The Effectiveness of Social Robots for Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Background and Objectives

Social robots may promote the health of older adults by increasing their perceived emotional support and social interaction. This review aims to summarize the effectiveness of social robots on outcomes (psychological, physiological, quality of life, or medications) of older adults from randomized controlled trials (RCTs).

Research Design and Methods

A mixed-method systematic review of RCTs meeting the study inclusion criteria was undertaken. Eight databases were electronically searched up to September 2017. Participants' characteristics, intervention features, and outcome data were retrieved. The mean difference and standardized mean difference with 95% confidence intervals (CI) were synthesized to pool the effect size.

Results

A total of 13 articles from 11 RCTs were identified from 2,204 articles, of which 9 studies were included in the meta-analysis. Risk of bias was relatively high in allocation concealment and blinding. Social robots appeared to have positive impacts on agitation, anxiety, and quality of life for older adults but no statistical significance was found in the meta-analysis. However, results from a narrative review indicated that social robot interactions could improve engagement, interaction, and stress indicators, as well as reduce loneliness and the use of medications for older adults.

Discussion and Implications

Social robots appear to have the potential to improve the well-being of older adults, but conclusions are limited due to the lack of high-quality studies. More RCTs are recommended with larger sample sizes and rigorous study designs.

"She Had a Smile on Her Face as Wide as the Great Australian Bite": A Qualitative Examination of Family Perceptions of a Therapeutic Robot and a Plush Toy

Background and Objectives

Recent years have seen social robotic pets introduced as a means of treating behavioral and psychological symptoms of dementia, and many show promising potential. In this study, we sought to explore family members' perceptions of the Japanese-developed baby harp seal, Paro (version 9), and a look-alike, nonrobotic Plush Toy, when used by their relative with dementia for 15 min, 3 afternoons per week for 10 weeks.

Research Design and Method

The study employed a descriptive qualitative approach, which was nested within a larger cluster randomized controlled trial. A convenience sample of 20 family members (n = 10 each from the Paro and Plush Toy conditions) with relatives in 9 long-term care facilities in Queensland, Australia, completed individual semi-structured interviews (telephone or face-to-face). Inductive, data-driven thematic analysis of the data was undertaken with the assistance of the qualitative management software, ATLAS.ti®.

Results

Family members of long-term care residents with dementia expressed positive perceptions of the Paro, perceiving that it improved mood, reduced agitation, and provided opportunity for communication for their relative. Negative perceptions of the Plush Toy were given by family members, primarily because of its lack of movement and engagement.

Conclusion

Family members were keen for their older relative with dementia to use a social robot that moved and engaged with them, and Plush Toys that were static and unresponsive were perceived as being unimportant in improving quality of life. However, the current cost of Paro was identified by family members as a major limitation to use.

Feasibility and Effect of a Multidimensional Support Program to Improve Gerotranscendence Perception and Depression for Older Adults: A Pragmatic Cluster-Randomized Control Study

Improving perception of gerotranscendence can increase life satisfaction in older adults to achieve successful aging. The purpose of this study was to evaluate the feasibility and effect of a multidimensional support program (MSP) on gerotranscendence and depression in community-dwelling older adults. Using a cluster-randomized control trial design, four sites (98 participants) were randomly assigned to a MSP or control group. The Gerotranscendence Scale and Geriatric Depression Scale were administered pre- and postintervention. A total of 91 participants completed the study. The mean attendance rates in the MSP and control groups were 85.5% and 84.3%, respectively. The MSP was found to significantly enhance the perception of gerotranscendence in older adults but not their level of depression. This study demonstrated the MSP is a feasible and effective program to improve perception of gerotranscendence and may potentially lead to positive psychological well-being for older adults. [Res Gerontol Nurs. 2019; 12(3):148-158.].

Using a therapeutic companion robot for dementia symptoms in long-term care: reflections from a cluster-RCT

OBJECTIVES

We undertook a cluster-randomised controlled trial exploring the effect of a therapeutic companion robot (PARO) compared to a look-alike plush toy and usual care on dementia symptoms of long-term care residents. Complementing the reported quantitative outcomes , this paper provides critical reflection and commentary on individual participant responses to PARO, observed through video recordings , with a view to informing clinical practice and research.

METHOD

A descriptive, qualitative design with five participants selected from the PARO intervention arm of the trial. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000508673).

RESULTS

The five participants and their responses to PARO are presented in terms of three issues: i.) Different pre-intervention clinical presentations and different responses; ii.) Same individual, different response - the need for continual assessment and review; and iii.) The ethics of giving and retrieving PARO. Implications for clinical practice and future research are discussed in relation to each issue.

CONCLUSION

The findings suggest that one approach does not fit all, and that there is considerable variation in responses to PARO. A number of recommendations are discussed to aid the delivery of psychosocial interventions with PARO in practice, as well as to guide future research.

Tai Chi Combined With Resistance Training for Adults Aged 50 Years and Older: A Systematic Review

BACKGROUND AND PURPOSE

Despite Tai Chi and resistance training being recommended as suitable exercise for older adults, there are no systematic reviews synthesizing the effectiveness of a combination of Tai Chi and resistance training on health promotion of older adults. This study aimed to review the existing literature regarding the effect of Tai Chi and resistance training on physical health, mental health, pain, health-related quality of life, and age-related impairment in adults aged 50 years and older.

METHODS

A systematic review was conducted to report the health outcomes of Tai Chi combined with resistance training research in adults aged 50 years and older. Articles were identified by searching PubMed, Scopus, Web of Science, CINAHL, MEDLINE, Physiotherapy Evidence Database (PEDro), and the Cochrane library using search terms representing "Tai Chi" and "resistance" and "older adults." Quantitative experimental studies with participants aged 50 years and older, where one of the interventions was Tai Chi and resistance training, were included.

RESULTS AND DISCUSSION

The literature search yielded 648 articles from which 7 met the inclusion criteria. Collectively, the studies involved 703 participants aged 50 years and older, including healthy older adults, older adults with history of falls, postmenopausal women, and people diagnosed with end-stage hip osteoarthritis. Studies included different Tai Chi forms in combination with various types of resistance training. Training sessions were 2 to 7.5 h/wk and lasted between 12 weeks and 12 months. After long-term Tai Chi and resistance training, the participants showed significant improvement in upper and lower extremity muscle strength, aerobic endurance, balance, and mobility. However, 1 study failed to show improvement in Functional Movement Screening compared with traditional Tai Chi and nonexercise groups. No study examined the effects of Tai Chi and resistance training on health-related quality of life, fear of falling, or mental health in adults aged 50 years and older.

CONCLUSIONS

The review supports that Tai Chi in combination with resistance training improves physical function and muscle strength in adults aged 50 years and older.

Physical Activity and Psychological Well-Being in Older University Office Workers: Survey Findings

Prolonged sitting time has been reported among university workers which can have adverse health effects. The aim of this study was to examine the sitting time, physical activity, and psychological well-being reported by older university office workers. An online self-reported survey was distributed to all office workers 55 years and older at one university in Australia. Sixty-six office workers were recruited. They reported an average sitting time of 7.5 hours per day on weekdays. In all, 72.7% of the sample reported both moderate and high physical activity levels. A high percentage of the office workers reported depression (25.8%) and anxiety (12.1%). Lower education levels were significantly related to higher perceived stress and more depressive symptomatology ( p = .03 and .02, respectively). Significant associations were found between stress, depression, and anxiety ( p < .001) among this group of workers.

Eutectic mixture of local anaesthetics (EMLA®) as a primary dressing on painful chronic leg ulcers: a pilot randomised controlled trial

BACKGROUND

The physical, occupational, social and psychological impact of chronic leg ulcers (CLUs) on an individual is considerable. Wound-related pain (WRP), the most common symptom, is frequently reported as moderate to severe and mostly occurs at dressing change. WRP pain may not be alleviated by oral analgesics alone. Persistent poorly controlled leg ulcer pain can negatively impact wound healing and health-related quality of life (HRQoL).

METHODS

A pilot, parallel group, non-blinded, randomised controlled trial was conducted in six procedure clinics located in a public community nursing service in New South Wales, Australia to evaluate eutectic mixture of local anaesthetics (EMLA®) on painful CLUs when used as a primary dressing. The primary objective was to assess feasibility by using pre-determined criteria: at least 80% recruitment rate, 80% retention rate and 80% adherence to the study protocol. Key eligibility criteria were that participants had a painful CLU no larger than 100 cm2, a numerical rating scale (NRS) wound-related pain intensity score equal to or greater than 4, low to moderate exudate, no contraindications to EMLA® and capacity to consent. One hundred and seven patients with painful CLUs were screened for eligibility; 56% (n = 60) were eligible and consented to participate in the study. Participants were randomly assigned to the intervention (n = 30) or control (n = 30) groups. The intervention group received a measured dose of the topical anaesthetic EMLA® 5% cream daily as a primary dressing for 4 weeks followed by usual wound management for a further 8 weeks. The control group received usual wound management. Participants and investigators were not blinded to the treatment. WRP was measured at every dressing change. Wound healing and HRQoL were measured at baseline, 4 and 12 weeks.

RESULTS

Recruitment rate was lower than expected which likely meant patients were missed. Study retention rate was 90% (n = 54). Intervention fidelity was impacted by availability of resources and patient factors such as increased WRP.

CONCLUSION

This study identified that a larger randomised controlled trial investigating EMLA® applied as a primary dressing on painful chronic leg ulcers is feasible with modifications to the study protocol.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Register: Registered 16 December, 2009.

Engagement of a Person with Dementia Scale: Establishing content validity and psychometric properties

AIM

To develop and psychometrically test the Engagement of a Person with Dementia Scale.

BACKGROUND

It is important to study engagement in people with dementia when exploring the effectiveness of psychosocial interventions that can promote meaningful activity, stimulation and well-being, through an increase in positive emotions and an improvement in quality of life. The Engagement of a Person with Dementia Scale was developed based on current literature and previous research work on a video coding tool to ascertain the effect of psychosocial interventions on engagement in people with dementia.

DESIGN/METHOD

Using the Delphi technique, the content validity of the scale was evaluated by 15 dementia experts and formal/informal dementia carers. Psychometric properties of the scale were evaluated using 131 videos of people with dementia presented with PARO-a therapeutic, interactive, robotic seal-in long-term aged care facilities.

RESULTS

A 10-item scale was established following the rewording, combining and elimination of prospective items, with revisions made to the instructions for using and scoring the scale. An overall consensus with agreement for the scale was established among the panel of experts. The scale demonstrated robust internal consistency, inter-rater and test-retest reliability and convergent and discriminant validity.

CONCLUSION

This study successfully developed the Engagement of a Person with Dementia Scale, with established content validity and psychometric properties. The scale assesses the behavioural and emotional expressions and responses of engagement by people with dementia when partaking in a psychosocial activity in five areas: affective, visual, verbal, behavioural and social engagement.

The impact of early psychosocial intervention on self-efficacy of care recipient/carer dyads living with early-stage dementia-A mixed-methods study

AIM

To evaluate the effect of a targeted community-based psychosocial intervention on self-efficacy outcomes for care recipient/carer dyads living with early-stage dementia.

BACKGROUND

There is increasing interest in the role of self-efficacy and self-management structures in determining positive outcomes for people with dementia. The assumption is that care recipient/carer dyads who receive early support to identify and adjust to dementia-related changes will cope better in the long term.

DESIGN

An explanatory sequential mixed-method design was employed. Primarily quantitative with qualitative data providing a supportive secondary role to expand on and illuminate the quantitative findings.

METHODS

Eighty-eight dyads were recruited and allocated on a regional basis to an intervention or control group. Intervention group dyads received the Early Diagnosis Dyadic Intervention. Control group dyads received two information manuals. Quantitative data were collected at three time points. Qualitative data were collected via evaluation questionnaires and semistructured interviews.

RESULTS

Intervention structure, content, and delivery were acceptable to the dyads but few quantitative self-efficacy findings reached statistical significance. Improvements in self-efficacy were evident in the postintervention evaluation qualitative responses where dyads expressed greater confidence in identifying and accessing community support.

CONCLUSION

There is an urgent need for effective psychosocial interventions to help reduce the impact of dementia symptoms on patients, carers, and society. This study makes an important contribution to our understanding of the capacity of psychosocial interventions to improve self-efficacy outcomes for care recipient/carer dyads with early-stage dementia while also illustrating the challenges associated with measuring self-efficacy in the early stages of the condition.

Effectiveness of psychosocial interventions in reducing grief experienced by family carers of people with dementia: a systematic review protocol

REVIEW OBJECTIVE

The objective is to examine the existing evidence regarding the effectiveness of psychosocial interventions to assist grief pre- and post-bereavement for family carers of people with dementia residing in the community or in a health or social care facility.

REVIEW QUESTION

What psychosocial interventions for family carers of people with dementia are most effective in reducing: (1) anticipatory grief, (2) post-death grief (bereavement), and (3) complicated grief?

Interventions to build resilience in family caregivers of people living with dementia: a comprehensive systematic review

BACKGROUND

Recent studies have indicated that family caregivers of people with dementia have higher rates of depression, anxiety and hopelessness, as well as higher levels of burden, stress and distress. Not all caregivers, however, succumb to the negative effects of caring. Caregivers who are able to recover from, resist or adapt to the physical and psychological demands of caring can be considered "resilient".

OBJECTIVES

The objective of this review was to examine the existing evidence regarding interventions for building resilience in family caregivers of people living with dementia.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

This review considered studies that included family caregivers of people with dementia.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

Studies investigating interventions to build resilience in family caregivers were considered by the review. For qualitative studies, the phenomena of interest were family caregivers' experiences of the interventions including factors affecting implementation and their subjective experience of outcomes.

CONTEXT

Studies conducted in any cultural or geographical context and any settings including participants' homes in the community, residential aged care or hospital, medical or allied health practice were considered for inclusion.

TYPES OF STUDIES

Quantitative studies incorporating experimental and descriptive study designs and qualitative studies, including, but not limited to, phenomenology, grounded theory, ethnography, action research and feminist research were considered for inclusion.

OUTCOMES

Quantitative studies were included that contained either objective or subjective outcome measures (or a combination of both). In cases in which proxy measures of resilience were used, only those papers that explicitly related the aims of the intervention and the measurement of outcomes to resilience itself were considered for inclusion. Proxies could include, but were not limited to, self-efficacy, locus of control, perceived burden, psychological wellbeing, strength, coping, positive adjustment and resourcefulness. Qualitative studies were similarly considered for inclusion if they explicitly related the aims of the intervention to resilience.

SEARCH STRATEGY

Eleven electronic databases were searched for research studies published in English in or after 1990.

METHODOLOGICAL QUALITY

Quantitative and qualitative studies selected for retrieval were assessed by two independent reviewers for methodological validity using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) and Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI).

DATA EXTRACTION

Quantitative and qualitative data were extracted from publications included in the review using the standardized data extraction tools from JBI-MAStARI and JBI-QARI.

DATA SYNTHESIS

It was not possible to pool quantitative findings for statistical meta-analysis using JBI-MAStARI. Qualitative research findings were too limited to be pooled using the JBI-QARI. The findings are presented in narrative form.

RESULTS

The review included three publications reporting one quantitative intervention study and one mixed-method intervention study. There was a lack of available studies and, of the two intervention studies that were identified, neither found any statistically significant change in quantitative measures of resilience. Qualitative data suggested positive impacts of a poetry writing intervention and a positive experience of the intervention.

CONCLUSION IMPLICATIONS FOR PRACTICE

The studies differed in both the nature of the intervention and the way resilience was conceptualized and operationalized. Consequently, it was not possible to offer any recommendations for practice.

IMPLICATIONS FOR RESEARCH

Implications for research relate to the development of a more comprehensive theory of resilience in family caregivers that can be used to develop and rigorously evaluate reliable and valid measures of resilience in line with that theory. Further, well-designed, sufficiently powered intervention studies informed by theory are needed.

Does Cognitive Impairment and Agitation in Dementia Influence Intervention Effectiveness? Findings From a Cluster-Randomized-Controlled Trial With the Therapeutic Robot, PARO

OBJECTIVES

To explore whether severity of cognitive impairment and agitation of older people with dementia predict outcomes in engagement, mood states, and agitation after a 10-week intervention with the robotic seal, PARO.

DESIGN

Data from the PARO intervention-arm of a cluster-randomized controlled trial was used, which involved individual, nonfacilitated, 15-minute sessions with PARO 3 afternoons per week for 10 weeks.

SAMPLE AND PARTICIPANTS

One hundred thirty-eight residents-aged ≥60 years, with dementia-from 9 long-term care facilities.

MEASURES

A series of stepwise multiple linear regressions were conducted. Dependent variables were participants' levels of engagement, mood states, and agitation at week 10 [assessed by video observation and Cohen Mansfield Agitation Inventory-Short Form (CMAI-SF)]. Predictor variables were baseline levels of cognitive impairment [assessed by Rowland Universal Dementia Assessment Scale (RUDAS)] and agitation (CMAI-SF).

RESULTS

Five models were produced. The strongest finding was that participants with more severe agitation at baseline had higher levels of agitation at week 10 (R² = .82, P < .001). Predictors of positive response were less significant. Low levels of agitation at baseline predicted greater positive behavioral engagement with PARO (R² = .054, P = .009) and fewer observed instances of agitation (R² = .033, P = .045) at week 10, whereas greater visual engagement was predicted by both lower levels of agitation and cognitive impairment (R² = .082, P = .006). Less severe cognitive impairment predicted greater pleasure at week 10 (R² = .067, P = .004).

CONCLUSIONS/IMPLICATIONS

Participants with severe agitation had poor response to PARO. Lower levels of agitation and higher cognitive functioning were associated with better responses. In clinical practice, we recommend PARO should be restricted to people with low-moderate severity of agitation. Further research is needed to determine the optimal participant characteristics for response to PARO.

mHealth applications as an educational and supportive resource for family carers of people with dementia: An integrative review

Family carers encounter several challenges related to caring for people with dementia, and they need support in managing care recipients’ health needs. This study aims to identify, appraise and synthesise the existing evidence on the use of mHealth/smartphone applications as an educational and supportive resource for family carers of people with dementia. An integrative literature review approach was used. Seven databases were searched. The search generated 117 articles, with seven meeting the inclusion criteria. Three categories and their attendant sub-categories emerged from the literature. The categories are ‘carer support’, ‘evaluation strategies’ and ‘barriers and challenges’. mHealth applications appear to be a feasible intervention for family carers of people with dementia despite the limited available research and barriers for their development and implementation. Further research on mHealth applications with strong methodological rigour and more research on mHealth applications as an educational and supportive resource for carers of people with dementia are needed.

Supporting autonomy of nursing home residents with dementia in the informed consent process

Background

In studies involving people with dementia, researchers have historically defaulted to seeking consent from a proxy, the assumption being that people with dementia are unable to provide their own informed consent. This choice denies people with dementia a voice in the consent process, thus disregarding their autonomy and agency. Recently, other options for improving the consent process have been explored.

Objective

This study aimed to determine whether nursing home residents with dementia could demonstrate an ability to provide their own informed consent as determined by the Evaluation to Sign Consent instrument.

Methods

As part of a larger study on the quality of life of nursing home residents, the Evaluation to Sign Consent was administered to 392 people diagnosed with dementia. Data on demographic variables, such as gender and age, as well as level of cognitive impairment, were also collected.

Results

Just over one-fifth (22%) of the residents with dementia were judged as having the capacity to provide their own informed consent to participate in this specific research project. Consistent with existing literature, capacity to consent was significantly, and negatively, associated with cognitive impairment.

Conclusion

This study demonstrates that assuming all people diagnosed with dementia are unable to provide informed consent for research on the basis of cognitive test scores, or on clinical assessment alone, potentially denies them the autonomy to make a decision that they may be capable of making. Research involving people with mild-to-moderate dementia needs to consider evaluating whether potential participants have the capacity to provide their own consent.

Care staff perceptions of a social robot called Paro and a look-alike Plush Toy: a descriptive qualitative approach

OBJECTIVES

Social robots such as Paro, a therapeutic companion robot, have recently been introduced into dementia care as a means to reduce behavioural and psychological symptoms of dementia. The purpose of this study was to explore care staff perceptions of Paro and a look-alike non-robotic animal, including benefits and limitations in dementia care.

METHODS

The study assumed a descriptive qualitative approach, nested within a large cluster-randomised controlled trial. We interviewed a subsample of 20 facility care staff, from nine long-term care facilities in Southeast Queensland, Australia. Thematic analysis of the data, which was inductive and data-driven, was undertaken with the assistance of the qualitative software, ATLAS.ti®.

RESULTS

The findings refer to four categories: increasing excitement for Paro and decreasing enthusiasm for Plush Toy; value and function of Paro; opportunities for engagement; and alternatives vs. robustness.

CONCLUSION

Staff caring for people with dementia preferred Paro compared to a look-alike Plush Toy. Staff identified that Paro had the potential to improve quality of life for people with dementia, whereas the Plush Toy had limitations when compared to Paro. However, participants expressed concern that the cost of Paro could reduce opportunities for use within aged care.

Developing a dementia-specific preference--based quality of life measure (AD-5D) in Australia: a valuation study protocol

INTRODUCTION

Generic instruments for assessing health-related quality of life may lack the sensitivity to detect changes in health specific to certain conditions, such as dementia. The Quality of Life in Alzheimer's Disease (QOL-AD) is a widely used and well-validated condition-specific instrument for assessing health-related quality of life for people living with dementia, but it does not enable the calculation of quality-adjusted life years, the basis of cost utility analysis. This study will generate a preference-based scoring algorithm for a health state classification system -the Alzheimer's Disease Five Dimensions (AD-5D) derived from the QOL-AD.

METHODS AND ANALYSIS

Discrete choice experiments with duration (DCE_TTO) and best-worst scaling health state valuation tasks will be administered to a representative sample of 2000 members of the Australian general population via an online survey and to 250 dementia dyads (250 people with dementia and their carers) via face-to-face interview. A multinomial (conditional) logistic framework will be used to analyse responses and produce the utility algorithm for the AD-5D.

ETHICS AND DISSEMINATION

The algorithms developed will enable prospective and retrospective economic evaluation of any treatment or intervention targeting people with dementia where the QOL-AD has been administered and will be available online. Results will be disseminated through journals that publish health economics articles and through professional conferences. This study has ethical approval.

The Cost-Effectiveness of Using PARO, a Therapeutic Robotic Seal, to Reduce Agitation and Medication Use in Dementia: Findings from a Cluster-Randomized Controlled Trial

OBJECTIVES

To examine the within-trial costs and cost-effectiveness of using PARO, compared with a plush toy and usual care, for reducing agitation and medication use in people with dementia in long-term care.

DESIGN

An economic evaluation, nested within a cluster-randomized controlled trial.

SETTING

Twenty-eight facilities in South-East Queensland, Australia.

PARTICIPANTS

A total of 415 residents, all aged 60 years or older, with documented diagnoses of dementia.

INTERVENTION

Facilities were randomized to 1 of 3 groups: PARO (individual, nonfacilitated 15-minute sessions, 3 afternoons per week for 10 weeks); plush toy (as per PARO but with artificial intelligence disabled); and usual care.

MEASUREMENTS

The incremental cost per Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF) point averted from a provider's perspective. Australian New Zealand Clinical Trials Registry (BLINDED FOR REVIEW).

RESULTS

For the within-trial costs, the PARO group was $50.47 more expensive per resident compared with usual care, whereas the plush toy group was $37.26 more expensive than usual care. There were no statistically significant between-group differences in agitation levels after the 10-week intervention. The point estimates of the incremental cost-effectiveness ratios were $13.01 for PARO and $12.85 for plush toy per CMAI-SF point averted relative to usual care.

CONCLUSION

The plush toy used in this study offered marginally greater value for money than PARO in improving agitation. However, these costs are much lower than values estimated for psychosocial group activities and sensory interventions, suggesting that both a plush toy and the PARO are cost-effective psychosocial treatment options for agitation.