Elsevier

Geriatric Nursing

Volume 42, Issue 1, January–February 2021, Pages 37-45
Geriatric Nursing

Featured Article
The effect of PARO robotic seals for hospitalized patients with dementia: A feasibility study

https://doi.org/10.1016/j.gerinurse.2020.11.003Get rights and content

Highlights

  • Robotic seal therapy for patients with dementia has not been studied in acute care.

  • Eligibility challenges include: pacemakers, wounds, isolation, informed consent.

  • Physiological measures may not be the optimal evaluation metrics for acute care PARO interventions.

  • Participants' behaviors and comments show beneficial PARO interactions.

Abstract

Robotic seals have been studied in long-term care settings; though, no studies of patients with dementia in the acute care setting have been reported. The purpose of this study was to evaluate the feasibility of PARO interventions for hospitalized patients with dementia, determine physiological effects and describe social-affective interactions. Using a prospective descriptive design with pre-post PARO intervention physiological measurements, we studied 55 participants who received up to five 15-min PARO interventions. The PARO was favorably accepted for 212 (95%) of the 223 PARO interventions. Differences in pre- and post-physiological measures for mean arterial pressure, pulse, respiration, oxygenation, stress, and pain levels were evaluated using Wilcoxon Signed Rank test with statistically significant pre and post differences (p=<0.05); however, the differences were not clinically significant. Participants (95%) demonstrated beneficial PARO interactions with the most frequent interactions being speaking and petting. The PARO shows promise for enhancing social and affective responses for hospitalized patients with dementia.

Introduction

Caring for hospitalized older adults with dementia is challenging. These patients often are anxious and increasingly so when confronted with the high stimulus hospital environment, unfamiliar caregivers, painful procedures, and new medications.1 Currently between 5.5 and 5.8 million Americans are living with Alzheimer's dementia.2,3 Older adults with Alzheimer's and other forms of dementia are hospitalized at a rate twice that of individuals who do not have Alzheimer's or dementia.2,4 Addressing the needs of hospitalized patients with dementia is essential for promoting therapeutic environments and favorable outcomes.

Dementia is characterized by progressive impairment5 and decline in cognitive and functional domains.6 Following a diagnosis of dementia, patients frequently exhibit a sequela of behavioral and psychological symptoms of dementia (BPSD) with the most common being apathy, agitation, aggression, irritability, anxiety and resistance to care.1,7 In addition, hospitalized patients may experience delirium, an acute change in mental status with altered level of consciousness and orientation, hyperactive behaviors, impaired speech, and disorganized thinking.8 Delirium superimposed on dementia (DSD) is common and frequently under-recognized in hospitalized patients thus leading to heightened BPSD and further cognitive decline.1,8

Non-pharmacological interventions for dementia and BPSD are desirable and should be considered as first-line therapies.1,6,7 Robotic pet therapy is one non-pharmacologic approach that has been implemented and studied in long-term care settings.9, 10, 11, 12, 13 Robotic pet therapy is similar to live animal (usually dog) therapy without the disadvantages of potential allergies, infections, or scratches and bites.12 One of the most popular of the robotic pet therapy devices is the PARO (Japanese for personal robot) robotic seal.14 The PARO is an 8th generation, FDA-approved, neuro-therapeutic device (Fig. 1).15 With sensors for sound, light, temperature, touch, and posture, the PARO engages with individuals through movement of its tail and flippers, opening and closing of eyes, and sounds that are similar to a live baby seal reflecting emotions of surprise, happiness, and anger.16,17 The PARO has a fur-like covering that has anti-bacterial properties.18

Researchers have identified beneficial physiological and psycho-social effects using socially assistive robots (SARs) such as the PARO with older adults who have dementia.12,13,16 Petersen and colleagues12 studied the effects of using a robotic seal in a group dementia care setting for 20 min three times a week over a three-month period. Study findings showed positive results for reducing anxiety and depression with improvement in physiological measurements for oxygen saturation, pulse rate, and galvanic skin response (a measurement of physiological stress). In a recent randomized controlled trial, Pu, Moye, Jones and Todogvic13 noted that participants receiving PARO interventions (n=21) versus usual care (n=22) in the long-term care setting had a significantly lowered level of observed pain (−0.514, 95% confidence interval (CI) −0.774 to −0.254, p < .001) and received fewer PRN medications. In another randomized study of patients with dementia (n=415) at 28 long-term care facilities, Moyle and colleagues16 found that the PARO was superior to the plush toy or usual care in encouraging and engaging participants. Both the plush toy and PARO were more effective than usual care for reducing agitation and improving mood state.

The PARO is one of the most frequently studied SARs with a major focus on patients with dementia in long-term care settings. In a recent scoping review of SAR technology with older adults, Abdi and colleagues9 reviewed 33 SAR studies, with 23 identifying dementia as the study population. In 17 of the 23 SAR dementia studies, the researchers used the PARO robotic seal. Authors described five SAR roles: affective therapy, cognitive training, social facilitator, companionship, and physiological therapy.9 The review showed favorable outcomes for affective, cognitive, and social facilitator roles in 21 of the 23 studies when the PARO was used with older adults with dementia, but these findings were limited by the design and quality of the reviewed studies. A more recent scoping review by Hung and colleagues10 identified PARO barriers and benefits in care settings. Study settings for both scoping reviews included: nursing home, long-term care, veteran residential care, dementia-care home, psychogeriatric care facilities, health service facility, day service center, clinic, group home, and residential care. No studies were reported in acute care settings.

The purpose of this study was to evaluate the feasibility of PARO interventions for hospitalized older adults with dementia, determine the physiological effects, and describe participant social-affective interactions. We hypothesized that the study would be feasible, and participants would have improved physiological pre-post PARO intervention outcomes with positive social-affective interactions.

Section snippets

Study design

This pilot study used a prospective descriptive design with single group pre-post PARO intervention physiological measurements. The study was approved by the system Institutional Review Board.

Sample

Participants were recruited from the orthopedic, progressive cardiac care units, and medical-surgical units at an 898 bed acute-care urban hospital in the Southwestern part of the United States. Participants met the following inclusion criteria: 65 years or older with documentation of dementia and/or

Delirium assessment

The four-question Short CAM (Confusion Assessment Method), also called the bCAM or Brief CAM, was given prior to each PARO intervention to screen for delirium. The bCAM has a sensitivity of 82% and specificity of 96%.20 We incorporated inattention questions21 by asking participants to name the months backward from December to July and assessed orientation to person, place, date and time, and situation.

Physiologic measures

The research nurse assessed each participant's blood pressure, heart rate, respirations,

Demographics

Data were collected on 55 participants, mean age 85.5, range 67 to 104 years of age. The majority were white (n=51, 92.7%) and female (n=38, 69.1%). All participants had dementia documented in the EHR. The most common admitting diagnosis was “fracture” (n=17; 31%) followed by “fall” (n=8; 15%). Demographic information is summarized in Table 1.

Delivery and receipt of the intervention

The dedicated research nurse performed 222 of the interventions with a back-up evening nurse providing one intervention. Most participants received five

Feasibility

Although most participants accepted the PARO intervention, had positive interactions, and completed at least four interventions, we noted several challenges that affect feasibility and deserve attention for future studies. We suggest an upper limit of three PARO interventions as five interventions were difficult to complete within a short-stay format. Stricter study exclusion criteria are needed in the acute care setting compared with long-term care studies. In this study, the most common

Limitations

This single site study did not have a control group. The study lacked diversity as most participants were older white women. We did not differentiate degree of severity or subtypes of dementia diagnoses, and the range of participants’ ages was wide (67–104). We used several models and manufacturers for the vital signs monitoring equipment. The stress thermometer that was used in the study has limited accuracy information. Not all participants completed five PARO interventions over time.

Summary

This feasibility study is one of the first PARO studies from the United States targeting hospitalized patients with dementia. Although there were screening and implementation challenges, we established that PARO acute-care studies are feasible and acceptable. As such, this study lays the groundwork for future acute-care PARO research. Significantly, the participants’ positive social and affective interactions hold promise for using the PARO as a non-pharmacologic treatment for improving the

Declaration of Competing Interest

None.

Acknowledgments

Funding for the PARO seals and research nurse's time was provided by the Chilton Fund for Gerontology held by the Texas Health Resources Foundation.* The authors thank Janet Gehring, PhD, CRNP-P, CPNP-PC for data review, Elizabeth H. Winslow, PhD, RN(R), FAAN for manuscript editing, and the Texas Health Resources’ librarians for literature searching

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    • Socially assistive robots for people with dementia: Systematic review and meta-analysis of feasibility, acceptability and the effect on cognition, neuropsychiatric symptoms and quality of life

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      PARO is by far the most extensively researched robot in dementia care. Several trials had reported benefits of PARO, such as improving quality of life (Joranson et al., 2016c), mood (In Soon and Hee Sun, 2018; Inoue et al., 2021b; Kelly et al., 2021; Takayanagi et al., 2014), pain (Jøranson et al., 2016b), and agitation (Lane et al., 2016b; Pu et al., 2022). There are existing systematic reviews on this topic, but the published evidence for use of robots in dementia had mixed findings, likely due to mixed methodological approach and diverse study quality of these reviews (Hung et al., 2019b; Leng et al., 2019; Moyle et al., 2017a).

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      Previous studies have shown that lack of or limited social resources can increase the risk of dementia by 60% [1], whereas maintaining certain social activities can provide some protection against AD [2]. Thus considering the need for social activities, HRI systems are proposed to interact with the elderly and to assist them in staying socially active, thereby maintaining their cognitive health [3-5]. However, current HRI systems often have inconveniences related to disharmony when communicating with humans [6,7].

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    The Chilton Fund for Gerontology and Texas Health Resources Foundation had no role in the study design, the collection, analysis and interpretation of the data, the writing of the report, or in the decision to submit the manuscript for publication.

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