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Abstract

Social robot pets promote engagement and psychosocial well-being among older adults, yet little is known about their use among community-dwelling Veterans living with dementia. This programmatic evaluation used a within subjects, pre-post design to examine the usability (frequency of use, frequency of caregiver reminders) and acceptability (benefit, satisfaction) of social robot pets among Veterans with dementia (N = 20). An intervention usability and acceptability tool was completed by telephone with family caregivers 3 months after delivery of the pet to the home. Overall, 80% of Veterans used the pet often or daily, while 7 caregivers provided reminders for the Veteran to use the pet. Caregivers indicated that Veterans experienced benefit with the pet, as well themselves. Regarding satisfaction, 89% reported they would recommend a social robot pet to others. Research is needed to expand generalizability, evaluate effects on outcomes, and enhance implementation of social robot pets among Veteran families with dementia.

Keywords

dementia caregiver non-pharmacologic intervention pet robots

Significance Statements

(1) High frequency of use of social robot pets was demonstrated among community-dwelling Veterans living with moderate to severe dementia.

(2) High degrees of benefit with pet use were reported by family caregivers, such as benefit to the Veterans (including decreasing challenging symptoms experienced by the Veterans) and to caregivers themselves.

(3) High degrees of satisfaction with social robot pets were demonstrated by 89% of caregivers reporting they would recommend a social robot pet to others living with dementia and their caregivers.

Introduction

As the Veteran population ages, the number of Veterans living with dementia is expected to reach nearly half a million by 2033.¹ Informal caregivers, such as relatives and friends play a pivotal role in managing care for Veterans with dementia.² Due to the multifactorial nature of the disease’s impact coupled with the high complexity of care demands, Veterans living with dementia and their caregivers are at high risk of social isolation and the psychological sequalae that follows.^3-5 The COVID-19 pandemic has heightened the need for in-home care strategies to address the psychosocial needs of Veterans living with dementia and their families.

Social robot pets designed to interact with human users by mimicking the behaviors and responses of pet animals represent an innovative therapeutic tool to support Veteran families living with dementia.⁶ Although use of social robot pets has demonstrated positive impacts on psychosocial outcomes, most evaluative efforts have focused on older adults (not specifically those with dementia) living in long-term care settings.⁷ Findings primarily from long-term care settings support that social robot pets may benefit people living with dementia by improving psychosocial outcomes (e.g., social engagement, mood, affect) and decreasing behavioral manifestations (e.g., agitation, restlessness) commonly experienced by people living with dementia.^8-10 Yet, the degree of usability and acceptability of these pets by community-dwelling Veterans living with dementia remains unclear. Given the increasing demand for optimizing in-home care for Veterans living with dementia and their families, a formative evaluation of social robot pets in this population is critical to inform future research and implementation efforts.

Examining intervention usability and acceptability is a critical step in the National Institute of Health’s Stage Model for Behavioral Intervention Development¹¹ that helps: determine if costlier efficacy testing is warranted, inform planning of future trials, identify intervention components in need of refinement, and detect barriers to future implementation.^12,13 Historically, evidence-based non-pharmacologic interventions have had poor uptake by community-dwelling people living with dementia and caregivers,^14,15 which increases the need for early evaluations of intervention usability and acceptability. The purpose of this programmatic evaluation was to determine the usability and acceptability of social robot dogs and cats among community-dwelling Veterans living with dementia and their caregivers.

Methods

Design

This programmatic evaluation used a within-subjects, pre-post design among dyads of community-dwelling Veterans living with dementia and their family caregivers. Social robot pets were delivered to the homes of Veterans. Measures of usability (frequency of pet use, frequency of reminders/prompts provided by caregiver for Veteran to use the pet) and acceptability (benefit, satisfaction) were collected 3 months after delivery via a structured phone interview with caregivers. This was a program evaluation deemed by the Caring for Older Adults and Caregivers at Home (COACH) medical director to be an operational activity and thus not subject to institutional review board review, in accordance with VA Operations Activities Program Guide: 1200.21 (https://www.research.va.gov/resources/policies/ProgramGuide-1200-21-VHA-Operations-Activities.pdf).

Participants and Setting

Eligible participants included community-dwelling Veterans over the age of 65 and their informal caregivers served by the Durham VA’s Caring for Older Adults and Caregivers at Home Program (COACH). COACH, a longitudinal home-based dementia care program with an interdisciplinary and person-centered approach offers ongoing psychosocial support, education, and resources to caregivers through non-pharmacological interventions with the goals of increasing the Veteran’s quality of life and promote age in place. The program serves ∼240 Veterans over the age of 65 living with moderate to severe dementia in a home-based setting. Dementia severity is determined by standard cognitive testing and functional capacity completed by the program team.^16,17 A sample size of 20-25 was selected to determine usability and acceptability, which is comparable to similar studies.^18-20 The sample included Veterans in the moderate to severe spectrum of dementia; who demonstrated behavioral symptoms associated with dementia; who were unafraid of cats or dogs; whose caregivers were agreeable to the intervention. Due to the limited number of pets available to distribute, COACH staff (nurses and social workers) made recommendations during weekly, multidisciplinary team meetings to offer a pet if the Veteran presented with some behavioral symptoms such as significant restlessness and/or apathy reported by the caregiver. Frequency of behavior was not considered a criterion. In regards to the severity of dementia, it was preferred to target those with severe dementia, unless someone in the moderate stage presented behavioral symptoms. Informed consent was not required for this programmatic evaluation; however, participants were regularly informed that participation in the project was voluntary and they could choose not to engage at any point.

Social Robot Pet Intervention

Social robot pets (provided by the Triangle J Area Agency on Aging) were delivered to eligible Veterans by COACH team members (nurses or social workers) during regularly scheduled home visits from June-November 2021. Families received a 10-15 min, in-home educational demonstration by COACH staff on how to use the pet, as well as recommendations on ways to incorporate the pet into their daily routines to promote the Veteran’s engagement. Staff provided basic instructions to the caregivers on how to operate the social robot pet, and they were encouraged to remind, cue, and motivate the Veterans to use it as often as needed or tolerated. In cases of Veterans with specific identified behavioral symptoms their caregivers were encouraged to use it prior to or at the time of the behavioral presentation. In cases of Veterans with apathy, caregivers were instructed to offer the social robot pet to the veteran as often as tolerated.

Measures

Usability and Acceptability

Outcomes included measures of usability and acceptability. Usability was defined as the frequency of use of the pet by the Veteran as reported by the caregiver and the frequency of reminders, or prompts provided by the caregiver for the Veteran to use the pet. Acceptability was defined as the degree of benefit and satisfaction with the pet, as perceived by the caregiver.

A Social Robot Pet Intervention Usability and Acceptability Tool (See Supplemental Appendix A) was used with items modified from a validated tool to measure acceptability of a psychoeducational intervention for people living with cancer and their caregivers (Cronbach’s 𝛼 = .93),²¹ and from specific concepts and items used to capture acceptability of similar non-pharmacologic interventions for people living with dementia.^18,20,22,23 The psychoeducational intervention acceptability tool was used to guide development of the Social Robot Pet Intervention Usability and Acceptability Tool and the predefined benchmarks (described below) given that it captured the experience of caregivers and care recipients, and because few dementia-specific non-pharmacologic intervention studies have used standardized, psychometrically tested tools to measure intervention acceptability.²⁰

For measures of usability, caregivers rated how often the Veteran engaged with the pet, and whether/to what extent caregivers provided reminders, cues, or prompts for the Veteran to use the pet (0 = not at all to 4 = daily). To assess intervention acceptability, benefit was measured using a 3-item scale to capture the extent to which the pet benefited the Veteran, the caregiver, and the degree to which the pet was helpful in decreasing challenging symptoms (e.g., anxiety, agitation, restlessness, sleep disturbances) (0 = not at all to 2 = A great deal beneficial). Benefit items were averaged to yield an overall benefit score. Open ended items were included to evaluate when using the pet was most and least helpful for the Veteran. Satisfaction with the intervention was measured using two dichotomous (yes/no) response items reflecting whether the caregiver would recommend a social robot pet to others living with, or caring for someone with dementia, and whether they would continue to encourage the Veteran to use the pet.

To determine usability and acceptability, results were compared to a priori benchmarks selected based on comparable studies: ≥80% of Veterans use the pet often or daily^18,22,24 and ≥80% of caregivers would recommend a social robot pet to others and would encourage continued use of the pet by the Veteran.^18,21 Prior studies have not examined frequency of caregiver reminders/prompts as a component of usability, thus a pre-defined benchmark was not selected.

Few non-pharmacologic intervention studies focused on people living with dementia have combined benefit-related items on an intervention acceptability tool to yield a comprehensive benefit score.²⁰ A benefit score of 1.3 out of 2 was selected as a threshold of reasonable acceptability for this evaluation based on a prior study examining acceptability of weighted blankets for community-dwelling people living with dementia.¹⁸ The weighted blanket study demonstrated average benefit scores of 2.5 for caregivers, and 2.8 for persons living with dementia on a Likert scale that ranged from 1 = not at all to 3 = a great deal beneficial. The scale was modified for this evaluation to range from 0 to 2 based on COACH staff feedback that a “not at all” response is more clearly indicated by a 0 as opposed to a 1. A lower benchmark of 1.3 out of 2 compared to 2.5 out of 3 was selected for this evaluation: 1) as fewer benefit items were included on the Social Robot Pet Intervention Usability and Acceptability Tool with the intention of reducing caregiver burden as compared to the weighted blanket acceptability tool, and 2) because unlike the weighted blanket study, the perspectives of people living with dementia were not captured in this evaluation as all items were answered by proxy caregiver respondents.

Sociodemographic and Behavioral Information

To describe the sample, sociodemographic information and measures of behavioral symptoms were collected through Veterans’ administrative records. Sociodemographic variables included Veteran age, race, gender, education, dementia severity, and relationship between the Veteran and their caregiver.

Behaviors were measured using the Agitated Behaviors in Dementia Scale (ABIDs), which is regularly collected for all Veterans enrolled in the COACH program. The 16-item ABID measures the frequency and caregiver reaction to common agitated behaviors experienced by community-dwelling people living with dementia. It has demonstrated moderate reliability (Cronbach’s 𝛼 = .70; test-retest reliability (.6-.73)) and validity (Pearson correlation with the Behavior Rating Scale for Dementia and Revised Memory (r = .74, P < .0001) and Behavior Problems Checklist (r = .65, P < .0001)) in this population.¹⁷ Total frequency scores range from 0 to 48 with higher scores indicative of more frequent behaviors. Caregiver reaction scores range from 0 to 64 with higher scores indicating more severe distress experienced by the caregiver due to the behaviors. The ABIDs is completed by a trained COACH program social worker, or registered nurse through interview of the Veteran’s caregiver every 6 months.

Data Collection

The Social Robot Pet Intervention Usability and Acceptability Tool was collected via a one-time, structured telephone interview with caregivers 3-months after delivery of the pet. Interviews were conducted from October 2021-February 2022 and led by the first author (MHG), a PhD prepared nurse with advanced training in mixed methods data collection. On average, interviews lasted 14 minutes (SD = 2.98). Sociodemographic and behavioral data was collected via administrative records maintained by the COACH program. Records were reviewed by the third author (EA) for relevant variables, which were entered into an excel folder stored in a secure project folder. The most recent ABID scores were included that had been collected within 3 months prior to and 3 months after delivery of the pets to Veterans home.

Data Analysis

Descriptive statistics (frequencies, percentages, means, SDs) were used to analyze quantitative data, including frequency of use and reminders, benefit, satisfaction, sociodemographic, and behavioral data. Pre and post ABID frequency and caregiver reaction scores were compared using paired sample t-tests. Content analysis was used for open ended items related to benefit by clustering similar responses into categories and matching them to exemplar quotes provided by the caregivers.

Results

Sociodemographic Information and Behavioral Scores

On average, Veterans were 81 years of age (SD = 7.1). Most were non-Hispanic White (n = 13), male (n = 18), and well educated (Table 1). The majority were living with severe dementia (80%) and had been diagnosed with dementia for an average of 5.3 years (SD = 2.6). Veterans were cared for by their spouse (n = 16), daughter (n = 3), or ex-spouse (n = 1). ABID scores were similar from pre to post, but lower than comparable community-based samples.¹⁷

Table 1.

Sociodemographic Information and Behavioral Scores Among Veterans Living With Dementia (N = 20).

Age	80.5 (7.1)
Race/ethnicity no. (%)
White/not hispanic or Latino	13 (65)
White/Hispanic or Latino	1 (5)
African American/not hispanic or Latino	6 (30)
Male no (%)	18 (90)
Education
High school or GED	8 (40)
Some college	2 (10)
College and above	10 (50)
Severe dementia no. (%)	16 (80)
Years since dementia diagnosis	5.3 (2.6)
Veteran/caregiver relationship
Spouse	16 (80)
Daughter caring for parent	3 (15)
Ex-spouse	1 (5)
ABIDs (N = 20)	Pre	Post
Frequency	5.3 (3.4)	5.9 (3.4)
Caregiver reaction	10.6 (8.1)	11.6 (7.9)

Usability

Congruent with the pre-defined benchmark of usability (Table 2), the majority (80%) of Veterans used the pet often (n = 3) or at least once a day (n = 13), while 1 Veteran did not use the pet at all during the 3-month period. Seven caregivers reported providing reminders or prompts for the Veteran to use the pet, most of whom provided daily reminders (n = 4).

Table 2.

Results of Measures of Usability and Acceptability.

	Pre-Defined Benchmark	Results
Usability
Frequency of use of pet	≥80% used pet often or daily^18,22,24	80%
Percentage of caregivers that provided reminders/prompts for veteran to use pet	N/A	35%
Acceptability
Benefit	Overall benefit score ≥1.3¹⁸	M = 1.35 (SD = .8)
Satisfaction	≥80% would recommend to others and encourage continued use of pet by veteran^18,21	89%

Acceptability

The average overall benefit score was 1.35 (SD = .8), which was greater than the pre-defined benchmark of 1.3. Most caregivers reported that the pet benefited the Veteran a great deal (n = 13), as well as themselves as caregivers (n = 12). The majority (80%) indicated that the pet was somewhat or a great deal helpful in decreasing challenging symptoms experienced by the Veteran.

Open ended response items pertaining to benefit clustered into the 3 categories. The pets were viewed as a tool to promote the Veteran’s comfort and relaxation, as well as comfort for the caregiver (Table 3). One caregiver stated, “He uses it every night. It makes him laugh and smile every time. He doesn't remember its name, but he talks to it and loves on it before we fall asleep.” (CG03). Meanwhile, Veteran’s past experiences and preferences related to pets influenced the perceived benefit of the intervention, as indicated by another caregiver, “He doesn't really use it, because he had a real dog that he loved so much. He knows this one isn't real so he just kind of laughs at it, but doesn't use it.” (CG16).

Table 3.

Open Ended Response Categories Related to Benefit.

Category	Exemplary Caregiver Quotes
Promote veteran comfort and relaxation	He keeps it in his recliner that he sits in all day. I think it does bring him comfort. It doesn't add any burden on me either, which is great. (CG08)
Provide caregiver comfort	It not only brings him comfort, but I like to use it too. I would really recommend it to older adults in general, not just people with dementia. (CG19)
Past pet experiences and preferences matter	He doesn't pay any kind of attention to it. You know he didn't really like cats before, so it may just be that. (CG13)

Exceeding the pre-defined benchmark for satisfaction, the majority of caregivers (89%, n = 18) reported that they would recommend a social robot pet to others living with, or caring for someone living with dementia and would continue to encourage the Veteran to use the pet (Table 2). The two caregivers who indicated they would not recommend the pet described past experiences or preferences that seemed to influence the Veteran’s use of the pet (e.g., recent death of real pet; see Table 3).

Discussion

Social robot pets are an innovative tool to promote social engagement that are highly beneficial to older adults.²³ This evaluation highlights the usability and acceptability in a new population of community-dwelling Veterans living with dementia as perceived by their caregivers. Findings may inform future implementation initiatives to enhance person-centered care for Veteran families living with dementia.

High frequency of use and minimal caregiver reminders to use the social robot pet support that these are relatively passive tools that can be used regularly by Veterans with moderate to severe dementia while placing minimal burden on caregivers. Although this evaluation was not designed to examine effects on outcomes, high degrees of benefit and satisfaction support that social robot pets are at the very least a promising tool to promote comfort among community-dwelling Veterans living with dementia. Rigorous research is needed to evaluate the impact on pragmatic (e.g., behaviors, psychotropic medication use), as well as person-centered outcomes (e.g., social interaction, engagement, well-being) among Veterans with dementia and their caregivers.

Together findings of this evaluation combined with other efficacy studies support broader implementation of social robot pets among community-dwelling older adults,²⁵ including those living with dementia. This evaluation demonstrates how innovative technologies can feasibly be delivered to community-dwelling Veterans through existing care coordination programs, like COACH. Yet, a major barrier to broader delivery and uptake in the community is cost.^23,26 Some healthcare systems, community support organizations, and hospice programs provide social robots to eligible patients, but they are not covered by Medicare or private insurers. The VA represents a model system for identifying strategies to address financial barriers to implementation as social robot pets are already being considered as non-pharmacological interventions and provided through inpatient, as well as outpatient initiatives. This may include provision of pets through primary care provider consults and occupational therapy referrals. Alternative payment models for technology-based interventions in the home setting are needed to ensure equitable provision of person-centered interventions,²⁷ like social robot pets.

Limitations of this evaluation are fourfold. First, retrospective, single item measures of frequency of use may not be an accurate indicator of actual pet use. Alternative measures may be considered in future evaluations, such as prospective measures through real-time logging, or sensor-based technology. Second, measures of satisfaction using surveys have an inherit risk of biased response.²⁸ Effort was made to minimize this risk by having someone not involved with the delivery of the pet or other COACH services complete telephone interviews; however, families may have still felt inclined to give more positive responses. Third, due to the degree of dementia severity of Veterans served by COACH, the perspectives of Veterans living with dementia were not captured on the acceptability tool. This precludes a comprehensive understanding of satisfaction and benefit of social robot pets from a dyadic or family perspective. Satisfaction and benefit scores may have been lower in this evaluation due to not including the patient perspective, as persons living with dementia often report more positive experiences and perceptions compared to caregiver proxy respondents.^29,30 Finally, given that this project was done within the context of a programmatic evaluation, results are not generalizable to other non-Veteran, community-based populations.

Despite these limitations, this evaluation provides foundational knowledge to inform future research to expand generalizability of findings and rigorously examine the impact of social robot pets on Veterans living with dementia and their caregivers. Specifically, evaluative efforts need to include people with varied types of dementia and those in earlier stages of dementia who may be more able to express their own perceptions of benefit and satisfaction. Open ended responses pertaining to caregiver benefit suggest additional work is needed to examine the acceptability of social robot pets for caregivers. Future research may require alternative person-centered measures such as engagement and social interaction, given that validated measures of behavioral disturbances may not be sensitive enough to determine value and impact from a family perspective.

Conclusion

As families living with dementia are at high risk of experiencing social isolation, widespread coverage and broader implementation of social robot pets is needed to enhance well-being in this population. Findings of this evaluation expand the evidence by demonstrating high degrees of usability and acceptability of social robot pets among community-dwelling Veterans living with dementia, as perceived by family caregivers. The VA Health Care System represents a unique environment to further evaluate implementation of social robot pets to Veterans living with dementia and their caregivers.

Footnotes

Acknowledgments

We would like to acknowledge all members of the Durham VA’s Caring for Older Adults and Caregivers at Home Program Team for their contributions to this evaluation and their continued commitment to caring for Veterans and their caregivers. Social robot pets used in this evaluation were provided by the Triangle J Area Agencies on Aging. This article is the result of work supported with resources and the use of facilities at the Durham VA Health Care System. The content expressed in this article are those of the authors and do not necessarily represent the official views of the US Department of Veterans Affairs, the United States Government, or Duke University.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Melissa L. Harris-Gersten

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