The effectiveness of various robotic technologies in assisting older adults

Abstract

There is concern about the expanding size of the ageing population and burgeoning care costs for older adults. Robotic technology could assist older adults. In this study, the effectiveness of the robotic technologies is evaluated. A systematic literature review was undertaken of peer-reviewed literature. An initial set of 8533 studies was evaluated for relevance; these were reduced to a final subset of 58 studies finally subjected to analysis. This study categorised the problems encountered by older adults, identified robot types deployed to overcome them and derived a subjective effectiveness score. The most used and most effective robots were companion robots followed by telepresence robots. The findings imply positive effects of robotic technologies in helping elderly people’s problems. Although robotic technologies could bring some innovation into aged care, more research is needed to design and develop robots to be of assistance and support elderly in having an independent lifestyle.

Introduction

The world is ageing at a rapid rate, which means that older adults will take advantage of an increased lifespan in the coming years. It has been predicted that this trend is going to be reinforced and intensified as the number of older adults in aged care increases.

Researchers have shown that the health of older adults deteriorates over the years. ¹ Consequently, they will need more attention in terms of care services, which in turn will result in an increase in the amount of responsibility that falls on caregivers such as family members, friends and other individuals working in the caregiving area. Obviously, families, governments and health sectors would welcome any technological breakthrough that could help them face this problem. Alternative options in this case could result in lower care costs and more independence for older adults living in their homes.

Considering other dimensions, researchers have shown that this problem will worsen in view of the fact that the workforce and number of professional caregivers will decrease in the coming years, as the number of people entering this area is not increasing at the same speed as the increasing number of older adults.^2,3

Researchers who work in academic, governmental and industrial environments have tried to propose new technologies in response to the increasing need for addressing the problems of an ageing population.^4,5 However, although it is most ethical for human caregivers to provide the preferred type of care, other options could be considered, as they may help older adults with independent living. Innovation offers better access to care for older adults in their own homes and could reduce the need for hospital admissions. ⁶

Technologies can support families and professional caregivers with a broad range of equipment for use in aged care, for example, information technology, ⁷ remote monitoring ⁸ and online daily services. ⁹ One of the most promising areas in recent years is robotic technology.

Rapid advances in robotic technologies together with enormous demographic changes have led researchers to realise that robots may be the answer to our aged-care problems, and it is expected that products will have significant roles in assisting older adults. ¹⁰ It has been one of the most researched areas in recent years in relation to assisting older adults, and some researchers have shown that robots can be useful in certain areas of aged care; ¹¹ for example, some robots have been developed for recreational purposes, cooking, companionship and health monitoring. Robots could have major advantages for older adults (people of age 60–65 years and older as World Health Organization (WHO) suggests which is nearly equivalent the age that people normally start to retire as beginning of old age (http://www.who.int/healthinfo/survey/ageingdefnolder/en/)), although the effectiveness of robotic technologies in addressing older adults’ needs has not been researched yet. It is this effectiveness that we estimate in this research project.

Given the above-mentioned issues, the aim of this research project is to identify the position of robotic technology in aged care and to provide a comprehensive picture of its position in older adults’ problems. To do this, the following research questions have been considered:

• RQ1. What type of robot technologies have been developed to address aged care so far?

• RQ2. How effective have robotic technologies been in overcoming older people’s problems?

This study has identified recent researches that have been undertaken in the robotic technology field to demonstrate its roles in aged care, as well as identifying how effective these studies have been in addressing older adults’ problems. This understanding will be useful for older adults and their informal caregivers (family members, friends and other people connected with them) to choose the right robot for the right purpose, in order for the older adult to live in an independent manner.

This research has been conducted through a systematic literature review as suggested by Kitchenham. ¹² Section ‘Methodology’ explains the method and necessary steps taken to conduct this study. In this research, we systematically searched related databases and extracted papers that are relevant to the above-mentioned research questions. We then extracted attributes such as geographical distribution, robot types and problems addressed. Section ‘Results’ discusses the findings, including how we adapt a method to estimate the effectiveness of robots in aged care. Finally, section ‘Discussion’ concludes the article with a discussion of the results, including a demonstration of implications that are useful for the health sector, researchers and other stakeholders involved in the aged-care industry.

Methodology

Aim and procedure of systematic literature review

The purpose of this systematic literature review has been to gather all research literature relating to the application of robot technologies to aged care in recent years and to provide an overview, as well as evaluating the effectiveness of robot technologies in addressing older adults’ problems.

A systematic literature review is a method of systematically searching the literature on a topic using library databases to find relevant papers that meet criteria, extracting information for each study and then interpreting that information to make a brief summary. In this way, results are reliable and can be reproduced by another researcher using the same steps. For this research, the guidelines proposed by Kitchenham ¹² were used, as used by Broekens et al., ¹³ Vichitvanichphong et al. ¹⁴ and Kachouie et al. ¹⁵ They^13–15 mainly discussed socially assistive robots, while in this study we have used comprehensive search to include all types of robot technologies that have been applied in aged care. According to Kitchenham’s method, ¹² three main phases must be carried out: planning the review, conducting the review and reporting the review.

Search terms and targeted databases

The first step to take in performing a systematic review is to develop a set of keywords and to search for them in databases. To generate a general set of keywords to be sought within the publication titles, keywords, abstracts or full texts, we proceeded as follows.

An initial search in the selected databases revealed an enormous number of irrelevant results, including military, space, discovery and industrial robots (manufacturing, welding, handling, etc.). These had to be excluded from the search terms. Additionally, as the term robotics refers to the branch of technology that deals with the design, construction and operation of robots, only the word robot was included. Also, as our research was focused on older adults, we excluded the terms that refer to other age groups, such as young or juvenile. After several iterations, the final word set was as follows:

• Robot AND (old* OR senior* OR elder* OR ‘long lived’ OR aged OR ‘older adults’ OR ‘old adult’ OR ‘old people’ OR ‘older people’) AND NOT (automobile OR car OR industry OR industrial OR automation OR manufacturing OR assembly OR military OR space OR farm OR handling OR exploration OR discovery) AND NOT (young OR juvenile OR adolescen* OR infant OR teenage OR youth OR child)

This research was conducted in May and July 2015. Systematic searches were undertaken in the MEDLINE, ScienceDirect, ProQuest, PubMed, Scopus and SpringerLink databases.

Inclusion/exclusion criteria

The purposes of this step were (a) to narrow and filter the search results from the initial list to obtain a subset of final studies that were relevant to our research questions and could be considered for this research and (b) to exclude the ones that were not pertinent; these included duplicated papers and those with irrelevant titles or abstracts.

To identify relevant papers, a filtering process was applied in five steps. In the first step, duplicate papers were eliminated. The second and third steps were taken to eliminate irrelevant studies based on the title and abstract, respectively. The fourth step aimed to eliminate irrelevant papers by studying the full text. Finally, papers that were identified through citations were added to the paper data pool. The initial search retrieved 8533 title and abstracts, and these were reviewed. The steps followed to identify the final number of papers are demonstrated in Figure 1 and Table 1.

Figure 1.

Relevance appraisal process.

Table 1.

Distribution of papers in each database.

Database name (source)	Initial result	Exclusion based on being duplicated	No. remained	Exclusion based on title	No. remained	Exclusion based on abstract	No. remained	Exclusion based on full text	Final pool
MEDLINE	1743	11	1732	1581	151	130	21	9	12
ProQuest	3007	32	2975	2439	536	503	33	23	10
PubMed	90	3	87	69	18	14	4	3	1
ScienceDirect	799	8	791	656	135	131	4	3	1
Scopus	2004	51	1953	1328	625	581	44	17	27
SpringerLink	890	8	882	748	134	103	31	29	2
Sum based on databases	8533	113	8420	6821	1599	1462	137	83	53
From reference list	−	−	−	−	−	−	−	−	5
Total	58

The papers that met one or more of following criteria were removed from the final set:

• Were not peer reviewed;

• Did not involve older adults or were not related to them;

• Did not include robotic technology that could address aged-care problems;

• Were published before 2000 (as we aimed to study the most recent researches in this area);

• Were not in a pertinent field or could not be related to the current research aim;

• Were not in the English language.

It should be pointed out that the definition of ‘older adult’ or ‘older people’ is not consistent in all studies. Consequently, the term was identified using the same criteria employed in studies to cover all related papers in robotic technologies that were applied to older adults’ problems.

Data extraction and synthesis

In order to obtain relevant data from selected papers in the final pool, key sorts of information were retrieved. For each paper, the following types of data were collected:

• Robot types: we identified the type of robot and technology that was used in each paper to assist older adults.

• Problem type related to each robot technology: we determined which older adult problems had been addressed by the researcher.

• Study settings: we determined how robotic researchers had addressed independent life issues for older adults.

• No. of participants: we analysed the results in terms of generalisation.

• Outcome of studies: we determined each paper’s outcome (this was necessary to evaluate the role of robotic technology in aged care).

Evaluation of the effectiveness of the robot technologies in the studies

Morrison et al. ¹⁶ have suggested criteria for evaluating effectiveness that we could use with robot technologies in aged care. Furthermore, we have adapted the method proposed, and new criteria were developed to enable us to assess the results in the final pool, as shown in Table 2.

Table 2.

Effectiveness criteria.

Subjective effectiveness (score)	Sample criteria
More effective (3)	Improvement for the majority, or at least more effective than comparison group or no intervention control group 16
Less effective (2)	Improvement for the minority, or was not necessarily as effective as the control group 16
Ineffective (1)	The intervention did not lead to an improvement in any of the outcome measures

Results

Analysis of study settings and number of participants

The number of publications in each study setting is depicted in Figure 2. We have identified four settings of studies. The first is of studies performed under laboratory or experimental conditions (Lab). This has the highest number of papers in the final pool, with 17 studies (about 28%). It shows the attention that researchers have given to performing studies under controlled conditions, whereas the majority of older adults tend to stay at home to have an independent lifestyle. The second category is of studies that have been done in Elder Care facilities, with 16 studies (about 27%); this shows that elder-care facilities have hosted a large number of older adults, and researchers have used these facilities to conduct their research projects. The third category is home settings, with 11 studies (around 18%). Regarding the tendency of older adults to have an independent lifestyle, this figure of a mere 18 per cent could be considered as low and an inefficient use of research resources, which would be better directed to experiments conducted within homes. Four studies were carried out in hospitals. An important point is that 11 studies (around 18%) did not specify their settings; this lack of detail in reporting prevents these experiments from being replicable by other researchers.

Figure 2.

Setting of studies in final pool.

We also identified the number of participants employed in each study (see Figure 3). As can be seen, most of the studies have fewer than 30 participants. Although this may be because of time and budget limitations, it implies that most of the studies suffer of the small number of participants, and that consequently the findings cannot be generalised.

Figure 3.

Number of participants in studies.

Problem areas that have been investigated by robotic technologies

In this section, we have categorised the problems addressed by robot technology researchers in the final pool. To develop categories into which the problems could be allocated, we applied the process proposed by Ghapanchi and Aurum ¹⁷ and also used in Vichitvanichphong et al. ¹⁸ To adapt that process for this study, we extracted older adults’ problems and provided an explanation for each one. The problem areas in aged care that have been addressed by robotic technologies are shown in Table 3.

Table 3.

Problem areas and descriptions.

Problem	Description and properties
Social isolation	Social isolation refers to feeling lonely because of limited social connections which in most of cases would result in feeling loneliness that may risk older adults’ psychological well-being.
Dependent living	The abilities to maintain the desired level of living could be categorised under dependent living, which is the ability to perform activities of daily living, like cleaning, cooking and bathing. 19
Physical or cognitive impairments	Cognitive impairments refer to a condition that older adult will encounter memory loss during ageing. 20 Also, physical impairments are likely to happen as motor abilities decrease with age; 21 furthermore, we have categorised these two items under one category as both refer to decrease in abilities related to ageing.
Mobility problems	Refers to the ability to move around in a safe and independent manner without needing to obtain help from other people.
Poor health monitoring	Related to monitoring health parameters, which are crucial for older adults’ well-being; for example, blood pressure and cholesterol level in blood.
Lack of recreation	Having some hours of healthy entertainment could upgrade the affective state of older adults, which is important as it has an impact on their decision-making abilities and good mood. 22
Reminding problems	Reminding includes medication management and schedule reminding, such as appointments with professional caregivers. Medication management is important, as failing to use medication safely is a major reason for transferring older adults to aged-care facilities. 23
Fall problems	Falls are generally costly and can result in injury or, in the worst case, death. 24

Robots used to assist older adults and their evaluated effectiveness

In this section, we have categorised robot technologies for aged care, defined their capabilities and then estimated their effectiveness in addressing older adults’ problems. Some researchers^13,25–27 have previously tried to categorise robots, but have mostly focused on assistive robots and home services robots. To find out which robot types have been used in addressing older adults’ problems, we applied the process mentioned in the previous section. To adapt that process for this study, we extracted information on robots and their functions from the final list of selected papers and eventually formed a primary list of robotic technologies.

As a result, nine categories of robotic technologies were found in the final set of publications. These categories – companion robots, telepresence robots, manipulator service robots, rehabilitation robots, health monitoring robots, reminder robots, domestic robots, entertainment robots and fall detection/prevention robots – are discussed in the following sections. The table in each section shows, for that robot type, the source studies, the problem areas, the results and the subjective effectiveness scores. In Table 4, definitions of each robot technologies are demonstrated.

Table 4.

Robot types and descriptions.

Robot types	Description and properties
Companion robots	Designed to enhance the psychological well-being by providing companionship, 28 mainly interactive and have social effect (like activate a communication). In the shape of pet (cat, dog, rabbit, seal, etc.) or humanoid robot, they are able to listen, make speech, recognise touch and detect sound and light.
Telepresence robots	Involve robots that provide two-way communications between two parties in which one party is older adult, mainly are means for remote communication with video-mediated medium and in-home navigation ability to provide guidance of a remote user. 29
Manipulator service robots	Include robots that have arm-shaped attachment(s) to grasp and carry objects upon request, 25 mainly are designed to support basic tasks of independent living. 30
Rehabilitation robots	Designed to provide physical assistive features and are not basically communicative 31 including walking-assistant robots and robotic wheelchairs.
Health monitoring robots	Designed to monitor physical health status (weight, sleeping pattern, high blood pressure, etc.) based on clinical and medical knowledge by measuring parameters via sensors. They usually send important feedbacks to who takes care of older adults. 32
Reminder robots	Designed to remind older adults’ proper medication taking and appointments. Failure to take medication on time and in proper portion could result in illness, in some critical cases could cause hospital admittance. 23
Domestic robots	The most important need for older adults is to remain in their homes as long as possible. 33 Domestic robots are defined as a type of robots which could help the elderly to support basic tasks of independent living via doing home chores like cleaning and cooking. 30 It is also called chore robot. 27
Entertainment robots	Having entertainment is important, especially for the elderly as it could affect decision-making, reaction to risky circumstances and in some cases could result in memory loss. 22 This category includes robots that could be used as a mean of entertainment such as card playing robots and coach exercising.
Fall detection/prevention robots	Fall detection/prevention is considered as one of the key tasks that robots are expected to perform 27 and send alerts to the elderly or caregivers. As ageing occurs, cognitive and motor impairments are likely to develop, 34 and the age-related decline in abilities becomes challenging, especially since many older adults live alone. Falls could expose older adults to severe health damage; 35 furthermore, preventing falls could result in enormous savings to health costs. Fall detection/prevention is considered as one of the key tasks that robots can be expected to perform; 27 hence, researchers have tried to design robots to prevent or detect falls.

Companion robots

Table 5 shows the studies that have used companion robots.

Table 5.

Companion robots.

Source	Problem	Result of the study	Subjective effectiveness score
Hutson et al. 36	Social isolation	Mostly unsatisfied with the social robots, and robots did not meet the expectations.	1
Banks et al. 37	Social isolation	Reduced loneliness (parameter: delta loneliness score) in residents – they were less lonely than those who were not exposed.	3
Tanaka et al. 38	Social isolation cognitive functions	Results stated that robot is effective for improving cognitive functions and reducing loneliness.	2
Mordoch et al. 39	Social isolation dementia	There is potential for the use of companionship robots with older adults who have dementia.	1
Broekens et al. 13	Social isolation	Some qualitative and quantitative evidence shows positive effects.	2
Louie et al. 40	Social isolation	Majority (74%) of the individuals were positive about acceptance for socially assistive robots.	3
Moyle et al. 41	Social isolation (interaction reading group)	PARO had a moderate to large positive effect on participants’ quality of life (QoL-AD) compared to the control group.	2
Heerink et al. 42	Social isolation	Showed that social presence correlates with the intention to use the system.	1
Sung et al. 43	Social isolation	Significantly improved the activity participation and interaction skills.	3
Bogue 44	Social engagement	Potential of robots to assist older adults; ethical issues are discussed (also discusses social engagement for older adults).	1
Kachouie et al. 15	Social isolation	Socially assistive robots could potentially enhance well-being of older adults and decrease the workload for nurses.	3
Heerink et al. 45	Social isolation	Scores on social presence correlated with the scores on the intention to use the system in the near future.	2
Heylen et al. 46	Social isolation	The rabbit set-up was not considered useful by either of the two participants. (Introduce companion robots to satisfy social goals and establish effective bonds.)	1
Greco et al. 47	Physical or cognitive impairments	Seems not to be a significant advantage because some of the subjects were unable to recognise it.	1
Tamura et al. 48	Physical or cognitive impairments	The presentation of AIBO resulted in positive outcomes for severe dementia patients, including increased communication between the patients and AIBO.	3
Mordoch et al. 39	Physical or cognitive impairments	Some positive feedbacks and some negative.	1
Moyle et al. 41	Physical or cognitive impairments	PARO had a moderate to large positive influence on participants’ quality of life (QoL-AD). Intervention group had higher pleasure scores.	3
Shibata and Wada 49	Physical or cognitive impairments	Showed that PARO has a great potential to provide mental healthcare for isolated elderly.	3
Tanaka et al. 38	Physical or cognitive impairments	Result stated that robot is effective for improving cognitive functions and reducing loneliness.	2
Khosla et al. 50	Lack of recreation	It has proved to be a very effective device for social activities.	3
Tamura et al. 48	Lack of recreation	The presentation of AIBO (artificial intelligence bot) resulted in positive outcomes for severe dementia patients, including increased communication between the patients and AIBO.	2

QoL-AD: Quality of Life in Alzheimer’s Disease.

In this category, there are 21 studies discussing three problem areas. First, companion robots have been widely used in addressing social isolation, which older adults will face more than other people because of the increased possibility of health problems and life-changing events – for example, the death of loved ones and friends; ⁵¹ furthermore, social isolation is a common problem that is frequently experienced by older adults. ⁵² Researchers have therefore tried to address this problem with companion robots, as reflected in the 13 studies in the final pool. The next problem, physical or cognitive impairment, has six studies that involve companion robots. These have been used mainly in cognitive impairment problems, because of their capabilities to interact with older adults, and because the symptoms of cognitive impairment are usually demanding for families to manage. ⁴¹ Also, this type of robot has been used to provide entertainment for older adults. The overall effectiveness of companion robots in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Telepresence robots

Table 6 shows the studies that have used telepresence robots.

Table 6.

Telepresence robots.

Source	Problem	Result of the study	Subjective effectiveness score
Wu et al. 53	Social isolation	Participants showed low intention to use the robots and did not perceive the device as useful for daily life (acceptance is studied).	1
Moyle et al. 54	Social isolation	The impact of Giraff on residents and their families was very positive, with average engagement of 93%.	3
Zsiga et al. 55	Social isolation	Shows that robot has the potential to be useful; almost all participants showed interest in robotic helpers (six areas studied: acceptability, services, obstacles, motivation to use, organisation issue and recommendation).	2
Granata et al. 56	Social isolation	Some points are mentioned for GUI improvement (performance measure).	1
Takahashi and Yatsumonji 57	Social isolation	Obstacle sensor is proposed in telepresence robot. It could be used for older adults, but is functioning under laboratory conditions – further field test is needed.	1
Park 58	Social isolation	The results demonstrate that attitude has the most powerful effect on intention to use (user perception and motivation studied through Internet survey).	1
Kristoffersson et al. 29	Social isolation	Older adult health professional attitude towards telepresence. Professional were more positive than older people.	1
Pineau et al. 59	Social isolation	The Pearl telepresence robot successfully could autonomously provide guidance for elderly residents (three module software developed and tested).	2
Moyle et al. 54	Physical or cognitive impairment problem	Showed a general state of positive emotions across the calls with a high level of engagement and a minimal level of negative emotions – the impact was very positive.	2
Palumbo et al. 60	Poor health monitoring	The system has been tested and is deployed in real homes across Europe for the long-term monitoring of physiological data, the activities of daily living and the behaviours.	2

GUI: graphical user interface.

In the final pool, 10 studies have used telepresence robots for aged care. Eight of the 10 have used this type of robot to address social isolation and loneliness problems. As telepresence robots could bring a sense of connectedness between older adults and their loved ones, such as family members and friends, these robots are reported to have positive effects in decreasing social isolation and the sense of loneliness. Two other problem areas in which telepresence robots could be beneficial are (a) physical and cognitive impairment and (b) poor health monitoring problems. In these two areas, telepresence robots could connect older people with informal caregivers (family members and friends) or professional caregivers, to make sure that older adults are safe regarding their mental and physical health. In this way, their relatives would have peace of mind. The overall effectiveness of telepresence robots in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Manipulator service robots

Table 7 shows the studies that have used telepresence robots.

Table 7.

Manipulator service robots.

Source	Problem area	Result of the study	Subjective effectiveness score
Cabas et al. 61	Dependent living	Can accurately respond to the intention of users and can guarantee the comfort and safety of the walking process.	1
Hoppenot et al. 62	Dependent living	It functions properly under laboratory conditions.	1
Smarr et al. 63	Dependent living	They preferred robot assistance over human assistance for tasks related to chores, manipulating objects and information management. Also, they preferred human assistance to robot assistance for tasks related to personal care and leisure activities.	2
Jain and Kemp 64	Dependent living	Retrieve objects from and deliver objects to flat surfaces. Grasp objects from the 25 object categories.	1
Van Osch et al. 65	Dependent living	This paper describes the design and experimental results of a tele-operated service robot, ROSE.	1
Hoppenot and Colle 66	Dependent living	It functions properly under laboratory conditions.	1
Bogue 44	Dependent living	Potential of robots to assist older adults. Ethical issues are discussed.	1
Wu et al. 67	Physical or cognitive impairment problem	The subjects reported a desire to retain their capacity to manage their daily activities, to maintain good health and to stimulate their memory.	1

ROSE: remotely operated service robot.

Manipulator service robots are mainly used in addressing dependent-living problems (seven of eight studies) as the majority of older adults prefer to live in their own homes rather than in nursing facilities. This preference is facilitated by manipulator service robots, designed with the aim of carrying out home chores. Also, one study used a manipulator service robot to address physical impairment problems. Robots in this category could help to assist older adults with some kinds of motor impairment to lead independent lives in their homes. The overall effectiveness of manipulator service robot in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Rehabilitation robots

Table 8 shows the studies that have used this type of robot.

Table 8.

Rehabilitation robots.

Source	Problem	Result of the study	Subjective effectiveness score
Chen and Pham 68	Mobility problems	Although the experiment is done with a child, the robotic wheelchair ascends and descends stairs in a statically stable manner and has an efficient planar navigation capability. (This could provide an effective solution for mobility for the elderly.)	1
Engelbrektsson et al. 69	Mobility problems Navigation aid	The user trials provided the designers with an opportunity to meet users and observe hands-on the users and the user situation. Navigation aid is discussed.	1
Kairy et al. 70	Mobility problems	Subjects have expressed some concerns that only some features are related to them (participants 55 ± 21 years old from 22 to 88).	1
Uratsuji et al. 71	Mobility problems	Both quantitative evaluation and subjective survey demonstrate the effectiveness (the wheelchair is tested under laboratory conditions; could be used for the elderly).	1
Tang and Cao 72	Mobility problems	New motion control algorithm has been proposed and the user will not feel tired during walking.	1
Bogue 44	Mobility problems	Potential for robots to assist older adults; ethical issues are discussed.	1
Urdiales et al. 73	Mobility problems	All of them finished a complex test path with assistance. Both users and caregivers’ opinions on the system were very positive. Acceptance was good according to the psychosocial impact of assistive devices scale.	2
Urdiales et al. 73	Physical or cognitive impairment problem	All of them successfully finished complex test path with assistance. Both users and caregivers’ opinions on the system were very positive. Acceptance was very good according to the psychosocial impact of assistive devices scale.	3

In the final pool, there are eight studies that used rehabilitation robots for aged care. Seven of the eight were used to address mobility problems. This is very reasonable, as they have been designed to provide transport facilities for the elderly in order to enable them to move safely within their home or community. Mobility problems are demanding and likely to afflict the elderly, because motor impairments are likely to develop with ageing. ³⁴ Another application is to address physical impairment using a walking-assistant robot. The overall effectiveness of rehabilitation robots in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Health monitoring robots

Table 9 shows the studies that have used this type of robot.

Table 9.

Health monitoring robots.

Source	Problem	Result of the study	Subjective effectiveness score
Broadbent et al. 27	Poor health monitoring problems	The most popular robot tasks were detection of falls and calling for help, lifting and monitoring location.	1
Dadlani et al. 33	Poor health monitoring problems	Although provided information was good, people in the targeted user group, and in the social context, mostly prefer to get long-term trend information regarding their well-being.	2
Tseng et al. 32	Poor health monitoring problems	The results indicate the developed system is highly accepted by older adults in terms of performance expectation, endeavour expectation, social influence and facilitating condition.	3
Oyabu et al. 74	Poor health monitoring problems	The robot has healing capabilities for the aged and can also receive and transmit information.	1
Portet et al. 75	Dependent living	Almost all seniors (7/8) appreciated the possibility of controlling the house using voice commands.	3

In the final pool of studies, there were five that reveal benefits of using health monitoring robots in aged care; four of the five studies addressed poor health monitoring problems. As ageing occurs, the levels of mental and physical health decrease. Furthermore, robots that monitor health have vital and crucial roles to play in bringing peace of mind for both the elderly and their dependants. Also, one study attempted to address the dependent-living problem. The overall effectiveness of health monitoring robots in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Reminder robots

Table 10 shows the studies that have used this type of robot.

Table 10.

Reminder robots.

Source	Problem	Result of the study	Subjective effectiveness score
Tiwari et al. 76	Reminding problems	Residents successfully interacted with the dialogue system and were generally satisfied.	1
Tiwari et al. 77	Reminding problems	All users could successfully complete the session, and most participants found it easy to use and appropriately designed. They felt confident.	2
Pollack 78	Reminding problems	Verbal feedback – enjoyed interacting with the robot, but some other features are needed.	1
Pollack et al. 79	Reminding problems	Robot control software and sense of acceptability were tested successfully.	3
Neven 80	Poor health monitoring problem	Design and implementation are expressed from elderly.	1
Pollack 78	Physical or cognitive impairment problem	Older adults enjoyed interacting with the robot (verbal feedback).	1

Six studies used reminder robots in aged care. Reminder robots have been designed to enhance the accuracy of medication management as most older adults could be required to perform complicated self-care tasks including medication taking. ⁸¹ Research has shown that the risk of not taking medication appropriately is prevalent in 60 per cent of the elderly population, ⁸² and failing to take proper medication safely is often a major reason for transferring the elderly to an aged-care facility. ²³

Four studies discussed reminding problems, and the other two were about poor health monitoring and cognitive impairment (because older adults with cognitive impairment are more likely to forget their medications and appointments related to their health). Additionally, for older adults who have mild cognitive impairment, reminder robots have been designed and developed to assist them with their daily schedule, such as meeting appointments. The overall effectiveness of reminder robots in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Domestic robots

Table 11 shows the studies that have used this type of robot.

Table 11.

Domestic robots.

Source	Problem	Result of the study	Subjective effectiveness score
Pigini et al. 83	Dependent living	An autonomous robot is considered to be an interesting solution in some circumstances.	1
Ma et al. 84	Dependent living	Most of them (9/12) thought the auto mode was good and no one thought it was bad. They were very satisfied with the auto mode.	3

Although dependent living is one of the greatest concerns of older adults, few robots have been designed to assist in this area. As can be seen, only two robots are in the final pool of those specially developed for aged care. One explanation is that each robot needs its own customised design for each older adult. From the marketing point of view, this is not a very profitable pursuit, despite the fact that there is a large market in this area. The overall effectiveness of domestic robots in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Entertainment robots

Table 12 shows the studies that have used this type of robot.

Table 12.

Entertainment robots.

Source	Problem	Result of the study	Subjective effectiveness score
Sebastian et al. 85	Lack of recreation	Participants showed that positive results regarding seniors’ acceptance of WOBOT and level of anxiety were low while interacting.	1
Park et al. 86	Lack of recreation	The piano-playing robot is functional in a laboratory experiment condition.	1
Kanoh et al. 87	Lack of recreation	All participants were in favour of the impression of the robot and nearly all had a positive opinion.	3
Fasola and Matarić 88	Lack of recreation	They show a strong user preference as an exercise coach, varying user preferences regarding choice and high user ratings of the system across multiple metrics.	1

In the final pool, there were four studies that used robots to entertain older adults. It should be noted that older adults who have some hours of healthy entrainment will exhibit better moods and better affective states. ⁸⁹ Such entertainment is vital for older adults as it can affect decision-making, memory and reaction to dangerous situations. ⁹⁰ Furthermore, lack of recreation can be harmful to mental and physical health. The overall effectiveness of entertainment robots in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Fall detection/prevention robots

Table 13 shows the only study that used this type of robot.

Table 13.

Fall detection/prevention robots.

Source	Problem	Result of the study	Subjective effectiveness score
Seo et al. 91	Fall problems (from bed)	Bed fall prevention has been tested experimentally for effectiveness and could have some therapeutic outcome.	1

This publication in the final pool used fall detection/prevention robots developed for bed-ridden people who need a system for informing caregivers if a fall occurs. The overall effectiveness of fall detection/prevention robots in each problem area is discussed in section ‘Critical analysis of robot technologies studies in aged care’.

Infrastructure for healthcare

A healthcare infrastructure is composed of many components: facilities to make care accessible and feasible, trained personnel, sufficient training, users who maybe older adults or their family and friends and mechanisms to make sure that older adults will get enough help and support when they need it. In this section, we will discuss what infrastructure is needed to achieve this goal.

For each robot category, a certain set of infrastructures is needed. Companion robots are used to bring companionship to older adults. They use sensors to sense the situation and environmental surroundings using devices such as range finders, microphones, camera and angular velocity measurement devices. Other devices used include acceleration sensors and elevation and bumper sensors.^15,38 In these types of robots (e.g. the Nabaztag), the need for an Internet connection is common as they need to connect to a server to execute certain commands. ¹⁵

For telepresence robots, the most important feature is videoconferencing (including a camera, display, speaker and microphone); ⁶⁰ therefore, the requirement is a wireless Internet connection to make calls. ⁵⁴ They also need a smooth floor for travel and enough room for the remote user to navigate through the location. ⁵⁵

Manipulator service robots have an arm to grip objects. This arm can be mounted on wheelchairs or grips. They do need an apparatus like a wheelchair to provide support for the arm. Rehabilitation robots are designed to provide physical assistive features, including robotic wheelchair and walking-assistant robots; the infrastructure required is obstacle detection, control for manual or automatic control, switch for parking brake, ⁶⁹ speed control option and sound alert when approaching obstacles. ⁷⁰

Health monitoring robots may detect falls and call for carers or monitor location of people. ²⁷ To make sure older adults are in good condition, information on medication, meals, activities, mood and calendar items could be provided and they will be sent to doctors remotely using weight, heart rate and other sensors such as load sensors in bed to monitor weight and sleep pattern. ³³ Other sensors are common like odour sensing to detect breath odour, ⁷⁴ light control sensors, heat adjust sensors, windows and shutters’ controllers (manage them remotely), control of kitchen devices like oven and refrigerators and a contact person in the event of an emergency situation. ⁷⁵ They therefore need communication infrastructure and connection to a power source.

For reminder robots, reminding activities are applied via software modules and medication reminder application. Also, speaker could be used to announce time of medication intake. ⁷⁷ Domestic robots need to be fit in home setting to do home chores like cooking, cleaning, washing and bathing. The infrastructure is customised based on the home environment; however, general robots like cooking robot could be implemented in home. ⁶³

Entertainment robots are able to perform entertainment activities such as card playing, teaching exercise techniques and playing a piano within a motion imitation system. ⁸⁶ Some of these activities can be done with companion robots, ⁸⁷ for example, physical exercise and memory games. For fall detection, the robot infrastructure needed are sensors to sense the fall of the person and Internet access to allow for contact with relatives or the doctor to report emergency situations. ⁹¹

Critical analysis of robot technologies studies in aged care

After categorising and evaluating the effectiveness of each study (as described in previous sections), we examined how researchers used robots from these categories in aged care. Figure 4 depicts the percentage of publications in each category; Figure 5 shows the number of publications in each robot category in the final pool, along with the average subjective effectiveness score.

Figure 4.

Percentage of publications in each robot technology (studies demonstrated in sections ‘Companion robots’ to ‘Fall detection/prevention robots’).

Figure 5.

Number of publications in each robot category, with the average of subjective effectiveness.

In Figure 5, the red bars represent the number of publications and the blue bars show the average subjective effectiveness score. As can be seen, about one-third of all studies used companion robots to address older adults’ problems – mainly problems of social isolation and cognitive impairment; these had an average effectiveness score of 2.04, which shows that companion robots are about 70 per cent (2.04/3) effective in addressing the two above-mentioned problem areas.

In rank 2, telepresence robots are seen to account for about 20 per cent of all studies. As with companion robots, social isolation is the most studied problem area with telepresence robots. In summary, robotic researchers have addressed social isolation with companion robots (13 studies) and telepresence robots (8 studies). The average effectiveness score is about 54 per cent (1.6/3), which shows that more research is needed in this area due to its being a relatively new field in aged care.

Rank 3 illustrates the data on rehabilitation robots. This type of robot could be more beneficial for older adults, the majority of whom experience motor impairment during ageing. Seven of the 10 studies addressed mobility problems; the others studied physical impairment problems. The average effectiveness score is 46 per cent (1.38/3), which shows that robots are not quite successful in this problem area, and that there is plenty of room here for improvement.

Other robot types – reminder, health monitoring, entertainment, domestic and fall detection/prevention robots – account for 40 per cent of all studies (Figure 5). It should be noted that these areas are directly related to dependent living of older adults and have attracted less attention from researchers; for example, domestic and fall robots may have been neglected due to their complexity and the level of customisation that is needed in these areas. Also, the design and development of robots in such areas are more complicated and budget-demanding compared with the first two categories (companion and telepresence). These limitations inhibit research centres from becoming more involved.

The effectiveness of the various robotic technologies for specific problems, based on their subjective effectiveness scores, is compared in Table 14. The effectiveness scores are shaded in green, and the number of publications in each segment is highlighted in yellow.

Table 14.

Comparative analysis of the effectiveness of various robotic technologies.

Problem areasRobot types	Social isolation		Dependent living		Physical or cognitive impairment		Mobility problems		Poor health monitoring		Lack of recreation		Reminding problems		Fall problems
	A	B	A	B	A	B	A	B	A	B	A	B	A	B	A	B
Companion	2	13			2.1	6					2.5	2
Manipulator service			1.1	7	1	1
Rehabilitation					3	1	1.1	7
Telepresence	1.5	8			2	1			2	1
Health monitoring			3	1					1.8	4
Reminder					1	1			1	1			1.8	4
Entertainment											1.5	4
Domestic			2	2
Fall detection/prevention															1	1

A =  average of subjective effectiveness scores; B =  number of publication(s).

Various robotic technologies have been applied to specific problem areas, except for fall problems, reminding problems and mobility problems. Entertainment, domestic and fall detection robots have been applied to address one problem, whereas companionship, telepresence and reminder robots have been used in three different problem areas, with the highest subjective effectiveness score of 2.1 for companionship robots.

Among the problems that have been addressed by several types of robot is impairment (physical or cognitive), which shows the attention given by researchers to taking different approaches. The outcomes of these attempts are more positive for cognitive impairments, especially dementia, as the majority of publications have addressed this issue.

The data of Table 14 must be interpreted with caution, as the numbers of publications in the segments differ widely, from 1 to 13. To make better comparisons, both average subjective effectiveness score and the number of publications should be considered simultaneously. Some robotic technologies, such as companionship, have attracted more attention, and different dimensions have been scrutinised by performing several studies; however, this does not apply to some others, like domestic robots.

Discussion

The design and development of technologies to help older adults are growing rapidly. ²³ Whereas human caregiving cannot be replaced by intelligent technologies, technologies can provide supplementary caregiving, which has the potential to improve the quality of life of older adults and professional caregivers. ¹⁰ One of the promising areas is robotic technologies, which have made a significant impact on healthcare in recent years. ⁹²

The main aim of this study has been to identify, select and synthesise all the research on robotic technology conducted within the aged-care field. Based on the final set of selected papers, it is apparent that researchers in recent years have become more interested in robotic technologies to address the problems of older adults (Figure 6); this is depicted in the linear trend line shown in black. This research has contributed to knowledge about the usefulness of robotic technologies by determining the role of this technology in assisting older adults, and thus by improving their lifestyles.

Figure 6.

Number of publications in each year.

It should be noted that the results of this research have depended on the set of keywords, inclusion/exclusion criteria and subjective effectiveness of the scores, which are based on outcomes. Also, the inaccessibility of papers in languages other than English has put a limit on the final set used. We tried to broaden our inclusion criteria to cover, as much as possible, the widest range of robot technologies in aged care to provide the most comprehensive picture. The results of this research should be considered with these limitations in mind.

To answer the first research question – What type of robot technologies have been developed to address aged care so far? – we categorised robot technologies that were applied in older adults’ problems, based on their main application (for example, companion robots could be used for companion or entertainment; but based on their main application, this kind of robot was used more to provide companionship for the elderly). Robots were categorised as companion, telepresence, rehabilitation, manipulator service, reminder, health monitoring, entertainment, domestic and fall detection/prevention robots.

To answer the second research question – How effective have robotic technologies been in overcoming older people’s problems? – and to find out how robot technologies are effective in addressing older adults problems, we evaluated the effectiveness of each study based on the stated results. In total, based on this evaluation, robotic technologies are 54 per cent effective (1.608/3), which is relatively low; however, in general, this result implies that these technologies have a positive effect. According to these results (see section ‘Critical analysis of robot technologies studies in aged care’), more research is needed in this area to increase the level of application of robots in aged care.

Furthermore, we investigated the average effectiveness score of robot clusters in addressing each problem area. The comparison table (Table 14) reveals that the most effective robot type in addressing social isolation is companion robots, with an effectiveness score of 2 (in 13 publications), followed by telepresence robots, with an effectiveness score of 1.5 (in 8 publications). These are promising results and show that social isolation and loneliness have been at the centre of researchers’ attention in recent years.

As can be seen in Table 14, robotic technologies have been given the greatest attention in addressing social isolation problems, with 21 publications in the final pool, while the least attention has been given to addressing fall problems (only one paper). It is apparent that researchers have been attracted to problems involving mental or psychological states of the elderly, whereas other problems – such as independent living and fall detection, although as important as mental health – received less attention. A possible explanation is that running interventions to address mental issues requires a smaller budget and less time in comparison with other problems involving physical aspects.

As stated in Table 14, the three problems that are best tackled via robotic technologies are social isolation, physical and cognitive impairment problems and reminding problems, while the three at the other end of the scale are dependent living, mobility and fall problems. Furthermore, researchers are recommended to ensure uniformity in addressing older adults’ problems and to focus on less researched areas, such as dependent living, mobility and fall problems.

Based on the results from section ‘Rehabilitation robots’, this study showed that robotic technology needs more attention from researchers to improve its effectiveness for older adults; however, the main point is that other stakeholders too – professional caregivers, family members and friends – are required to be involved. These caregivers are in constant contact with older adults and can contribute additional information about the kind of needs to be addressed and about their expectations and attitudes to robotic technologies. As one of the main aims of robotic technology is to assist older adults, it could result in reducing aged-care costs and increasing the acceptance of robotic technologies generally. With these insights about needs, researchers are in a better position to conduct appropriate research and develop products that would be more effective in addressing older adults’ problems.

Most of the studies in the final pool were conducted under experimental conditions but did not use a control group; however, all were included in the study because they contributed some positive observations. We acknowledge that researchers have limited time and budgets; however, we recommend that future research use randomised controlled trials in home settings to obtain robust outcomes in the assessment of effectiveness.

Other problems with the studies in the final pool are that most of them were unclear in their reporting, provided inadequate details and used relatively small sample sizes. These flaws make their results difficult to replicate and are unreliable sources for making generalisations applicable to other cases (Figure 3). In spite of these limitations, such studies have been included because they demonstrate potentially positive effects and potentially worthwhile insights into outcomes of robotic technologies applied in aged care.

Therefore, future researchers need to answer the question of how different robotic technologies can contribute to assisting with specific problems and to measure their acceptance by a large sample of older adults.

Finally, robotic technologies must be designed carefully to avoid encouraging lifestyles that degenerate into unhealthy ways of living; for example, there is a risk of replacing human contact with non-human robot contact, or decreasing human contact in a harmful way that could affect the older adults’ psychological well-being. Therefore, it is essential for robotics researchers to consider ethical factors associated with the well-being of individuals.

Implications for practitioners

The findings of this study provide several implications for practitioners by showing the benefits of robotic technologies.

First, governments are trying to cope with the economic pressure of aged-care expenses, ⁹³ as the number of older adults is set to increase over the next decades. Another problem is that the number of caregivers will be insufficient in coming years and the ratio of caregivers to the elderly is decreasing. Based on demographic information of birth and death rates, this decreasing trend seems to be continuing. Furthermore, governments have the responsibility to address the increasing demand for professional caregivers. Because the utilisation of robotics in aged care is a relatively new area and needs to be accepted by older adults’ society, governments should implement new legislation and regulations about technologies to assist the elderly to maintain independent lifestyles.

This study has demonstrated that robotic technologies have some positive potential in aged care and, regarding the above-mentioned issues, governmental bodies and policy makers are advised to support new research to increase the acceptance of robotic technologies through better budget allocations. The media are also encouraged to play a role in generating images of the elderly being in favour of using robots. For governments, the most important advantage of exploiting robotic technologies is the potential for creating new jobs and opportunities that will help both society and older adults.

Second, for aged-care practitioners, studies have shown that they are in favour of robotic technology functions with better health monitoring capabilities such as fall detection, detecting dangerous positions and calling professionals when an individual needs help. ⁹⁴ Utilising robotic technologies could create opportunities for caregivers to offer better services while monitoring activities are carried out by robots. In addition, new jobs and possibly greater career prospects are likely to be created. Furthermore, caregivers’ jobs will undergo modifications in the future. The disadvantage of this trend is that it could result in a loss of jobs; however, applying robots to aged care offers a huge easing of physical and mental burdens. This issue needs professional caregivers to escalate their skills and enhance their attitudes towards robotic technologies by referring relevant tasks to robots and concentrating on the new needs of the elderly.

Third, the findings of this study will be beneficial to designers, engineers and robot development companies. Some studies have shown that the acceptance of robots is fairly low among older adults. ⁵³ Companies may benefit from the new trend by investing in research on designing and developing robots to address older adults’ needs and making a new feasible market by escalating the acceptance of robots in society. This could be achieved by involving all the stakeholders in the early stages of design and development by carefully establishing their attitudes and needs and ensuring their acceptance in the final stage. Companies could have new possibilities to expand their market opportunities in the domestic and international ranges.

Implications for researchers

For new robotics researchers, this study provides an extensive overview of the research that has already been conducted by other researchers. The study recognises the problems and the robots designed to address each problem, as well as measuring the effectiveness of robotic technologies. This study showed that robotic technologies offer various advantages to support older adults in maintaining an independent lifestyle and a better quality of life. These technologies could provide opportunities for researchers on state-of-the-art robotic technologies to raise their research profile and status. They are also encouraged to make connections with potential investors to introduce the results to the robotic aged-care market. To be successful in the market for aged-care robotic technologies, researchers should integrate older adults’ needs with the new robotic technologies developed in recent years.

This literature review has shown the kinds of needs of older adults that have been addressed by robots and the gaps in the studies that could be useful for future researchers. It is crucial to understand that the first major step in addressing older adults’ needs is to determine which needs have the highest priority. An extensive and broad needs’ assessment seems to be mandatory prior to undertaking the design and development of new robots by researchers; such an assessment would make a great contribution to finding out where robotic assistance would be most profitable as well as the design requirements in the future.

It is worth reiterating that some fields in robotic technology have received more attention than others, such as using companion robots to address memory cognitive impairment problems. Furthermore, researchers should carry out research in the new fields, for example, activities of daily life, which will enable older adults to remain in their homes.

Other critical issues are (a) that most of the studies suffered from a lack of details about the study design, (b) that most failed to employ a randomised control and (c) that to measure the acceptance of robots by the elderly, experiments should be conducted at home, not under laboratory conditions.

Conclusion

Robotic technologies have been a rapidly growing field in recent years and can be applied to improve the quality of life of older adults. This study has reviewed and consolidated the research into how researchers have introduced various robotic technologies to assist older adults. This review shows that although robotic technologies have achieved positive effects, more studies are needed.