine meetings (3 for each institution)n = 30 staff (clinical and allied health)No duration specifiedThree interventions were developed in preparation for a subsequent RCT: providing comfort; facilitating the provision of care, and supporting social contact
      Tapus et al.
      • Tapus A.
      • Tapus C.
      • Mataric M.
      The role of physical embodiment of a therapist robot for individuals with cognitive impairments.


      Assisted living, United States
      Pilot study to measure subjects’ responses, preferences and engagement using a music-based cognitive game with subjects interacting with robot or computer simulation of robot. Pre and post within subject comparison was done for SMMSEHumanoid torso mounted on a mobile base; 10–20 min. Computer simulation of the same humanoid robot projected on a 2D screen; 10–20 minn = 3 female; 1 mild, 1 moderate, 1 severe (SMMSE)8 months (includes 2 months for orientation)No adverse responses to the robot. Participants preferred the robot. Social interaction and task performance improved. Post SMMSE test administered after 8 months showed a slight improvement in scores
      Tapus et al.
      • Tapus A.
      • Tapus C.
      • Mataric M.
      The use of socially assistive robots in the design of intelligent cognitive therapies for people with dementia.


      Assisted living, United States
      Pilot study to measure subjects cognitive attention and robot's ability to adapt behavior to improve the subjects task performance using a music-based cognitive game with user interacting with robotHumanoid torso mounted on a mobile base; 10–20 min; once per weekn = 4 (3 female, one male); over 70 years old; 2 mild, 1 moderate, 1 severe (SMMSE)6 months (excludes 2 months for orientation)Robot was able to improve or maintain the cognitive attention of the patients with dementia and/or cognitive impairments through its encouragements. Robot's capability of adapting its behavior to the individuals’ level of disability helped maximize the user's task performance in the cognitive game. One case study was highlighted
      Odetti et al.
      • Odetti L.
      • Anerdi G.
      • Barbieri M.P.
      • et al.
      Preliminary experiments on the acceptability of animaloid companion robots by older people with early dementia.


      Dementia assessment centre, Italy
      Post-test questions to assess patient comfort, desire to interact and have future contact with robotic dogRobotic dog, AIBO; time not specifiedn = 24; average age 76.6 ± 6.2; 12 males, 12 females; MMSE: 27 ± 3Single sessionAIBO was described as harmless, friendly and cute but not useful except for subjects who do not reject technology; females and those with less formal education seemed more attracted to AIBO
      Wada and Shibata
      • Wada K.
      • Shibata T.
      Social effects of robot therapy in a care house – change of social network of the residents for two months.


      Nursing home, Japan
      Videotaped observation of residents prior, during and after introduction of Paro into two communal areas; pre and post measure was self-reported assessment of social ties; post measure was self-reported change to daily lifeTwo robotic seals, Paro; 830–1800n = 12; 67–89 years; 1 male, 11 females; MMSE ranged from 15 to 29 (25.3 + 3.9)3 monthsVideotape analysis indicated increased interaction and social network density for subjects; interviews indicated (n = 9) increased social network density
      Marti et al.
      • Marti P.
      • Bacigalupo M.
      • Giusti L.
      • Mennecozzi C.
      • Shibata T.
      Socially assistive robotics in the treatment of behavioural and psychological symptoms of dementia.


      Nursing home, Italy
      Videotaped observation of single case study, an interaction between subject, with severe neuropsychiatric disturbances, and robotic seal with therapist presentRobotic seal, Paro; as neededn = 1; male; MMSE = 13; NPI indicated severe agitation and anxiety6 monthsVideotaped and transcribed interactions between the subject and the therapist indicated subject's acceptance and concern for Paro; Paro seemed to provide a means for open communication
      Wada et al.
      • Wada K.
      • Shibata T.
      • Sakamoto K.
      • Tanie K.
      Quantitative analysis of utterance of elderly people in long-term robot assisted activity.


      Nursing home, Japan
      Pre and post measures of Face Scale after interaction with robotic seal; videotaped interactions to measure utterances; and interviews with nursing staffTwo robotic seals, Paro; 60 min × 2 days × 4 weeksn = 13 female; 77–98 years; HDS-R range included non-dementia to somewhat high degree2 monthsFace Scale analysis (n = 8) indicated improvement in mood; utterance analysis (n = 5) indicated increased utterance for n = 4; staff indicated Paro made residents laugh and become more active
      Wada et al.
      • Wada K.
      • Shibata T.
      • Saito T.
      • Tanie K.
      Effects of three months robot assisted activity to depression of elderly people who stay at a health service facility for the aged.


      Nursing home, Japan
      Pre and post-test GDS1 measure of depression for subjects interacting with robotic seal; interviews with nursing staffTwo robotic seals, Paro; 60 min × 2 days × 4 weeksn = 14 females; 77–98 years; HDS-R indicated nondementia to a little high degree3 monthsGDS1 scores (n = 10) decreased after 8 weeks; staff indicated that Paro made residents laugh more, became more active and more communicative
      Wada et al.
      • Wada K.
      • Shibata T.
      • Saito T.
      • Tanie K.
      Effects of robot-assisted activity for elderly people and nurses at a day service center.


      Day service centre, Japan
      Pre and post-tests measured mood (Face Scale and six items from the POMS) and recovery from stress (urine analysis). Post-test comments collected from nursing staff who completed burnout scaleRobotic seal, Paro, 20–40 min × 3 days × 5 weeksn = 23 females; 73–93 years; HDS-R indicated nondementia to high degree11 weeksFace Scale (n = 12) and POMS items (n = 11) indicated improved mood; urinanalysis (17-KS-S and 17-OHCS) indicated improved ability to recover from stress; staff comments indicated increased interaction and communication between subject and Paro; staff burnout scores (n = 6) decreased (s.s.)
      RCT, Randomized Controlled Trial; DCM, Dementia Care Mapping; MMSE, Mini Mental Status Examination; SMMSE, Standardized Mini Mental Status Examination; EEG, Electroencephalogram; HDS-R, Hasegawa Dementia Scale-Revised; NPI, Neuropsychiatric Inventory; GDS1, Geriatric Dementia Scale; GDS2, Global Deterioration Scale; 17-KS-S-17, Ketosteriod sulfate; 17-OHCS-17, Hydroxycorticosteriods.

      4. Terminology related to robots

      Of note, there are a confusing array of terms used to describe robots that may fall under a general category of human interactive robots for psychological enrichment and are then further sub-classified as interactive autonomous robots which provide personal interactions, pleasure and relaxation [
      • Feil-Seifer D.
      • Mataric M.J.
      Socially assistive robotics.
      ]. Other literature identifies the classification of social assistive robots. The social assistive robot bridges the assistive robot functions which provide physical assistance with the social interactive robot functions of providing social and non-physical interaction. In our reading of the literature, a multitude of terms, i.e. social commitment robot, social robot, therapeutic robot, caring robot, mental health robot, entertainment robot, interactive autonomous robot, interactive engaging robot and mental commitment robot appear to refer to similar types of robots [
      • Feil-Seifer D.
      • Mataric M.J.
      Socially assistive robotics.
      ,
      • Davenport R.D.
      Robotics.
      ]. In addition, several terms may be used within the same article, terms are not consistently used within the literature and often lack clear operational definitions [
      • Roger K.
      • Guse L.
      • Mordoch E.
      • Osterreicher A
      Social commitment robots and dementia.
      ]. As described in the search strategy, the authors began with the term ‘social commitment robot’ and, expanded the search to include additional terms that appear to be used somewhat interchangeably within the literature.

      5. History of robotics

      The term ‘robot’ was first used in 1920 by the Czech playwright, Capek in a play entitled Rossum's Universal Robots. Here robots turned against their human masters, a plot which may partially explain the tension between fascination and distrust of robots. While the Japanese culture has welcomed robots and recognized them as “Iyashi” (healing) [
      • Nomura T.
      • Tejima N.
      Critical considerations of applications of affective robots to mental therapy from psychological and sociological perspectives.
      ], North Americans have been slower to accept the concept of social and personal robots [
      • Libin A.
      • Libin E.
      Robots who care: robotic psychology and robotherapy approach.
      ,
      • Tak S.H.
      • Benefield L.E.
      • Mahoney D.F.
      Technology for long-term care.
      ,
      • Davenport R.D.
      Robotics.
      ,
      • Nomura T.
      • Tejima N.
      Critical considerations of applications of affective robots to mental therapy from psychological and sociological perspectives.
      ]. North Americans are more accepting of animal assisted therapy than the Japanese, which may partially explain North America's limited use of robots in the care of elderly people with dementia and Japan's robust interest [
      • Nomura T.
      • Tejima N.
      Critical considerations of applications of affective robots to mental therapy from psychological and sociological perspectives.
      ]. Industrial robots, which perform assembly line work in various industries such as the automotive industry, have been in existence since 1950. There are a variety of other established areas in which robots are used, such as space, surgery, rescue, military and health care settings [
      • Davenport R.D.
      Robotics.
      ]. Robots in health care have functioned to provide rehabilitation services and to assist with personal activities of daily living; strategies which are being actively pursued in Japan and Korea to address the needs of their aging populations. The newer use of social and entertainment robots in health care is currently being explored with the majority of these robotics designed to provide companionship, improve mental health and affect and to monitor safety for vulnerable populations [
      • Feil-Seifer D.
      • Mataric M.J.
      Socially assistive robotics.
      ,
      • Shibata T.
      • Wada K.
      Robot therapy: a new approach for mental healthcare of the elderly – a mini review.
      ,
      • Libin A.
      • Libin E.
      Robots who care: robotic psychology and robotherapy approach.
      ,
      • Tak S.H.
      • Benefield L.E.
      • Mahoney D.F.
      Technology for long-term care.
      ,
      • Davenport R.D.
      Robotics.
      ,
      • Libin A.V.
      • Libin E.V.
      Person–robot interactions from the robopsychologists’ point of view: the robotic psychology and robotherapy approach.
      ]. The interaction of human and robot is of current interest with development in the areas of robotic psychology which examines the compatibility of robots and people in emotional, cognitive and social areas. Interactive engaging robots, ‘caring robots’ respond to people through touch, voice, and within a social context and provide companionship [
      • Libin A.V.
      • Libin E.V.
      Person–robot interactions from the robopsychologists’ point of view: the robotic psychology and robotherapy approach.
      ]. There are four types of interactive robots namely: performance robots; tele-operated performance robots; and building, programming and controlling robots of which all three are designed for entertainment and creativity. The fourth type is the interactive autonomous robots, inclusive of the mental commitment robot which is intended to be interactive and improve social interaction and mood. This class of robot is capable of soliciting personal interaction between human and robot, a relatively new area of interest that is being actively examined [
      • Shibata T.
      • Wada K.
      Robot therapy: a new approach for mental healthcare of the elderly – a mini review.
      ,
      • Libin A.
      • Libin E.
      Robots who care: robotic psychology and robotherapy approach.
      ,
      • Nomura T.
      • Tejima N.
      Critical considerations of applications of affective robots to mental therapy from psychological and sociological perspectives.
      ]. Robot therapy is designed from a framework of human robot interaction with the goal of redefining negative experiences and building more positive coping strategies through the use of robotic creatures. There is current interest in the study of how people interact with robots and the potential of robot therapy, one area being elderly people with dementia [
      • Libin A.V.
      • Libin E.V.
      Person–robot interactions from the robopsychologists’ point of view: the robotic psychology and robotherapy approach.
      ].

      6. Literature review

      During the course of the search, 4 review articles were found that pertained to the area of technology and care of the elderly person. The articles were from Switzerland, Finland, and two from The Netherlands [
      • Broekens J.
      • Heerink M.
      • Rosendal H.
      Assistive robots in elderly care: a review.
      ,
      • Topo P.
      Technology studies to meet the needs of people with dementia and their caregivers: a literature review.
      ,
      • Bemelmans R.
      • Geldeblom J.
      • Jonker P.
      • de Witt L.
      Social assistive robots in elderly are: a systematic review into effects and effectiveness.
      ,
      • Preschl B.
      • Wagner B.
      • Forstmeier S.
      • Maercker A.
      E-health interventions for depression, anxiety disorder, dementia and other disorders in old age: a review.
      ] and demonstrated a robust interest in finding innovative solutions to care. These reviews focused on broad e-health interventions which covered a wide range of options (for example, internet resources, video conferencing, home monitoring systems); or identified diverse studies with samples that included participants without dementia; or focused on the caregivers’ use of the identified technology. A mini review from Japan focused primarily on Paro the robotic seal with few comments about other comparable interventions [
      • Shibata T.
      • Wada K.
      Robot therapy: a new approach for mental healthcare of the elderly – a mini review.
      ].
      The results of the literature review (9 publications in academic journals, 12 of conference proceedings) indicate that social commitment robots are potentially useful as a therapeutic intervention for people with dementia. Research into all new innovative efforts generally builds slowly and develops with subsequent findings and research questions. There is beginning evidence that therapeutic robotics are useful in engaging people to interact with each other, producing a calming effect, and providing companionship, motivation and enjoyment [
      • Broekens J.
      • Heerink M.
      • Rosendal H.
      Assistive robots in elderly care: a review.
      ,
      • Libin A.V.
      • Libin E.V.
      Person–robot interactions from the robopsychologists’ point of view: the robotic psychology and robotherapy approach.
      ,
      • Topo P.
      Technology studies to meet the needs of people with dementia and their caregivers: a literature review.
      ,
      • Bemelmans R.
      • Geldeblom J.
      • Jonker P.
      • de Witt L.
      Social assistive robots in elderly are: a systematic review into effects and effectiveness.
      ]. Current studies, however, are not robust, i.e. have small samples, lack controls and often are difficult to replicate [
      • Broekens J.
      • Heerink M.
      • Rosendal H.
      Assistive robots in elderly care: a review.
      ]. Randomized clinical trials are needed to determine the therapeutic effects of person/robot interactions [
      • Gelderblom G.J.
      • Bemelmans R.
      • Spierts N.
      • Jonker P.
      • de Witte L.
      Development of PARO interventions for dementia patients in Dutch psycho-geriatric care.
      ].
      The majority of the research reports on social commitment robots are with Paro, the baby harp seal, AIBO, a robotic dog, and NeCoRo, a robotic cat [
      • Broekens J.
      • Heerink M.
      • Rosendal H.
      Assistive robots in elderly care: a review.
      ,
      • Libin A.
      • Cohen-Mansfield J.
      Therapeutic robocat for nursing home residents with dementia: preliminary inquiry.
      ,
      • Wada K.
      • Shibata T.
      Social and physiological influences of robot therapy in a care house.
      ]. Each of these robots are designed to evoke emotions and interact in sophisticated multi-sensory ways; audio, visual, and tactile. Some studies have used toy robotic animals and videos rather than the uniquely designed therapeutic robots and reported satisfactory results [
      • Marx M.
      • Cohen-Mansfield J.
      • Regier N.G.
      • Dakheel-Ali M.
      • Srihari A.
      • Thein K.
      The impact of different dog-related stimuli on engagement of persons with dementia.
      ,
      • Tamura T.
      • Yonemitsu S.
      • Itoh A.
      • et al.
      Is an entertainment robot useful in the care of elderly people with severe dementia?.
      ,
      • Campbell A.
      Dementia care: could animal robots benefit residents?.
      ]. There is a volume of writing from Japan, mainly in IEEE conference proceeding reports, on the therapeutic robotic baby harp seal Paro. Some of these studies collected data from physiological measures such as EEG and urinalysis reports, and face scales measuring affect changes pre and post intervention [
      • Wada K.
      • Ikeda Y.
      • Inuoe K.
      • Uehara R.
      Development and preliminary evaluation of a caregiver's manual for robot therapy using the therapeutic seal robot Paro.
      ,
      • Wada K.
      • Shibata T.
      • Sakamoto K.
      • Tanie K.
      Quantitative analysis of utterance of elderly people in long-term robot assisted activity.
      ]. While these studies are gathering data and building the knowledge base in the area of therapeutic robotics, several significant problems exist within this literature. It is often difficult to clearly understand the study design, to decipher which studies are the original primary studies and which are pieces of the same study. In addition, the authors of these papers often work with the inventor of Paro, the robotic seal. Replication of their studies by others would strengthen the scientific merit of the findings.
      Projects are underway in several countries. The Netherlands is investigating the use of Paro as a therapeutic intervention in psychogeriatric care. Currently, three major Dutch institutions have collaborated on identifying interventions with Paro in preparation for a randomized clinical trial to be conducted in facilities that provide dementia care. Three main areas to test the efficacy of Paro are: social behaviors and well-being; facilitating daily care; and assisting with family interactions which often become frustrating for family members [
      • Gelderblom G.J.
      • Bemelmans R.
      • Spierts N.
      • Jonker P.
      • de Witte L.
      Development of PARO interventions for dementia patients in Dutch psycho-geriatric care.
      ]. Projects from Canada have also explored the use of Paro in three pilot projects one of which aimed to use Paro to facilitate family conversations [
      • Roger K.
      • Guse L.
      • Mordoch E.
      • Osterreicher A
      Social commitment robots and dementia.
      ]. Similar to Wada and Shibata's identification of a need for instruction on how to best use Paro [
      • Wada K.
      • Ikeda Y.
      • Inuoe K.
      • Uehara R.
      Development and preliminary evaluation of a caregiver's manual for robot therapy using the therapeutic seal robot Paro.
      ], family members in the Canadian studies, while enthusiastic about Paro, also identified a need for ideas on how to fully utilize the robot [
      • Roger K.
      • Guse L.
      • Mordoch E.
      • Osterreicher A
      Social commitment robots and dementia.
      ]. In addition, while the face scale has been used successfully in Japanese studies, the use of the face scale as a measurement of change in affect was not reliable in the Canadian studies [
      • Roger K.
      • Guse L.
      • Mordoch E.
      • Osterreicher A
      Social commitment robots and dementia.
      ,
      • Wada K.
      • Shibata T.
      • Sakamoto K.
      • Tanie K.
      Quantitative analysis of utterance of elderly people in long-term robot assisted activity.
      ]. Denmark has invested in studying the effects of robotics in the care of their elderly population. One branch of this investigation involves The Danish Paro Project [
      • Hansen S.T.
      • Andersen H.J.
      • Bak T.
      Practical evaluation of robots for elderly in Denmark – an overview.
      ]. Approximately 65 Paro seals have been distributed to different municipalities in Denmark with the intent to investigate their therapeutic use in the care of the elderly people with dementia. Formal reports on these projects have not yet been released but articles in Danish informal newsletters indicate positive responses. In the final report of the Danish Be Safe project, inclusive of 12 Paro seals in one nursing home, the use of Paro as a tool for dementia therapy was recommended [
      • Hansen S.T.
      • Andersen H.J.
      • Bak T.
      Practical evaluation of robots for elderly in Denmark – an overview.
      ]. In Canada, several pilot studies have been conducted highlighting the potential use of Paro for people and families living with dementia. These studies have focused on improving communication and regulating anxiety, depression and agitation [
      • Roger K.
      • Guse L.
      • Mordoch E.
      • Osterreicher A
      Social commitment robots and dementia.
      ].
      AIBO, the robotic dog from Sony (currently not in production) has been used in studies in Japan, Italy and the United States [
      • Kimura R.
      • Miura H.
      • Murata A.
      • Yokoyama A.
      • Naganuma M.
      Consideration of physiological effect of robot assisted activity on dementia elderly by electroencephalogram (EEG): estimation of positive effect of RAA by neuroactivity diagram.
      ,
      • Marx M.
      • Cohen-Mansfield J.
      • Regier N.G.
      • Dakheel-Ali M.
      • Srihari A.
      • Thein K.
      The impact of different dog-related stimuli on engagement of persons with dementia.
      ,
      • Campbell A.
      Dementia care: could animal robots benefit residents?.
      ,
      • Odetti L.
      • Anerdi G.
      • Barbieri M.P.
      • et al.
      Preliminary experiments on the acceptability of animaloid companion robots by older people with early dementia.
      ]. Generally, studies compare toy, robotic and real dogs and their effects on interaction and attachment. The findings are varied ranging from positive to no interaction, with little significant differences between real dog, toy or robotic dogs. Results indicate that when human contact is present with the object, the human will evoke the most response [
      • Kramer S.C.
      • Friedmann E.
      • Bernstein P.L.
      Comparison of the effect of human interaction, animal-assisted therapy, and AIBO-assisted therapy on long-term care residents with dementia.
      ]. In their comparison of live dogs, robotics, video and coloring activity, researchers found live dogs the most effective but also found a role for alternative formats [
      • Marx M.
      • Cohen-Mansfield J.
      • Regier N.G.
      • Dakheel-Ali M.
      • Srihari A.
      • Thein K.
      The impact of different dog-related stimuli on engagement of persons with dementia.
      ]. NeCoRo, a robotic cat has also been used and compared to the use of a toy cat with little difference noted between the two interventions and both interventions resulted in decreased agitation and disruptive behaviors [
      • Libin A.
      • Cohen-Mansfield J.
      Therapeutic robocat for nursing home residents with dementia: preliminary inquiry.
      ].
      The use of therapeutic robots, AIBO, NeCoRo and Paro have each demonstrated specific effects on people with dementia in the areas of affect regulation, social interactions, and decreases in psychological stress reactions measured by cortisol levels, electro-encephalogram cortical neuron monitoring and stress hormone ratios detected by urinalysis [
      • Wada K.
      • Shibata T.
      • Sakamoto K.
      • Tanie K.
      Quantitative analysis of utterance of elderly people in long-term robot assisted activity.
      ,
      • Inoue K.
      • Wada K.
      • Uehara R.
      How effective is robot therapy? PARO and people with dementia.
      ,
      • Wada K.
      • Shibata T.
      • Musha T.
      • Kimura S.
      Effects of robot therapy for demented patients evaluated by EEG.
      ,
      • Wada K.
      • Shibata T.
      Living with seal robots – its sociopsychological and physiological influences on the elderly at a care house.
      ,
      • Wada K.
      • Shibata T.
      • Saito T.
      • Tanie K.
      Effects of robot-assisted activity for elderly people and nurses at a day service center.
      ,
      • Wada K.
      • Shibata T.
      • Musha T.
      • Kimura S.
      Robot therapy for elders affected by dementia.
      ,
      • Wada K.
      • Shibata T.
      • Saito T.
      • Tanie K.
      Robot assisted activity at a health service facility for the aged for ten weeks: an interim report of a long-term experiment.
      ,
      • Wada K.
      • Shibata T.
      Social effects of robot therapy in a care house – change of social network of the residents for two months.
      ,
      • Marti P.
      • Bacigalupo M.
      • Giusti L.
      • Mennecozzi C.
      • Shibata T.
      Socially assistive robotics in the treatment of behavioural and psychological symptoms of dementia.
      ,
      • Wada K.
      • Shibata T.
      • Saito T.
      • Tanie K.
      Effects of three months robot assisted activity to depression of elderly people who stay at a health service facility for the aged.
      ]. In addition, there is preliminary evidence that staff experienced less burnout when therapeutic robots were used in a day service unit [
      • Wada K.
      • Shibata T.
      • Saito T.
      • Tanie K.
      Effects of robot-assisted activity for elderly people and nurses at a day service center.
      ]. Other forms of robots have preliminary evidence for instigating positive interactions. Bandit, a humanoid torso, is a different form of social assistive robot that is programmed to stimulate cognitive responses in a musical game format. While there was some indication of enjoyment associated with the robot interaction and improved time responses on tasks, results for this study were inconclusive, in part due to the small sample size [
      • Tapus A.
      • Tapus C.
      • Mataric M.
      The role of physical embodiment of a therapist robot for individuals with cognitive impairments.
      ,
      • Tapus A.
      • Tapus C.
      • Mataric M.
      The use of socially assistive robots in the design of intelligent cognitive therapies for people with dementia.
      ]. YORISOI, classified as a partner robot designed with the goal of decreasing loneliness in the elderly nursing home population, is currently being refined for increased therapeutic use to overcome the effects of novelty which may decrease interest over time and improve communication [
      • Kanoh M.
      • Oida Y.
      • Nomura Y.
      • et al.
      Examination of practicability of communication robot-assisted activity program for elderly people.
      ].
      An overview of the literature suggests that there is potential for the use of social commitment robots with the elderly who have dementia. The literature identifies that robotic intervention has developed from a need to augment adjunct therapies, such as animal assisted therapy and to develop other innovative ways of connecting with people with dementia. Further scientific exploration of the use of robots is warranted with a pressing need to continue to develop strong study designs inclusive of randomized clinical trials that can more clearly provide evidence on the efficacy of robotic therapy in dementia care.

      7. Discussion

      The world population continues to age with a corresponding decline in caregivers to meet the needs of the increasing global prevalence of people living with dementia [
      • World Health Organization and Alzheimer's Disease International
      Dementia: a public health priority.
      ,
      • Alzheimer Society of Canada
      Rising tide: the impact of dementia on Canadian society.
      ,
      • Davenport R.D.
      Robotics.
      ]. Dementia, which affects cognition, affect, communication and behavior, is a progressive illness with escalating care needs that impacts individuals and families. Often the caregiver's health is also affected [
      • World Health Organization and Alzheimer's Disease International
      Dementia: a public health priority.
      ,
      • Alzheimer Society of Canada
      Rising tide: the impact of dementia on Canadian society.
      ]. The level of care that is required is costly to provide. The nature of dementia with deficits in short term memory, and communication, often accompanied by hearing loss, predisposes family members and formal caregivers to ongoing difficulties in the care of people with dementia. Researchers in the areas of gerontology and robotics need to collaborate on endeavors that investigate non-traditional ways, such as robot therapy, to manage some of the problems related to dementia and to ensure optimal quality of life for this population. The existing body of research despite its limitations, such as unclear research designs, small samples, and lack of randomized clinical trials, has contributed to the beginning of knowledge development on the use of therapeutic social assistive robots. More collaborative rigorous experiments with control groups, expansion of alternative robotic models and interventions that are inclusive of family members are needed to explore the full potential of these robots.
      The results show that there is a paucity of robust research on the use of social assistive robots in the care of people with dementia. There is interest in this area of innovative research; however, currently there are few randomized clinical trials to examine the efficacy of robotics. Plans are developing for a randomized clinical trial [
      • Gelderblom G.J.
      • Bemelmans R.
      • Spierts N.
      • Jonker P.
      • de Witte L.
      Development of PARO interventions for dementia patients in Dutch psycho-geriatric care.
      ] in the Netherlands which will make a unique contribution to the field [
      • Inoue K.
      • Wada K.
      • Uehara R.
      How effective is robot therapy? PARO and people with dementia.
      ]. Japan's interest in innovative intervention for the care of elderly people with dementia arose from their increasing aging population and evidence on the efficacy of animal assisted therapy. In Japan, animals are not accepted into care homes or hospitals, therefore robotic creatures are suggested as a potential alternative [
      • Kimura R.
      • Miura H.
      • Murata A.
      • Yokoyama A.
      • Naganuma M.
      Consideration of physiological effect of robot assisted activity on dementia elderly by electroencephalogram (EEG): estimation of positive effect of RAA by neuroactivity diagram.
      ]. In North America, animal assisted therapy is more commonly used and the use of robots may be viewed skeptically or, at best, as a possible adjunct to animal assisted therapy. Communication problems with people with dementia are often complex and layered with additional multi-sensory losses, such as hearing and sight. Multi-faceted and diverse approaches inclusive of the emerging field of robotic therapy, animal assisted therapy and other innovative methods of reaching out to this population are all important avenues to continue to explore and use to their full potential.
      To advance the research on robotic therapy several issues require attention. Within the current literature, there is a need for clarity on current studies and their results. Some of the literature seems redundant when several papers report selected findings from the same study with only minor modifications. There is a need for increased publications in peer reviewed academic journals for two main reasons: (1) to provide a means to replicate studies in order to add to the knowledge base and (2) to promote the uptake of the research findings into the clinical areas. Replication and improvement of the existing studies i.e. randomized clinical trials will build a stronger evidence base for robotic interventions. Much of the literature is dominated by a series of studies on the use of Paro, the therapeutic seal robot. While this literature has contributed to the field, conflict of interest needs to be clearly stated and how it has been managed between the dual roles of inventor and researcher.
      In addition there are several ethical considerations that require reflection [
      • Sharkey N.
      • Sharkey A.
      The eldercare factory.
      ]. The use of social assistive robots to meet the companionship needs of elderly people with dementia requires monitoring and careful thought. Robots are not meant to replace human care but to augment and bridge human contact. While professional and family caregivers know that symptoms of dementia can be difficult to manage and that innovative solutions are needed, interventions and solutions to these issues must be monitored for undue infantilization and deception and tendencies to overly reduce human contact [
      • Broekens J.
      • Heerink M.
      • Rosendal H.
      Assistive robots in elderly care: a review.
      ]. As such guidelines for appropriate and ethical use of robotics need to be developed along with the emergent science to ensure that the rights and dignity of this vulnerable population of elderly people with dementia are upheld. Human contact is a critical component of care and as such any interventions that minimize this require careful thought to ensure that quality of care is upheld.

      8. Conclusion

      We are at the threshold of change in the care of people with dementia due to global demographics, specifically, the graying of society with subsequent decreases in the caregiver demographic, particularly in developed countries. At this time, innovative new ways of managing health care situations for this population are needed. Social assistive robots may provide important and feasible alternatives to some of the care demands. These alternatives must be balanced with cautions to provide quality human contact in this care and to not unnecessarily dilute the important aspect of human compassion in the care of vulnerable populations.

      Contributors

      Elaine Mordoch, RN PhD Assistant Professor University of Manitoba, helped in reviewing the literature, synthesize and write and edit a large portion of the article. Angela, Osterreicher, BSC MLS AHIP JW Crane Memorial Library, helped in the literature search and contributed to the article with edits and recommendations throughout the process and contributed to the formation of tables and synthesis of data. Lorna Guse, RN PhD Associate Professor University of Manitoba, contributed for writing and synthesizing tables and content. Kerstin Roger, PhD Human Ecology University of Manitoba, have contributed to this article by providing thoughtful comments and editorial suggestions. Genevieve, Thompson Assistant Professor University of Manitoba, have contributed to this article by providing thoughtful comments and editorial suggestions.

      Competing interest

      All authors have no conflicts of interest to report.

      Provenance and peer review

      Commissioned and externally peer reviewed.

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