International Psychogeriatrics (2017), 29:1, 67–79 © International Psychogeriatric Association 2016doi:10.1017/S1041610216001435

Robots to assist daily activities: views of older adults withAlzheimer’s disease and their caregivers

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Rosalie H. Wang,1,2 Aishwarya Sudhama,3 Momotaz Begum,4 Rajibul Huq5

and Alex Mihailidis1,2

1Intelligent Assistive Technology and Systems Lab, Dept. of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario M5G1V7, Canada

2Artificial Intelligence and Robotics in Rehabilitation Research Team, Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario M5G2A2, Canada

3Centre for Vision Research, York University, Toronto, Ontario M3J 1P3, Canada4Department of Computer Science, University of New Hampshire, Kingsbury Hall, N215A, Durham, New Hampshire 03824, USA5The Mathworks, Natick, Massachusetts 01760, USA

ABSTRACT

Background: Robots have the potential to both enable older adults with dementia to perform daily activitieswith greater independence, and provide support to caregivers. This study explored perspectives of older adultswith Alzheimer’s disease (AD) and their caregivers on robots that provide stepwise prompting to completeactivities in the home.

Methods: Ten dyads participated: Older adults with mild-to-moderate AD and difficulty completing activitysteps, and their family caregivers. Older adults were prompted by a tele-operated robot to wash their handsin the bathroom and make a cup of tea in the kitchen. Caregivers observed interactions. Semi-structuredinterviews were conducted individually. Transcribed interviews were thematically analyzed.

Results: Three themes summarized responses to robot interactions: contemplating a future with assistive robots,considering opportunities with assistive robots, and reflecting on implications for social relationships. Older adultsexpressed opportunities for robots to help in daily activities, were open to the idea of robotic assistance,but did not want a robot. Caregivers identified numerous opportunities and were more open to robots.Several wanted a robot, if available. Positive consequences of robots in caregiving scenarios could includedecreased frustration, stress, and relationship strain, and increased social interaction via the robot. A negativeconsequence could be decreased interaction with caregivers.

Conclusions: Few studies have investigated in-depth perspectives of older adults with dementia and theircaregivers following direct interaction with an assistive prompting robot. To fulfill the potential of robots,continued dialogue between users and developers, and consideration of robot design and caregivingrelationship factors are necessary.

Key words: activities of daily living, aged care, Alzheimer’s disease, carers

Introduction

Alzheimer’s disease (AD) and other dementias canresult in decreased attention, memory loss, poorexecutive functioning, and changes in language andcomprehension (American Psychiatric Association,2013). Older adults with AD and other dementiasoften require support from family caregivers

Correspondence should be addressed to: Rosalie Wang, Intelligent AssistiveTechnology and Systems Lab, Department of Occupational Science andOccupational Therapy, University of Toronto, 160-500 University Avenue,Toronto, Ontario M5G 1V7, Canada. Phone: +1-416-946-8566. Email:rosalie.wang@utoronto.ca. Received 7 Jun 2016; revision requested 16 Jul2016; revised version received 6 Aug 2016; accepted 8 Aug 2016. Firstpublished online 23 September 2016.

to perform daily activities. Difficulties manifestin initiating tasks, problem solving, executingactivity sequences, and balancing safety concerns.Maintaining abilities to perform meaningful activ-ities is desirable in order to preserve feelingsof independence and well-being. For example,completing everyday activities such as making a cupof tea autonomously is important as it can providea sense of social significance, promote feelings ofaccomplishment and presence, support learningand engagement, and foster positivity (Sakuae andReid, 2012).

Family caregivers often strive to preserve olderadults’ sense of autonomy; dementia caregiving

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68 R. H. Wang et al.

can provide positive opportunities for the caregiverlike becoming closer to the care receiver, andprovide a sense of reciprocity (Peacock et al.,2010). However, the majority of family caregivers(68%) of persons with dementia experience burdenand stress from caregiving, and 65% experiencedepressive symptoms (Papastavrou et al., 2007).Caregivers face day-to-day challenges in supportingphysical safety and daily activity performance asongoing supervision and step-by-step remindersbecome necessities. The need for assistance iscompounded when older adults have concurrentphysical limitations. Feelings of burden andstress associated with caring for persons withdementia are linked to mental exertion, feelingsof depression, physical exertion, and risk ofcardiovascular disease (Papastavrou et al., 2007;Richardson et al., 2013; Jennings et al., 2015).Options to augment care with technology, possiblywith the use of robots to assist persons withdementia to perform daily activities (Faucounauet al., 2009; Kerssens et al., 2015), can contributeto improvements in quality of care and decreasecaregiver burden and stress (Mitzner et al., 2010).

Assistive robots can help people physically (e.g.,retrieving items) and/or socially (e.g., providingencouragement). Robots are being explored world-wide to help older adults in various ways (Bedafet al., 2015). For example, the European UnionCompanionAble project aimed to assist personswith mild cognitive impairment and included amultifunctional mobile robot Hector that commu-nicated with a smart home environment (Schroeteret al., 2013). Among other features of the integratedsystem, Hector provided high-level reminders forappointments based on the system’s stored agenda,suggested predetermined activities to be carriedout, offered a means for video chats with others,and provided cognitive stimulation activities.Remotely-controlled mobile robots such as Giraffhave been investigated with older adult long-termcare residents with mild-to-moderate dementia inAustralia (Moyle et al., 2014). The purpose ofthe robot was to allow video chats between olderadults and their family, thereby supporting socialinteraction and reducing isolation. While most as-sistive robots remain in development, robotic pets,such as Paro the baby harp seal, are commerciallyavailable. Developed in Japan, Paro was intendedto fulfill psychosocial and companionship needs ofolder adults with severe dementia in hospitals andlong-term care homes (Shibata, 2012). Paro, themost studied robot for older adults with dementia,has been found in studies in multiple countries toimprove mood and decrease stress with residents,foster communication between residents, and evendecrease staff stress.

Few robots, however, have been developed toassist older adults with dementia who require step-by-step prompting to complete everyday activities.While various low and high technologies have beenapplied (e.g., large format boards with reminders)or developed (e.g., mobile applications for smartphones), for some older adults who require stepwiseactivity prompting, a satisfactory solution has yetto be found. Some environmentally embeddedtechnologies (e.g., used with smart homes) haveexplored stepwise prompting strategies for olderadults with dementia (e.g., for drinking water,brushing teeth and upper body dressing (Bewernitzet al., 2009), and handwashing (Mihailidis et al.,2007; 2008). While they are designed to requirelittle interaction from users to initiate assistance,embedded systems cannot adequately engage userswith their static interfaces and cannot track andassist users when they move away from locationswhere the sensors and interfaces are installed. Amobile, interactive robot interface that can providestepwise prompts may address these issues forapplications in the home. A robot’s embodiedphysical presence can help to make interactionsmore socially engaging, effective, and acceptable.Previous studies have described the benefits ofproviding instructions through a robot comparedto a tablet computer (Mann et al., 2015) and avirtual coach (Fasola and Mataric, 2013). Thesocial presence of the robot and its nature mayincrease engagement with the robot and motivationto comply with directions.

To develop robots that will be acceptableand useful to older adults with AD and otherdementias and their caregivers, it is essential tounderstand and incorporate users’ perceptions,attitudes, and needs regarding use of robotsin daily life at home (Faucounau et al., 2009;Mitzner et al., 2010). Older adults need to bemore involved during the design process so thattheir needs and concerns are addressed (Frennertand Ostlund, 2014) and there is a significantgap in assistive robotics research examining theperspectives of older adults with AD and theircaregivers. It is rare to find studies that presentthe detailed views of older adult users with ADalong with their caregivers’ perceptions, and evenfewer studies that report this information followingdirect interaction with an assistive robot. Moststudies investigating the role of robotic assistantsfor home use employ surveys and questionnaires,which provide a broad understanding of olderadult and caregiver perceptions. The disadvantageof this methodology is the lack of in-depthexploration of varying perceptions and possiblebiases inherent in the questions being asked. In-depth examination through qualitative interviews

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Robots to assist daily activities of older adults 69

Figure 1. Tele-operated assistive robot, “Ed”, inside HomeLab, indicating components of robot.

and analysis following interaction with a robot canprovide developers with indispensable knowledgein regards to supporting acceptance, utility, andhigher integration of robotic assistants within thehome. This paper addresses the following questionswith respect to older adults with AD and theircaregivers:

1. What are the perceptions of an assistive robot thatprovides step-by-step assistance for daily activities?

2. What are the implications for social relationshipswith the introduction of an assistive robot in thecaregiving context?

Methods

Study designThis paper included qualitative, thematic analysisof semi-structured interview data from older adultswith mild-to-moderate AD and their caregiverscollected from a descriptive mixed methods study.The main study examined the usability of a robotthat provided step-by-step prompting assistance tocomplete activities, in this case hand washing andtea making. A descriptive mixed methods approachwas used for the study given the limited informationavailable on assistive robot use by these user groupsand the need to elucidate design requirementsto guide technical development. Data from themain study, not included in this analysis, consistedof audio/video recordings of the older adults’robot interactions (to enable behavioral observation

coding and transcriptions of verbal interactions)and questionnaires. The interview guides weredeveloped by the research team, which includedresearchers with clinical and research experienceworking with older adults with dementia. Theguides were also reviewed by two expert researchersprior to use in the study.

SettingThe study was conducted in HomeLab (iDAPT,Toronto Rehabilitation Institute), a simulatedhome (Figure 1). Approval was received from theresearch ethics boards of Toronto RehabilitationInstitute and the University of Toronto. Data werecollected between August and December 2012.

ParticipantsParticipants were recruited from clinical partnersat Toronto Rehabilitation Institute sites and localcommunity-based care agencies, and through ad-vertisements posted at clinical sites and non-profitorganizations (e.g., Alzheimer Society of Canada).Clinical partners screened participants according tothe inclusion/exclusion criteria. If participants wereeligible, the clinical partner set up appointmenttimes for the participants and researchers. Ifresponding to an advertisement, participants couldcall the researchers to enquire about the study.Participants were enrolled consecutively.

Older adults and their caregivers were recruitedas dyads. Older adults had to be 55 years or older,able to hear normal levels of speech, diagnosed

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70 R. H. Wang et al.

Figure 2. Display of tele-operator’s screen, indicating commands available to the operator during the study.

by their physician as having mild-to-moderateAD, experiencing difficulty completing commonsequences of activity steps (according to theircaregiver), and able to give informed consent orassent (with a substitute decision maker givingconsent). Caregivers had to be 19 years old orolder, a family member or privately hired caregiverwho provides more than seven hours of care perweek, and able to give informed consent. Allparticipants had to be fluent in English.

Five to ten dyads were targeted for recruitment.Nielsen and Landauer (1993) suggested that fiveparticipants are sufficient to identify a majority ofthe usability issues before moving to the next designiteration for evaluation. As such, data from 5–10dyads was anticipated to be sufficient to explore theresearch questions in the main study.

Assistive robot, “Ed”A custom-designed tele-operated robot, Ed, wasused. A trained tele-operator remotely controlledEd’s movements, speech, and prompting functions.Ed was constructed with an iRobot Create platform(iRobot, Boston, USA), a personal computer, aLCD screen, microphones, speakers, and webcameras inside a customized shell (Figure 1). TheLCD screen displayed either a face (with lipsthat moved during speech) or pre-recorded videos.Audio output included both pre-recorded (e.g.statements, questions, and prompts) and real-time audio output via the tele-operator interface(Figure 2). All audio output was via a text-to-speech synthesizer (Cepstral, “David” voice).

ProceduresFollowing consent procedures the Mini MentalState Examination (Folstein et al., 1975) was

administered to screen for dementia and for de-scriptive purposes. Demographic and backgroundinformation was collected in an interview formatwith each dyad.

Participants were introduced to Ed and receiveda brief demonstration of Ed’s functions (movement,communication, and prompting). Participants wereinformed that the researcher would operate Ed re-motely. The older adult was oriented to HomeLaband asked to complete the two activities with Edproviding stepwise prompting, as needed. The twodaily activities, hand washing in the bathroomand tea making in the kitchen, were broken downinto several prompt steps (Figure 3). Audio andaudiovisual prompts were formulated accordingto these steps. Each of the prompts were pre-recorded and delivered with an increasing degreeof assistance. This systematic method ensuredefficiency of the prompting method. Promptingassistance progressed as follows: Min – suggestiveaudio prompt (e.g., “Can you fill the kettle withwater now?”), Max – directive audio prompt,preceded by the participant’s name (e.g., “Tryfilling the kettle under the water”), and MaxVid –Max prompt with a video clip demonstrating howthe step is performed (e.g., model picks up kettleand puts it under tap with running water). Theaudio and audiovisual prompts were similar in typeand format to those used in our previous studieswith the COACH (Cognitive Orthosis for AssistingaCtivities in the Home) system (Mihailidis et al.,2007; 2008). Because Ed was mobile, guidance wasprovided for activity locations and by whole bodygestures that directed attention to items within theenvironment.

Caregivers were asked to observe the interactionwith Ed, and to provide feedback on their

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Robots to assist daily activities of older adults 71

Figure 3. Tele-operated assistive robot, “Ed”, assisting a parti-

cipant to make a cup of tea in the kitchen.

observations afterwards. They were asked torefrain from interacting with the older adult,unless they felt the older adult was upset,frightened, or uncomfortable. A researcher waspresent at all times to monitor the older adults’responses and to intervene if necessary (e.g., forpersonal or technical assistance). Older adults andcaregivers completed semi-structured interviews(and questionnaires) separately. Interviews with theolder adults were conducted with the robot nearbyto allow reference to the robot as needed. Thesemi-structured interviews, while including specificand concrete questions intended to be easilyunderstood, were also flexible to allow interviewersto ask further questions to explore ideas broughtup by the participants. The interview guides forthe older adults and caregivers are included inappendix A1 (published as supplementary materialonline attached to the electronic version of thispaper at http://journals.cambridge.org/ipg). Audioand video recordings were made throughout eachstudy session.

Qualitative data analysisInterviews were transcribed verbatim and reviewediteratively by two authors (RHW and AS). Them-atic analysis was conducted with the transcriptsto gain insight into how participants perceivedtheir experiences with the robot. Thematic analysisallowed for categorization of large amounts ofdata so that they can be interpreted, enabled

pattern identification, and made it easier totease apart consistencies and variations withinand between the groups (Saunders and Byrne,2002; Braun and Clarke, 2006). Initially, the twoauthors familiarized themselves with the individualinterviews for the older adults and the caregivers.Data were examined by dyads and within groupsto explore themes beyond comparisons of the twogroups. The authors individually reviewed anddeveloped preliminary codes for three sets of dyadinterviews (30% of randomly selected sets). Theauthors reviewed each transcript together to discussindividual codes. Assumptions and differences ininterpretations were discussed until agreement.The coding scheme was refined and preliminarycategories for the data were defined. Both authorsindividually and then together reviewed the othertranscripts to refine the codes and categories.Categories were then organized into a thematic mapwith themes and subthemes. Continued analysiswith the other authors to explore alternativeunderstandings of the data helped to consolidatethe themes. Segments of transcripts that bestrepresented the themes and subthemes wereincluded in the manuscript as illustrative examples.

Several strategies were used to ensure trust-worthiness (Saumure and Given, 2008) in thedata collection and analysis. The authors whoconducted the interviews (RHW and MB) andother members of the research team debriefedfollowing each dyad’s study session to reflecton initial observations and interview findings.Strategies to refine interview questions andtechniques were discussed in preparation for sub-sequent study sessions. To enhance dependabilityand credibility, two authors analyzed the data.The two authors also reviewed, compared, anddiscussed individual cases to examine those thatsupported or challenged emerging ideas. Finally,the diverse backgrounds of the researchers servedas a form of triangulation to examine biases andalternative approaches to understanding the data.The authors have complementary backgrounds inoccupational therapy, biology, psychology, robotics,and biomedical engineering.

Results

Description of participantsTen dyads were recruited from one communitycare agency. Dyads were numbered, where OArepresented the older adult and C representedthe caregiver. Table 1 summarizes the demographicinformation of participants. OA1 and C1 wereunable to complete the full interviews because of

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72 R. H. Wang et al.

Table 1. Participant demographics

older adult age gender mmse 1 lives alone (Y/N) caregiver age relationship............................................................................................................................................................................................................................................................................................................................

OA1 76 F 9 N C1 36 SonOA2 86 M 24 N C2 76 WifeOA3 88 M 25 N C3 58 DaughterOA4 77 F 25 Y3 C4 48 DaughterOA5 59 F 182 N C5 59 HusbandOA6 63 M 23 N C6 63 WifeOA7 77 F 252 N C7 78 HusbandOA8 83 F 192 N4 C8 56 SonOA9 84 F 25 Y C9 54 DaughterOA10 85 M 15 N C10 74 Wife

1MMSE: Mini Mental State Examination.2Item for spelling “WORLD” backwards as opposed to serial counting.3With dog.4In separate suite of son and family’s home.

Table 2. Overview of themes and subthemes

themes subthemes............................................................................................................................................................................................................................................................................................................................

1 Contemplating a future with assistive robots ImpressionsRobots for home use

2 Considering opportunities with assistive robots3 Reflecting on implications for social relationships Influence on caregiving dynamics

A robot’s role: Friend or appliance?

time limitations and OA1 was also fatigued and haddifficulty responding to all of the questions.

Summary of themes and subthemesTable 2 summarizes results from the thematicanalysis presented as themes and subthemes.

Theme 1: Contemplating a future withassistive robots

Impressions

Both older adults and caregivers were captivatedby the novelty of the robot. Reflecting on herexperience with Ed, OA7 exclaimed: “Oh Iwas fascinated!…it’s coming towards you…it’s gettingmessages…it’s almost like watching something onTV…the whole thing has been great.” C6 relayed herstory of hearing about study: “…when they called usto see if we’d be interested …to work with a robot, I kindof laughed, I thought that sounded crazy…having seenit work… I’m not thinking it’s crazy anymore…Yousold me.”

Participants wanted to learn more aboutrobots out of curiosity, but also wanted moreinformation or exposure before considering a robotin their lives. OA2 wondered about reliabilityand maintenance needs. Caregivers posed specificquestions on the robot’s development, adaptability,and appropriateness for varying users. C9 askedabout the robot’s suitability for users with varying

cognitive levels and questioned if the robot couldadapt to users’ preferences and changing abilities.C10 wondered about cost-effectiveness, how long aperson with AD might make use of a robot, and alsowhether it may be reprogrammed for someone elseif the original owner no longer needed it. Overall,the experience was thought-provoking and novel forparticipants and many had not considered such apossibility prior to this study.

Robots for home use

Older adults’ views were mixed with regards tohaving robots assist in their daily lives. Some didnot want a robot (e.g., OA1, OA10), others wereunable to respond (although appeared to enjoy theinteraction, e.g., OA5, OA6), and the remainingwere open to robotic assistance. Most participantsfelt they did not need one, but considered it as afuture possibility. Primary reasons for not wanting arobot were because they lived with a family memberwho helped them or they did not feel they were at astage where a robotic assistant was necessary. Thetwo older adults with mild dementia and who livedalone (OA4 and OA9) were among those who didnot feel a robot was needed. Other reasons for notwanting a robot at the time included psychologicalreadiness (e.g., OA7 was not prepared to havesomeone in addition to her husband remindingher of things), preference for assistance froman “efficient human being” (OA9), challenges in

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Robots to assist daily activities of older adults 73

learning new skills, and the robot’s questionablecost-effectiveness (OA10). Older adults suggesteda robot would be useful for someone living alone,who did not have help, or whose health, primarilyphysical health, they perceived as worse off thantheir own. OA4 indicated that a robot would beworthwhile later if it prevented a move to a carehome and reduced her reliance on her children.

The caregivers’ openness and willingness towardrobot use diverged from the older adults’ withregard to the timing of having a robot. Most wereopen to the possibility of using assistive robotsand several (C3, C4, C6) would use a robot rightaway. C6 especially welcomed the possibility: “…Ithink it[‘d] be fun to take it home with me andtry different things…just to see, which ones it wouldwork with and which chores it wouldn’t and see how[OA6] would respond to it…I need all the help Ican get believe me….” C4 enthusiastically stated,“Work faster so then we can get them in the houses foreverybody…I thought it was awesome.” Caregivers’openness toward robot use did not differ whenconsidering the older adults’ stage of dementia orwhether the older adults lived alone. Interestingly,some caregivers incorrectly felt that the older adultswould be just as open as they were to using andintegrating a robot right away.

Theme 2: Considering opportunities withassistive robotsRegarding the two activities explored in this study,most participants did not feel that promptingassistance from a robot was necessary during handwashing, as this was a common activity. Tea-makingin contrast was a more complex and unfamiliaractivity, and so prompting from a robot was seenas beneficial.

Direct interaction with the robot stimulatedmuch consideration for other daily activities inwhich reminders and prompting assistance maybe useful. Caregivers tended to provide moreactivity examples and tended to be more specificin their suggestions compared to the older adults.Caregivers often focused on needing support toensure older adults’ physical safety (e.g., detectionof falls, or reminders for locking doors, or turningoff the stove), but in contrast, none of the olderadults mentioned needing safety reminders. Therobot was acknowledged by some of the olderadults and caregivers to be applicable to assistingolder adults to complete unfamiliar activities (e.g.,for OA4 – making tea) and reinforcing routines(e.g., for C6 – getting up in the morning,weighing himself, taking blood pressure). Examplesof opportunities ranged from reminders of generalinformation (e.g., appointments, orientation to

time, locations of items, safety precautions) toassistance with basic activities of daily living(e.g., dressing, showering) and more complexinstrumental activities of daily living (e.g., payingbills, taking medications, preparing meals, doinglaundry). Caregivers mentioned instrumental activ-ities of daily living such as cooking and cleaningto be important to facilitate with older adults,as they often wished to contribute to householdactivities. The assistance levels ranged from high-level reminders to stepwise prompts, as caregiversnoted many activities necessitated detailed step-by-step prompting because of uninitiated, missed, orout of sequence steps.

The varied examples and expressed needshighlighted potential benefits of using embodiedsystems (e.g. mobile interactive robot with a socialpresence) as opposed to static or embedded systems(e.g. notes, reminder boards or even embeddedsensors and screen interfaces). Older adults carriedout activities in different locations in the homewhere context-specific and often dynamic andtailored reminders or prompts were required. C7suggested using a giant memo device with theday’s events or leaving notes but he, along withother caregivers, recognized that these aids werenot consistently or effectively used. For example,older adults had to remember to go to a specifiedlocation to get required information. Once therethey may not remember the context of the neededinformation. C6 noted how readily OA6 conversedwith the robot and felt that he would enjoyengaging with a social robot that provided himwith needed orientation and activity informationand thereby minimize confusion and frustration.She noted the usefulness of such a robot: “…if Icould program that robot at the beginning of everydayjust to repeat what day it is, what month it is, whatthe activities are for that day… if I had a robot thatjust could repeat every ten minutes, he could pushthe button and the robot would repeat to him todayis….” C8 mentioned that a robot could function toreduce anxiety and to provide answers to repetitivequestions; the social presence of the robot couldinduce feelings of comfort for the older adult.The interactivity and social presence of a robotmay be useful for complex activities that requiredolder adults to make context-specific choices.Dressing was identified by several caregivers tobe a challenging activity because of the choicesthat need to be made to select suitable clothing(e.g., to put on a clean shirt or event-appropriateclothing) and the need to locate and sequenceclothing to dress appropriately. C7 described thedaily dressing process to be difficult because OA7required stepwise prompting but refused familyassistance. An interactive robot that prompted,

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74 R. H. Wang et al.

offered positive encouragement along the way,and offered choices that respected her autonomycould better enable activity completion. C2 noted,however, that complex medication regimes or thoserequiring physical administration (e.g., eye drops)would likely not work, even with an embodiedrobot.

Theme 3: Reflecting on implications for socialrelationships

Influence on caregiving dynamics

Experiences with the robot generated discussionaround the potential impact of a robot on care-giving dynamics. Both older adults and caregiversgave examples showing the varied ways in whicha robot may improve interactions and relationshipsby avoiding conflict, decreasing worry and anxiety,and moderating frustrating interactions that mayhave long term consequences. Some caregiversfelt that if the robot provided accurate promptingassistance, they could focus their resources on otheraspects of the relationship. OA4 stated that a robotmight allow her to stay living at home longer andavoid family conflict in deciding with which of herchildren she would live. C6 and C8 illustrated thefrustrating daily interactions they experienced andidentified that a robot could reduce relationshipstrain. C6 stated: “…this is where your wallet is,this is where your keys are, those are the things thatwe just spend so much time going over and over….Ijust feel so repetitive and then I lose my patienceand then I feel terrible…cause it’s not his fault.”She recognized that her husband was impactedby these interactions because he apologized forasking repetitive questions or he tried not to askfor help. She thought a robot may be a solutionbecause asking a robot may be perceived as beingless burdensome than asking her. C8 acknowledgedthe escalating and negative effects of frustratinginteractions on their relationship: “…Those areactually the things that drive you crazy…It’s difficultfor them but they often are not the ones who are,you know frustrated by it… it’s not good for thembecause, you get frustrated as the caregiver and theycan see you’re frustrated that you just answered thesame question for th…72nd time….” C8 reported thathis mother needed constant reassurance such thatthe family was unable to leave her alone: “…shegets anxious being by herself…Far as she knows we’regone forever…” After observing his mother speakingwith the robot, C8 suggested that a robot mighthelp reduce some anxiety and relationship strain. Arobot companion could pacify some of her anxietyby answering her questions about where her familyhas gone, reminding her when they will return, andassisting by calling them if needed. A robot could

also help with difficulties in finding a caregiverfor two to three hours, alleviating stress for thewhole family. C8 suggested that a robot mighthelp his mother perform daily activities because“…she doesn’t like it sometimes when we help her”.He was encouraged because he saw that she readilyasked questions of the robot about the next stepsto carry out rather than wandering around lookingconfused, which was usual at home.

Worthy of mention was participant, OA7, whodescribed a potentially strained relationship withher husband, and contrary to other participants’reports, she suggested that a robot might negativelydisrupt her relationship with her husband. She wasacutely aware of her declining abilities and valuedthe time they spend together doing householdchores. She worried that he may want a robotso that he could spend more time alone with hiscomputer at the expense of spending time with her.

A robot ’s role: Friend or appliance?The robot interactions stimulated deliberation ona robot’s varied role in social relationships, withsome notable consistencies and variations amongolder adults and caregivers. The role that a robotmight assume ranged from a friend who supportedsocial and emotional needs to a machine thatenabled activity performance in the home with littlecapacity for personal connection. Most superficialwere variations in how participants addressed therobot (i.e., “he” or “it”) and the extent to whichparticipants attributed human-like qualities to therobot. Many of the older adults, but none ofthe caregivers, showed ambivalent responses. OA3stated that the robot was “an inanimate object”but recalled his conversation with the robot anddetermined that he was no longer sure since itcould provide companionship for someone who wasalone. OA8 who expressed some degree of socialisolation spoke most compellingly of a robot beinga valuable friend. The robot was “somebody” shecould talk with, that she could tease, and thatshe did not resent. She enjoyed the exchange withthe robot. The robot’s presence might feel like therewas someone in the house so there may “not [be]so many spaces of emptiness”. Nevertheless, she saidrobots are “a necessity, but you can never replacepeople”.

As many older adults as caregivers viewed therobot as a machine-like appliance. OA9 poignantlyasserted the robot’s place: “…[I was] doing what Iwas asked to do, and… instead of talking to a person Iwas talking to a machine….it’s still a machine…whicha human being is not….” She added, “…you don’tfeel connected to it because it’s a robot and you’renot….” Similarly, C7 felt that the connection or

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Robots to assist daily activities of older adults 75

attachment with people would not be there: “I don’tthink anybody is going to become attached to it…evenin the deepest of dementias I don’t think anybody’s goingto suddenly go over and hug it and kiss it and say, that’smy friend…” C10 was also convinced that the robotwas a machine: “… it’s a piece of machinery… justlike your computer screen …I just saw the two eyes thenose and… well it doesn’t really make you responsive,emotion response, it’s a piece of machinery.”

Discussion

Qualitative analysis of the semi-structured inter-views offered evidence to support the proposedpractical and social benefits of robots to carefor older adults with mild-to-moderate AD andto help caregivers. Robots to assist older adultswith dementia by providing stepwise promptsare uncommon. Findings also revealed that whilesome caregivers were eager, older adults wereopen to the idea but not prepared to haverobots assist them. This paper contributes findingsto advance the field by presenting previouslyundocumented in-depth perspectives of olderadults and their caregivers on whether they wanta robot, opportunities they see with home robots,and the anticipated relationship consequences ofrobot use. The following discussion addresses theresearch questions in relation to the resultantthemes, presents important considerations forassistive robot development and integration, andoutlines the study’s limitations.

Perceptions and consistencies or variations inperceptionsOlder adults in this study, with a few exceptions,were curious and open to the idea of assistiverobots. Other studies have shown that older adultsrespond positively towards robots after watchingvideo demonstrations of a robot’s capabilities suchas delivering objects (Smarr et al., 2014) or livedemonstrations of a robot with functions such asplaying a memory card game (Louie et al., 2014).While open to the idea, none of the older adultsin this study expressed the immediate desire touse one. Their reasons for not wanting a robotsuggested a lack of perceived need for the robot’sservices. Others studies have demonstrated thatolder adults are accepting of assistive technologyif benefits of use are clear (Mitzner et al., 2010).Participants in our study considered future robotuse, if their health, especially physical healthdeclined. The robot was deemed useful for otherswhose health was worse off than their own orwho were socially isolated, suggesting that theyperceived themselves to be more able or better

cared for than the expected users. Similarly, Wuet al. (2016) found that older adults with mildcognitive impairment felt they did not need anassistive robot as it would be useful for thosewho were older or more disabled. These findingsindicate that the social stigma often associatedwith assistive technology users being old ordisabled extended to robot users. Alternatively,maintaining autonomy and independence is ofutmost importance for older adults with dementia(Samsi and Manthrope, 2013) and this maytranslate to robot use. At least for OA4, if using arobot allowed her to live independently at home forlonger, a robot would be a serious consideration.

Caregivers in this study were more openand accepting to having a robot sooner, andsuggested more opportunities for activities in whichrobots may help compared to older adults. Dailychallenges with care and management of olderadults’ AD-related symptoms may have contributedto the differences in perspectives. Caregiversoften experience the shortcomings of currentstrategies to assist in daily activity performance,maintenance of safety, and support for wellbeing.Studies of family caregivers of persons withdementia have suggested that technology may beuseful to address many of these shortcomings(Broadbent et al., 2012; Rosenberg et al., 2012;Kerssens et al., 2015). In the study by Broadbentet al. (2012), caregivers mentioned that if arobot could do certain tasks (e.g., distributingmeals), caregivers could have more time to spendwith residents. Cognitive impairments in memory,abstract thinking, awareness of limitations, orfamiliarity with technology may also have hinderedolder adult participants from describing moreopportunities.

Implications for social relationshipsThe second objective explored the implicationsof introducing a robot in the care of an olderadult with AD and how this might impact socialrelationships. In a relationship-centered approachthat is necessary in dementia care, it is imperativethat assistive technology provide older adults withcognitive support and assistance to participatein daily activities, and provide caregivers withassurance and respite (Topo, 2009). Findings fromthis study indicate that there are differences inthe views of older adults with mild-to-moderateAD and their caregivers toward robot use. Abalance must be achieved to ensure that robotsare recommended based on the older adults’ andcaregivers’ needs and preferences, otherwise thereis a risk for loss of autonomy, privacy, and dignityfor the older adult.

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76 R. H. Wang et al.

Participants indicated that robots may help olderadults to carry out daily activities with less caregiverreliance and may decrease relationship strain. Somecaregivers expressed worry, stress, exhaustion, andfrustration owing to the older adults’ agitation,anxiety, and repetitive questioning. These areknown behavioral and psychological symptomsof dementia and arguably the most challengingsymptoms for family caregivers to manage (Kaleset al., 2015). Having robots take over frustrating orrepetitive activities can free caregivers to do morevalued activities with the older adult. With someparticipant dyads a robot may help to decreaserelationship tension when an older adult with ADdoes not like receiving help from a caregiver ordoes not want to constantly ask for help. While theexperience of caregiver stress results from multiplefactors, further study is needed to ascertain whethera robot can moderate caregiving stress or increasethe frequency of mutually positive experiences.

A critical concern with assistive robots includesimplications for social contact. Social contact andsupport are important for well-being and olderadults with dementia are at risk for experiencingloneliness (Moyle et al., 2011). OA7 highlighteda common concern of whether or not having anassistive robot decreases social contact (Sharkeyand Sharkey, 2012) or results in neglect by family.In contrast, some older adult participants spokespontaneously of the robot’s potential to functionas a social companion. Caregivers also value thecaregiving role and so they may not want to be“replaced” by a robot (Vallor, 2011). Prevalentbenefits of caregiving include having a strongersense of companionship, developing a sense ofreciprocity, fulfilling a duty/obligation, feeling anincreased sense of competence and personal growthas one assumes a caregiving role, and having a senseof improving the quality of life for the care receiver(Cohen et al., 2002; Peacock et al., 2010). Thevariations in participants’ responses highlight thenecessity to understand the needs, preferences, andliving situations of older adults and their caregiversif considering the inclusion of a robot in daily care.

Considerations for assistive robotdevelopment and integrationSeveral considerations emerged that will benecessary for the development of useful robots andthe future integration of robots into the homes ofolder adults with AD and their caregivers.

1. Participants expressed general interest and desireto learn about robots for daily activities. It will becritical for researchers to pursue this dialogue withother older adults and caregivers in the contextof public education and robot development to

continue knowledge exchange. With knowledgeand engagement, acceptance and integration ofnew care approaches may be enhanced.

2. Findings showed that older adults with AD andtheir caregivers have different views on aspects ofrobot care and functions. Both views need to beaccounted for in a relationship-centered approachto dementia care. If an assistive robot is considered,it is critical to be mindful of the social needs andrelationship dynamics of older adults and theircaregivers. The choice of involving any technologyin care needs to be individually determined by anolder adult and his or her caregiver(s).

3. Implementation goals of assistive robots may be toenable older adults’ autonomy and performance ofdaily activities, decrease frustration and stress ofolder adults and caregivers, and decrease caregiverburden without compromising social relationships.Long-term studies with assistive robots in thehome setting will be necessary to demonstrate ifthese goals are achievable.

4. Participants expressed numerous possibilities forthe development of robot functions for dailyactivities that are familiar or new, and simple tocomplex. The diversity of opportunities named,especially by caregivers, also means that thetechnology will need to be customizable.

5. Adaptability of the technology to changing needsof users with dementia and their caregivers willneed to be considered to support acceptance andlongevity with regards to robot use.

6. Participants’ perceptions of the robot’s role variedfrom companion to appliance. Researchers needto be cognizant of the roles that older adultsand caregivers expect of robots and the possiblerelationships that users anticipate so that robotsmay be designed with the interfaces and functionsto meet these expectations. It cannot be assumedthat older adults want robots to be their friends.

7. Some older adult participants alluded to thestigma associated with using technology intendedfor older people with whom they did notidentify. The implications of stigma on non-acceptance of potentially beneficial technologyneed to be considered by developers, researchers,and clinicians. Some of these issues may beaddressed by designing technology that may beusable by everyone and customizable for those whohave specific needs. Robots that may be usableby the whole family may be more acceptable andclinicians may introduce technologies earlier suchthat older adults may have the opportunity tobecome familiar with a robot that supports futureneeds.

LimitationsThis study has multiple limitations. The 10 dyadswho participated may not be representative of thepopulation of older adults with mild-to-moderateAD and their caregivers. There is potential forvolunteer bias as people who are more open to

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Robots to assist daily activities of older adults 77

participating in research or to technology such asrobots may be more likely to participate. Whileefforts were made to recruit from diverse sources,all participants came from one memory clinic.However, participants varied with respect to age,cognitive levels, abilities, symptoms, and care needsfor older adults, living situations, and relationshipstatuses. Transferability of the findings to otherolder adults with AD and their caregivers needsto consider the backgrounds of the participants.The unfamiliar environment, novelty of robot use,and degree of stimulation from being in the studymay influence how participants perceived the robotinteraction. Participants interacted or observed aninteraction with a tele-operated robot prototype soit may be challenging for them to imagine how anautonomous robot might function in the future.This may limit the possibilities of how the robot isperceived. Older adults’ memory impairment andrecall bias may make it difficult to get reliableaccounts of their experiences. However, even ifshort-term memory for events was impaired, theywould be able to express their overall impressionsor affective responses to the robot. Including theperspectives of caregiver observers greatly adds tothe interpretation of the findings. There is alsopotential for social desirability bias, where parti-cipants respond in a way they believe they will beperceived more positively. Researchers encouragedparticipants to respond critically and stressed thatthe robot was a prototype and that feedback wouldbe applied to make improvements. Participantswere exposed to the robot for only a short timeso factors such as novelty may have impactedparticipants’ responses. Long term studies in realhome settings are necessary. Studies with a largernumber of dyads are needed to explore patterns ofresponses to robot care, for example with respect torelationships between openness to robot care andthe severity of dementia or the living situation ofolder adults (e.g., living alone or with a spouse).

Conclusions

The study addresses several important gaps inthe development and implementation of assistiverobots for older adults with mild-to-moderateAD and their caregivers. Through interviewsfollowing robot interactions, in-depth perspectiveswere solicited on robots that help with stepwiseprompting for daily activities. Few projects haveincluded older adults with this degree of cognitiveimpairment in the development of robots that assistwith daily activities at home. Older adults in thestudy did not feel they needed such a robot at thetime of the study, but felt an assistive robot could be

useful for a range of daily activities for those whoneed the help. Most were open to the idea in thefuture. Caregivers were more open to an assistiverobot and identified a broad range of activitiesand ways in which a robot could help. Severalcaregivers would like to have a robot at home at thetime of the study. The introduction of an assistiverobot to a caregiving scenario could have positiveand negative consequences including decreasedfrustration and stress on both older adults andcaregivers resulting in decreased relationship strain,increased social interaction for older adults ifthey felt the robot could be a companion,or decreased social interaction with caregivers.Ongoing dialogue between users and developersand careful consideration of robot design andcaregiving relationship factors are necessary toachieve the potential of assistive robots.

Conflict of interest

None.

Description of authors’ roles

R.H. Wang formulated the research questions,designed the study, collected the data, analyzed thedata, and wrote the paper. A. Sudhama analyzedthe data and assisted with writing the paper. M.Begum collected the data and reviewed the dataanalysis and the paper. R. Huq developed the tele-operated robot used in the study, assisted withcollecting the data, and reviewed the data analysisand the paper. A. Mihailidis obtained the fundingand supervised the study, assisted with formulatingthe research questions, assisted with designing thestudy, and reviewed the data analysis and the paper.

Acknowledgments

The authors wish to thank all the participantswho were involved in this study and gratefullyacknowledge the assistance of Drs. Jennifer Boger,Goldie Nejat, and Sharon Cohen. Funding forthe study was provided by a Canadian Institutesof Health Research Catalyst Grant: Pilot Projectsin Aging (201009). Funding for R.H. Wang wasprovided by a Canadian Institutes of HealthResearch Postdoctoral Fellowship.

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