One of the most important aspects of dementia care is the maintenance of communication between people with dementia, family and staff so that care provision can be appropriately individualised [
1]. The loss of in-depth communication, as well as social conversations, can result in the person with dementia feeling socially isolated and without the opportunity to express their needs [
2]. Communication is further challenged by the disease state; people in the advanced stages of dementia lose the ability to express emotions verbally. Recent research however, has shown that analyses of non-verbal behaviours are an important means to assess emotional states in people with dementia and can help staff and family to individualise attention in order to encourage positive emotional states [
3].
When the person enters long-term care, communication opportunities with family can also be further reduced. This is particularly the case in situations: where work pressures challenge family; the distance to the long-term care facility may inhibit opportunity to spend time with their family member; and, family may feel they have a limited role in the provision of care [
4,
5]. Opportunities to connect families and people with dementia living in long-term care may now be made possible through new technologies such as telepresence robots. The aim of this study was to assess the feasibility of using such technology to enhance engagement between the person with dementia living in long-term care and their family.
Telepresence robots
Telepresence robots were first described in the literature as a human-machine interface. Telepresence robots do not possess autonomous behaviours and therefore they require a remote user to operate them. Through the telepresence technology, the operator can virtually see into another space through a two-way camera and can operate the robot via software on their computer. The operator can therefore feel they are physically present at the location of the robot no matter where the robot is located [
6]. Recent advances in information and communication technologies have facilitated the development of telepresence robots for consultations in healthcare and teaching settings [
7,
8]. However, given the newness of this technology, there are few noteworthy research papers available and discussions on the use of such technologies with older people have only recently surfaced.
The concept of a telepresence robot for in-home care for older people first appeared in the literature in 2007. Independently a group from Canada examined the requirements for an in-home telepresence robot through focus group discussion with six older people and six healthcare professionals. This qualitative research identified potential applications of opportunities where older people might use such a robot, such as to connect with staff and family [
9]. A team from Taiwan developed a prototype telepresence robot named “TRIC” (Telepresence Robot for Interpersonal Communication) to allow older people to remain at home while family and caregivers communicate with and monitor their older family members’ safety and health. “TRIC” was tested in a laboratory environment [
10]. According to the researchers, “TRIC” enabled an older person to recognise the telepresence robot as a representation of the operator, for example family, and this is thought to lead to effective communication.
Further developments have been advanced in the area of health consultation. The Physician-Robot is a 5-foot-tall telepresence robot equipped with a real-time video display on its flat-screen head. This robot is designed to facilitate easier and more frequent interactions between physicians and their hospitalised patients. Ellison and colleagues [
11] tested the effectiveness of the Physician-Robot with patients who required postoperative care. Patients, who were offered robotic tele-visit bedside rounds, reported substantial improvements in quality of care when compared with patients who received a standard once daily bedside round with the physician. Enhancements were observed in ratings of examination thoroughness, quality of discussions about medical information, postoperative care coordination, and satisfaction with physician availability. Similar results were also reported in another study, where 80 per cent of study participants indicated marked improvements in physician availability and interaction quality.
A telepresence robot designed specifically for older and disabled people includes the Giraff (Giraff Technologies AB) [
12] and VGo (VGo Communications Inc.) [
13]. VGo was originally designed for communication in business but VGO is now being used in hospital and assisted living communities. Both Giraff and VGo are also being tested in long-term care by the authors of this paper. Long-term care refers to facilities such as nursing homes that provide healthcare to people who are unable to manage in the community.
The most recent and advanced feasibility investigation of telepresence robots is taking place in a European project called ExCITE (Enabling Social Interaction Through Embodiment) [
14]. The Giraff robot is being tested by the ExCITE team [
15]. Giraff is a remotely controlled, mobile, human-height, telepresence robot. The researchers aim to develop and refine a prototype of Giraff through the involvement of end users and to explore the use of it for addressing social isolation and loneliness. The program also seeks to examine the interaction between the users (e.g. users, family, physician, and relevant organisation) and the telepresence system [
15].
Giraff is currently manufactured in Europe and is equipped with a videoconferencing system that includes a video camera, LCD screen, speaker and microphone. Giraff is battery powered with a charge lasting approximately one hour. A docking station charges the battery in around two hours. A standard computer with Giraff software allows the user to move Giraff by holding down the left button on a standard computer mouse while pointing to a place within the environment. This action will enable Giraff to move to the place indicated on the user’s computer screen. Giraff is intended to move forward but can turn in a circle as well as move backwards if it becomes stuck, for example, on a rug. The base of Giraff moves using a differential drive system. Giraff weighs 14 kg, enabling it to be easily transported as well as carried up stairs using an inbuilt carrying handle. It cannot however, climb stairs or inclines. The large video screen allows the user’s face to be near life size and the head can be tilted and moved sideways to simulate eye contact, as well as to control the field of view. During the testing of Giraff end users reported concerns in relation to privacy, which resulted in the development of a database to manage who has access to Giraff and a call button so that the user can respond or cancel calls. Giraff cannot directly connect to a cellular network to provide Internet access and relies on a USB wireless adapter (dongle) that is connected to one of Giraff’s exterior USB ports. This allows Giraff to connect to any available wireless network that provides Internet access and to establish calls. For the current project we added an external modem to Giraff to receive the cellular network from the telecommunication provider and the modem’s inbuilt router created and transmitted a secured wireless network for Giraff to connect to the Internet.
In the ExCITE project, further research proposed by European researchers Tiberio et al. [
16] plans to compare the implication of Giraff between a treatment group of five older people with Mild Cognitive Impairment and a control group of five hospitalised older people without MCI. Over three phases, the researchers will introduce participants to Giraff, demonstrate its functions, and facilitate basic communications between participants and researchers. Participant perceptions of social engagement, perceived utility and privacy will be assessed in an interview at the end of the project [
16]. Physiological markers of stress and measures of anxiety will also be collected. While Tiberio and colleague’s [
16] research will provide an important insight into the use of telepresence robots for older people, the study lacks practical applicability as communication will be with a researcher situated in another room rather than a genuinely remote family member or loved one.
The current project described in this paper used the Giraff telepresence robot to connect a family member and a person with dementia as a means of enhancing communication between these two parties. Using this videoconferencing, ‘skype-onwheels’ like system, families can ‘virtually’ visit people with dementia – engaging in two-way conversations, with their face appearing on Giraff’s ‘life size’ video screen for the person with dementia and allowing the family to view the person and their surroundings. Using such technology the family member can, from anywhere in the world, use their computer to virtually drive Giraff to the resident as well as anywhere within the long-term facility that offers a flat surface. There are many potential situations in which telepresence robots could be used to support older people and promote social interaction. However, the newness of this technology means there are limited studies that have tested the feasibility and the effectiveness of this particular technology in an older population and in particular with people with dementia living in a nursing home environment. This current project will add to information gathered in the ExCITE project as this project was conducted outside of Europe.
This study aimed to explore the use of a Giraff telepresence robot as a means of positively influencing communication and relationships between residents with dementia living in a long-term care facility and their family, and to examine the feasibility (according to the Bowen Feasibility Framework [
17] as outlined p. 9) of implementing a Giraff robot in a long-term care facility with older people with cognitive impairment. A feasibility study is an analysis of the viability of an idea, and in this case whether to use Giraff in a long-term care facility. As there is limited research in the use of telepresence robots it is important that small-scale projects such as this are made available so that researchers and clinicians are able to consider the use and further trial of this type of technology as well as the potential factors involved in the trial of telepresence robots in such settings.