As of 2012, the prevalence of people living with dementia in the world is estimated to be 35.6 million (World Health Organization, 2012). Without a major diagnostic and treatment breakthrough, it is estimated that by the year 2050, approximately 100 million people worldwide (1 of 85) will be living with dementia (Tapus, Fasola, & Mataric, 2008). By the year 2038, family and friends will be three times more likely than they are today to provide unpaid, informal dementia care for their loved ones (Alzheimer Society of Canada, 2010).
Caregivers should integrate intellectual, physical, social, and mental activities in dementia care to promote reserve and resilience in the brain and delay the progression of dementia (Aguirre et al., 2010; Karp, 2005). However, people with dementia may be given “quick fixes” such as antipsychotic medications or application of physical restraints to control aggressive, anxious, or noncompliant behaviors. These hasty remedies prevent nurses from uncovering the real reason for a patient’s disruptive behaviors and are inappropriate long-term treatment approaches to care (Cruikshank, 2009). More effective strategies need to be discovered that address the needs of these patients, family caregivers, health care professionals, and health care systems.
Socially assistive robots (SARs) offer a creative advancement in technological solutions for enhancing and supporting care of people with dementia. SARs are autonomous, mobile, interactive machines specifically designed to aid human beings with intellectual, social, and emotional care (Pineau, Montemerlo, Pollack, Roy, & Thrun, 2003). The purpose of this article is to provide an overview of use of SARs to offer support as therapists, companions, and educators for people living with dementia. Issues associated with use of SARs in caring for people with dementia are discussed.
The authors conducted a review of the literature focused on use of SARs in dementia care. The literature search was limited to the years 2000–2012, English language, and full-text peer-reviewed journal articles available in electronic databases. Research on SARs for dementia care is in the early stages; therefore, there is not a large body of conceptual and empirical literature on this topic. The majority of studies have been conducted in long-term care facilities or laboratories and not in acute or home care settings (Broekens, Heerink, & Rosendal, 2009; Tapus, Tapus, & Mataric, 2009; Wada, Shibata, Musha, & Kimura, 2008). Thus far, researchers have focused on short-term results and have not evaluated the long-term outcomes of SARs for dementia care (Broekens et al., 2009; Wada et al., 2008). Despite the fact that studies on SARs have taken place in Australia, France, Italy, Japan, the Netherlands, Sweden, and the United States, there remains a gap in the literature from other regions such as Africa, Canada, and South America.
Robots as Creative Solutions for Enhancing and Supporting Dementia Care
Numerous authors concur that our increasingly over-burdened health care systems require technological assistive solutions, such as robots, to support vulnerable patients diagnosed with dementia (Cesta et al., 2011; Feil-Seifer & Mataric, 2011; MacDorman, Vasudevan, & Ho, 2009; Shibata, Wada, Ikeda, & Sabanovic, 2009; Sparrow & Sparrow, 2006). Researchers are investing a great deal of time and attention toward the prospect of using SARs to help address the future needs of dementia care (Cesta et al., 2011; Sparrow & Sparrow, 2006; Tamura et al., 2004; Wada et al., 2008; Wu, Fassert, & Rigaud, 2012). (See http://www.cs.cmu.edu/~nursebot/web/scope.html and http://robotics.usc.edu/?/=Robots:index for more information about this research.) SARs are not intended to provide physical care but rather to encourage physical activity, provide entertainment, offer companionship, generate safety reminders, monitor daily activities, prompt prescribed activities, and facilitate intellectual stimulation, such as cognitive stimulation therapy (Cesta et al., 2011; Feil-Seifer & Mataric, 2011; Wu, Faucounau, Boulay, Maestrutti, & Rigaud, 2011).
SARs come in a variety of sizes, shapes, appearances, accessories, voice tones, facial expressions, body gestures, and capabilities (Wu et al., 2012). Careful design, selection, programming, implementation, and evaluation of a specific SAR is critical for user acceptance (Newton, 2008; Wu et al., 2012). Examples of robots that have been designed as SARs for older adults include: Aibo™, Bandit, Eve, Homie, HRP-4C, Huggable™, iCat®, Kobian, NAO, Mamoru, Paro, Pearl, Pomi, and Roomba® (Broekens et al., 2009; Feil-Seifer & Mataric, 2011; Pineau et al., 2003; Shibata et al., 2009; Tapus et al., 2009; Wada et al., 2008; Wu et al., 2012). Specific therapies that have been successfully implemented by SARs for people with dementia include music, arts and crafts, animals, attention, play, and reminiscence therapy (Broadbent et al., 2010; Butter et al., 2008; Tapus et al., 2008). Cesta et al. (2011) and Sparrow and Sparrow (2006) reported that some types of SARs are programmed to identify situations that are dangerous to the patient and send an immediate alert to health care professionals and/or family caregivers. This creative technological solution may enable many people with dementia to live at home as opposed to a long-term care facility (Broekens et al., 2009; Cesta et al., 2011).
SARs have been found to diminish stress levels, promote positive emotions, foster intrinsic motivation, stimulate nonverbal and verbal communication skills, and encourage recollection of past experiences (Pineau et al., 2003; Tamura et al., 2004; Tapus et al., 2009; Wada et al., 2008). Evidence indicates that some people with dementia who are easily agitated, aggressive, wander, and/or have difficulty speaking have been found to laugh, sing, talk, smile, gesture, and not wander away as a result of robot therapy (Shibata et al., 2009; Tapus et al., 2009; Wada et al., 2008; Wu et al., 2011). There is promising literature suggesting that SARs can support people with dementia to maintain the highest level of independence possible and improve their quality of life (Broekens et al., 2009; Cesta et al., 2011; Feil-Seifer & Mataric, 2011; Kinney, Kart, Murdoch, & Ziemba, 2003; Pineau et al., 2003; Tapus et al., 2009; Wada et al., 2008; Wu et al., 2011). Long-term studies have not been conducted; however, these recent studies show promising hope that SARs can improve quality of life.
Challenges with Socially Assistive Robots for Dementia Care
Despite the many opportunities that SARs can offer for dementia care, much of the literature notes challenges that need to be considered with this evolving technology. Although this type of robotic technology is highly intuitive and can enhance patient care, several researchers have emphasized that robots can never replace the essence of social and physical human-human interactions (Butter et al., 2008; Feil-Seifer & Mataric, 2011; MacDorman et al., 2009; Wu et al., 2012). There is concern that diminished interpersonal communication between human beings may occur, given that some robots can provide comfort by hugging, smiling, singing, laughing, listening, and holding hands (Broadbent et al., 2010; Feil-Seifer & Mataric, 2011; Wu et al., 2012). Furthermore, robot therapy provides artificial emotions and intelligence, which currently do not include the intuitive, reflective, and/or critical thinking skills needed to react to unpredictable events associated with care of patients with dementia (Cesta et al., 2011; Coeckelbergh, 2009; Veruggio & Operto, 2008). For example, if an individual with dementia is becoming aggressive, anxious, or is in danger, some robots may not have the programmed capabilities needed to deescalate the situation safely (Feil-Seifer & Mataric, 2011).
Problems with attachment may arise once SARs are introduced into the market for consumers to purchase (Feil-Seifer & Mataric, 2011; Newton, 2008). Feil-Seifer and Mataric’s (2011) study suggested that dementia caregivers may overuse SARs similar to the way parents of young children use electronics, such as television, to entertain and occupy their children. If such an attachment occurs, people with dementia may become emotionally upset if the SAR breaks, is replaced with an unfamiliar model, or is removed, even temporarily. An overreliance on the use of robot functions for activities the individual can do independently could potentially lead to dependency and loss of skills. Wu et al. (2012) expressed concern that SARs may further disorientate some people with cognitive impairments, particularly with robots that appear humanoid. For example, some people with dementia may believe that SARs are living human beings and true friends with genuine emotions (Feil-Seifer & Mataric, 2011).
User acceptance is another challenge to be considered with SARs (Broadbent et al., 2010; Kinney et al., 2003; Wu et al., 2012). Studies have concluded that people living with dementia and their family caregivers have happily accepted support from robots and the peace of mind that robots can bring for their family (Broadbent et al., 2010; Cesta et al., 2011; Kinney et al., 2003; Wada et al., 2008). However, resistance may be met by some health care professionals if and when robots are introduced into the mainstream health care system. Reluctance to embrace robots may be due to a variety of reasons such as fear of being replaced by a robot, fear of change, fear of operating highly advanced technology, concerns with ethical and legal issues, and/or poor deployment strategies that lack ongoing support within the organization (Broadbent et al., 2010; Veruggio & Operto, 2008). Broadbent et al. (2010) asserted that without the support of health care professionals, the use of SARs for dementia care may very well fail.
Ethical and Legal Factors of Socially Assistive Robot Therapy
Roboethics are a set of human ethical principles that have been created for researchers, inventors, manufacturers, technicians, and users of robots (Feil-Seifer & Mataric, 2011; Veruggio & Operto, 2008). The philosophic underpinnings behind this approach is that robots will only be created, manufactured, and used for the common good of and not for corruption or harm of human beings (Feil-Seifer & Mataric, 2011; Veruggio & Operto, 2008). Yet, this point brings up a concern that robots could potentially be created or reprogrammed to conduct illegal crimes; commit physical, sexual, and/or psychological abuse; or have their private data stolen (Butter et al., 2008; Veruggio & Operto, 2008). Veruggio and Operto (2008) were also concerned that health care robots will widen socioeconomic discrimination for those individuals who do not qualify for insurance coverage or cannot afford to buy or rent a health care robot.
Legal concerns exist about the use of SARs for dementia care. Robots are not people and members of a regulatory health professional body. Currently, robots and the performance of robotic tasks are not regulated, nor do they require a registration or licensure. There is no legally defined scope of practice for robots. Therefore, SARs are not sanctioned to perform interventions that are authorized for licensed nurses. Questions from this premise emerge: What happens if a regulated health care professional delegates a task to the SAR? Who should be held accountable for a robot’s error—the robot, the delegating professional, the designer, the programmer, the manufacturer, or the patient? (Feil-Seifer & Mataric, 2011; Veruggio & Operto, 2008). All of these issues must be considered if SARs are to enter mainstream dementia care approaches.
Nursing Implications of Socially Assistive Robots for Dementia Care
Researchers are currently in the midst of designing robots that will be cost efficient, faster, more productive, and have a conscience with higher levels of morals and intellectual functioning than human beings (Veruggio & Operto, 2008). Concerns are emerging that society may become overly dependent on robots as technological assistive support for patient care. This approach may result in a devaluing and disrespect for human lives (Veruggio & Operto, 2008). By substituting robots for human health care professionals, we could lose many dynamic, highly skilled, knowledgeable, and compassionate professionals—both regulated and unregulated—who are experts in the care for people with dementia (Butter et al., 2008; Veruggio & Operto, 2008).
That said, SARs could be an immense asset if they are used appropriately to proactively support, as opposed to replace, health care professionals in the provision of dementia care (Wu et al., 2012). For example, SARs could be very beneficial for nurses, patients, and their family caregivers in home care, long-term care, and acute care settings. The robots could be instructed to sit with, listen to, talk to, read to, sing to, laugh with, bring snacks to, and walk with people with dementia (Tamura et al., 2004; Tapus et al., 2009; Wada et al., 2008). This enhanced social support may help deescalate volatile problems and stimulate physical, emotional, and cognitive functioning, while reorienting the patient, ensuring his or her safety, and providing family members and nurses with peace of mind (Cesta et al., 2011; Kinney et al., 2003). Assistance from SARs could aid in delaying the progression of dementia, promote higher levels of autonomy, and improve quality of life for people with dementia (Butter et al., 2008; Tapus et al., 2009).
SARs should be designed to be affordable, accessible, easy to use, flexible, and adaptable to the patient’s unique needs (Cesta et al., 2011; Kinney et al., 2003; Pineau et al., 2003; Tapus et al., 2008). For example, cutting-edge robots that are customized to suit the individual’s gender, age, culture, language, religion, socioeconomic status, and level of cognitive impairment would be the most effective for dementia care (Cesta et al., 2011; Tapus et al., 2008). These robots should be easy to reprogram in situations when changes are required in the individual’s needs and care plan. This technology should not require frequent upgrading services or quickly become obsolete (Kinney et al., 2003; Pineau et al., 2003). The appearance, size, voice, body movements, facial gestures, and capabilities of the robot must be taken into consideration when selecting a SAR to support dementia care (Feil-Seifer & Mataric, 2011; Wu et al., 2012). Health care professionals, family caregivers, and older adults with dementia should be included in developing, programming, implementing, and evaluating SARs (Shibata et al., 2009; Wu et al., 2012). Lastly, careful considerations of deployment strategies, ongoing user support, and public education should be included to promote a global acceptance of health care robots (Broadbent et al., 2010).
The use of SAR therapy for dementia care is still in the early stages of research and implementation (Butter et al., 2008). Japanese and American scientists, engineers, and health care professionals are leading in the area of SARs research (Broekens et al., 2009; MacDorman et al., 2009; Shibata et al., 2009; Tamura et al., 2004; Wu et al., 2011). To date, the majority of studies that focus on SAR therapy for dementia care have been short term and have been conducted in nursing homes or laboratories with Japanese or Caucasian participants (Broekens et al., 2009; Tamura et al., 2004). Therefore, to be able to generalize the findings, researchers need to conduct longitudinal studies in a variety of environments that include minority ethnic populations, family caregivers, health care professionals, and people with various stages of dementia (Broekens et al., 2009; Wada et al., 2008).
There is an international awareness and concern with the demographic shift to older adults and the steady rise in chronic conditions such as dementia (Broadbent et al., 2010; Sparrow & Sparrow, 2006). This global issue is further compounded by a dwindling number of health care professionals, overburdened health care systems, and overreliance on family caregivers (Alzheimer Society of Canada, 2010; Broadbent et al., 2010). SARs provide an innovative technological solution that offers great potential for this increasing complex dilemma (Alzheimer Society of Canada, 2010; Broadbent et al., 2010). SAR technology can enhance support for people living with dementia by providing assistance as therapists, companions, and educators. People living with dementia deserve the chance to have access to and use cutting-edge technology such as SARs that could improve their quality of life, maximize their level of independence, and potentially delay progression of cognitive impairment (Broekens et al., 2009; Cesta et al., 2011; Tapus et al., 2009).
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