Best Practice Guidance
Human Interaction with Technology in Dementia

Guidance

The design of some existing pet robots for people with dementia do not sufficiently consider their preferences. For example, while some pet robots are designed to resemble unfamiliar animals such as a dinosaur or seal, people with dementia seem to prefer more familiarly designed pets, such as domestic animals like cats and dogs. As little research has been done into pet robot design preferences of people with dementia further investigation is needed.

Explanation and Examples

One of the most researched and used pet robots in dementia care is PARO, a robotic baby harp seal. The developer of PARO anticipated that users are likely to be more accepting of PARO, since they are less likely to have experiences and expectations of a seal. However, Bradwell and colleagues found that older adults including people with dementia have expressed a preference for familiar animals such as cats and dogs. A qualitative study uncovered similar findings – Care providers in nursing homes expressed that residents with dementia may prefer and react better to familiar animals. In line with a person-centred approach to care, the use of pet robots should account for the preferences and needs of people with dementia. However, there is a lack of studies that have explicitly investigated such design preferences. More studies are necessary to bridge this gap.

Guidance

Low-cost pet robots are a promising technology to improve the psychosocial health of people living with dementia. More high quality studies with sufficiently large sample sizes should be conducted to properly investigate their impacts.

Explanation and examples

Pet robots are a technology-based substitute to animal assisted therapy. However, the high costs of many pet robots can hinder the use of pet robots in dementia care. A scoping review was conducted to understand the impact of using lower-cost (more affordable) pet robots. Synthesised findings from nine studies suggested that low-cost pet robots improved the communication, social interactions and other health domains of older adults and people living with dementia. However, most studies had a small sample size and were of varying quality. Moving forward, more rigorous studies are necessary to investigate their impacts.

Guidance

Low-cost pet robots demonstrate the potential to positively impact the psychosocial health of people with dementia and their caregivers. Due to their lower cost, they may be more accessible and affordable and should therefore be considered for use in dementia care.

Explanation and examples

Although pet robots have demonstrated positive impacts on the wellbeing of people with dementia, their affordability can impede their uptake in dementia care. A scoping review, content analysis of consumer reviews and a qualitative study showed that the impacts of low-cost pet robots on people with dementia resembled the effects of other higher costed (but more advanced) pet robots. These included improved mood, companionship, increased activity engagement and reduced anxiety. Caregivers also experienced knock-on effects, such as feelings of joy and relief. Low-cost pet robots are more widely accessible to the public since they can be purchased off-the-shelf. While promising, findings of their positive impacts are subject to bias. More rigorous studies are necessary to confirm their impacts.

Guidance

To provide high-quality elderly and dementia care, Digital Health Technologies (DHTs) can potentially help achieve the full capacity of Comprehensive Geriatric Assessments (CGAs). In addition they can improve communication and data transfer on patients’ medical and treatment plan information between care settings and stakeholders as well as improve health decision-making. Finally, they can help to share the responsibility of the geriatric assessment between professionals, thereby avoiding overloading the workload of individual users and reducing their psychological stress.

Explanation and Examples:

Due to the higher rate of transitions between care settings in older populations, associated with the complexity of an ageing population and the shift from institutional care to home care, CGAs have become an important assessment tool as they encompass multiple domains and address the variety of complex problems in frail older people. They are considered as multidimensional assessments, using quantitative assessment scales, that support multidisciplinary care teams in clinical decision-making and personalized care planning to meet the needs of older people, their families and carers, focusing on functional status and quality of life.

However, to reach the full potential of CGAs, their implementation should be supported by electronic data systems, which provide relevant outputs and allow timely sharing of information within multidisciplinary teams of healthcare professionals and between different healthcare settings. The use of DHTs can potentially help them reach their full capacity and overcome the data transfer limitations between care settings and stakeholders. To improve the usability and implementation of these DHTs, the following features are recommended: a) accessibility of individual assessment by multiple healthcare professionals and the possibility of splitting sections according to professional expertise to share responsibility for assessments; b) the use of secure data storage, such as clouds; c) automatization of real-time calculation of scales and outcomes with a graphical representation of the person’s profile and health status; d) automatic alerts, notifications and continuous monitoring of item completion; and e) provision of personalized care plans according to the data collected.

Well-designed digital health technologies can contribute to the safety of the potential users (e.g. healthcare professionals and stakeholders) and reduce psychological stress, including burnout and low morale, by avoiding overloading the workload of healthcare professionals. For example, by sharing the responsibility for carrying out the assessments between different professionals.

Guidance

Technology developers and researchers should be aware of the different contextual factors that can affect the translation of research on social robots to real-world use.

Explanation and examples

Barriers and facilitators affecting the implementation of social robots can occur at different levels. For example, they relate to the social robots’ features, or relate to organisational factors or external policies. A scoping review was conducted to understand the barriers and facilitators to the implementation of social robots for older adults and people living with dementia. 53 studies were included in this review. Most existing studies have disproportionately focused on understanding barriers and facilitators relating to the social robots, such as their ease of use. However, there is significantly less research that has been conducted to understand organisational factors or wider contextual factors that can affect their implementation in real-world practice. Future research should pay more attention to investigating the contextual factors, using an implementation framework, to identify barriers and facilitators on different levels to guide the further implementation of social robots.

Guidance

Implementing assistive technology could be promising in long-term care to address loneliness in dementia, but further studies are needed to tailor assistive technology to people living with dementia in different care settings and to investigate its effect on loneliness.

Explanation and examples

Active & Assisted Living (AAL) technology aims to support coping with the consequences of dementia. A scoping review was conducted to learn if and how AAL addresses loneliness in people living with dementia in long-term care. Although, only one study focused directly on the impact of AAL technology on loneliness, findings suggest that AAL were used in the context of psychosocial interventions and proved to have had an impact on loneliness in people living with dementia. It remains unclear why loneliness was almost never included as an outcome in technology studies. Since we were not able to derive clear effects of assistive technology on loneliness from the included studies, we recommend using loneliness outcome measures in future intervention studies into AAL technology.

Guidance

To minimise potential distress and negative impacts from using pet robots, researchers and care providers should assess their suitability for individuals with dementia, and facilitate their use based on each individual’s preference, needs and abilities. As the needs of people with dementia can fluctuate, care providers should also monitor and re-evaluate the use of pet robots.

Explanation and examples

Findings from a scoping review of eight studies showed that some people with dementia did not respond to pet robots. Some had negative responses such as agitation, or became jealous when the robot was shared with other residents in care facilities. An analysis of 1,327 consumer reviews on a low-cost robotic cat showed similar findings. Likewise, interviews with care providers from nursing homes revealed that they had similar experiences. To minimise the risks of potential negative impacts, the use of pet robots for each individual has to be carefully considered. This should encompass:

• Assessment

  Assess the individual’s preferences, needs, functional abilities and needs (e.g. occupational needs, and physical, cognitive, and sensory abilities). If used in a care setting, consider discussing the use of pet robots with family members.

• Facilitation and Tailoring

  Based on the assessment, provide facilitation or tailored support to individuals. For example, if the individual has difficulties initiating interactions with the pet robot, consider providing assistance

• Monitoring & Evaluating

  Monitor and evaluate the individual’s reaction to pet robots, and intervene if the individual shows signs of distress. These observations should be shared with and discussed with other care providers if used in care facilities

Guidance

Residents with dementia and their family members should be involved when planning to introduce pet robots in long-term care settings and when using pet robots.

Explanation and examples

In a consensus-building exercise involving 56 international experts (care professionals, organisational leaders and researchers), experts established the importance of including residents with dementia and their family in the implementation of pet robots in long-term care facilities. When planning to adopt pet robots in long-term care facilities, the opinions of residents with dementia and their family members must be sought. Examples include

• Seeking their opinions on which pet robot to purchase by showing them different pet robots, and asking or observing their reactions to each robot
• Seeking feedback on their preferred ways of using robots, such as whether they prefer the robots to be individualised or shared with other residents.

When using pet robots, residents with dementia and their family members must be supported to be actively involved. For example:

• Residents may be involved in “taking care” of robots.
• Family members could provide support or use the robots as topics of conversations during visits.

Guidance

Before introducing pet robots in a long-term care facility, consensus discussions among stakeholders, such as care professionals and managers, should be conducted, to discuss whether (and why) pet robots should or should not be introduced for residents with dementia. In addition, the facility’s readiness to introduce pet robots should be carefully considered.

Explanation and examples

In a modified Delphi study involving 56 international experts (care professionals, organisational leaders and researchers), experts agreed that these strategies are critical to support the implementation of pet robots in long-term care facilities. Consensus discussions should involve all care providers who may be directly or indirectly involved in the care of residents with dementia. Examples of discussions may include:

• The importance of bringing in/using pet robots to address a chosen problem (e.g. to address residents’ needs or support care staff in their delivery of care for residents with dementia)
• Appropriateness of using pet robots to address the problem(s), such as whether they align with workflows.

In addition, the organisation’s readiness to implement pet robots should also be assessed. Examples include:

• Assessment of financial resources
• Assessment of manpower and logistical resources (e.g. sufficient space and charging point).

Guidance

Care staff should be educated about the use of pet robots in dementia care through educational meetings that are tailored to the needs of different staff. In addition, they should be provided with ongoing trainings to support them in applying this knowledge as part of their delivery of dementia care.

Explanation and examples

In a modified Delphi study involving 56 international experts (care professionals, organisational leaders and researchers), educational meetings and ongoing trainings are identified as critical strategies to support the implementation of pet robots in long-term care facilities. The purpose of conducting educational meetings is to provide care staff with overall knowledge on the role of pet robots for dementia care. Such sessions should be tailored to the different needs of each care professional. Examples of content may include:

• Evidence supporting the use of pet robots in dementia care, such as information about their impacts on residents, who may benefit and who may be at risk of distress
• How pet robots can support caregiving

While the purpose of education is to provide overall knowledge about pet robots, the purpose of conducting ongoing training is to support care professionals to acquire practical skills and confidence to use pet robots in dementia care giving. Examples include:

• On-the-job training
• Structured supervision
• Training based on each staff experiences/knowledge.

Guidance

The cost of pet robots can prohibit their uptake in long-term care facilities for dementia care. There may also be additional costs involved in implementing pet robots, such as manpower and time related costs. Different funding sources need to be considered to acquire sufficient funding to support the implementation effort.

Explanation and examples

In a qualitative study involving 22 care providers from nursing homes, the cost of purchasing pet robots have been reported as a concern. Some care providers reported the use of charity funds to support the purchase of pet robots. In a modified Delphi study, experts (care professionals, organisational leaders and researchers) established that it is necessary to creatively seek and acquire funding to support the implementation of pet robots in long-term care facilities. Examples of potential funding sources may include:

• Existing funding resources
• Raising private funds (such as donations or charity)
• Shifting or (re)prioritising the use of funds within the organisation based on their impact on people with dementia

The funds may be used to support different aspects of implementation. Examples include:

• Fund the introduction and adoption of pet robots
• Support other time limited actions needed for initial implementation, such as purchasing cleaning materials
• Training (e.g. developing educational materials)