Exploring Interactions of Older Adults with Mild Dementia Participating in Robotherapy with Robot Cats in a Day Hospital in Spain: A Qualitative Study

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This study suggests that robotherapy with robot cats can provide positive therapeutic effects, such as relaxation, mood improvement, cognitive stimulation, and increased social interaction, in older adults with mild dementia. These findings can guide healthcare professionals in integrating social robots into their daily practice and help developers improve the technological features of the robots.

Abstract

The growing aging population has raised concerns about the treatment of age-related diseases, such as dementia. An emerging technology that could assist individuals with dementia is the development of social robots. However, interactions with these robots have been underexplored. This study aimed to examine the interactions between a robot cat and older adults with mild dementia during robotherapy sessions. Thirteen older adults with mild dementia who used a robot cat during robotherapy sessions in a day hospital in Spain were interviewed. Following semi-structured interviews, a thematic qualitative analysis of the data was conducted, revealing four main themes: (1) therapeutic effects of robotherapy (relaxation, mood improvement, cognitive stimulation, and increased social interaction); (2) preferences regarding the types of robotherapy activities; (3) interaction with the robot cat during the sessions; and (4) technological characteristics of the robot cat. Overall, the findings indicate positive interactions and suggest promising benefits for older adults with mild dementia participating in robotherapy with robot cats.

1. Introduction

The global population is aging, leading to increased attention to dementia and other mental health disorders. These conditions are common among older adults and have become a significant public health issue [1]. Dementia, which primarily affects older adults, hinders daily activities and social interactions, significantly impacting well-being [2]. It mainly affects individuals over 65 years old, causing cognitive dysfunction, hyperactivity, sleep disturbances, aggression, and depression [3]. The primary treatment for people with dementia is medication. However, adherence to medication is often suboptimal because managing medication and adhering to a regular schedule can be extremely challenging due to the symptoms of dementia. As a result, a combination of medications and non-pharmacological treatments is often recommended [4]. Robotherapy is an innovative non-pharmacological approach for treating dementia, utilizing various technologies based on robots and artificial intelligence [5].

In line with the growth of technology, innovative technologies such as social robots have been studied in the older adult population, demonstrating promising emotional support and companionship for seniors [6]. A social robot is one that interacts with its audience based on social and cultural behavior norms and can be autonomous or semi-autonomous [7]. Robotic pets are a type of social robot that mimic the appearance and behavior of real pets, helping to reduce anxiety and aggression in individuals with dementia [8]. Animal robots are often the preferred designs for robotherapy, and older adults with dementia tend to favor robotic pets with familiar and realistic designs, such as robot cats or dogs [9].

Joy For All (JFA) robotic pets are equipped with sensors that can be activated by touch and light, allowing the robots to provide autonomous responses through verbal inputs and movements for interaction [10]. JFA robots lack advanced functions and programming capabilities, but older adults with dementia find them more interactive than more sophisticated robots [11]. Additionally, the affordability of JFA robots enables specialized centers to acquire and provide them to their clients [12]. This study aimed to explore the interactions of older adults with mild dementia using JFA cat-type robots and the potential benefits of robotherapy. In this study, the potential therapeutic effects of robotherapy were assumed to include positive emotional stimulation, reduction of anxiety, induction of calm or relaxation, and the promotion of emotional bonding through interaction with the robot. These assumptions were based on previous evidence showing that robotic pets can enhance emotional well-being, reduce behavioral symptoms, and improve the quality of life in older adults with dementia [13,14].

2. Materials and Methods

2.1. Study Design

The study design was qualitative and descriptive, aimed at exploring the interactions of older adults with mild dementia using JFA robot cats (Reviva, Unterhaching, Germany) [15]. This study examines the lived experience of using robotherapy with the JFA robot cat among individuals with dementia attending day hospitals in Tenerife, Spain. Participants received sixteen 50 min robotherapy sessions in their outpatient environment (day hospital) over a period of eight weeks. After completing the seventh week of robotherapy sessions [16], a structured interview was conducted to detail their experiences with robotherapy and the use of the robot cat. The questionnaire was designed by the research team, and the interviewers were occupational therapists or psychologists. The robotherapy sessions were recorded on video to facilitate the interview process by helping participants recall their experiences.

2.2. Participants

Thirteen participants took part in the robotherapy intervention using JFA robot cats in a small group consisting of two patients and one therapist over eight weeks. Convenience sampling was used to recruit participants who met the following inclusion criteria: (a) being 65 years or older and capable of maintaining a conversation and verbal comprehension; (b) having a diagnosis of mild dementia according to their medical history in the day hospital database; (c) demonstrating appropriate sensory abilities for interacting with the JFA robot cat, such as vision, hearing, and touch, which was assessed prior to the study by observing the potential participant’s behavior with a stuffed animal; and (d) having attended the day hospital for more than one year.

The day hospital created a list of potential participants based on their medical records. The researcher then contacted these potential participants, including patients and their caregivers, to inquire about their interest in participating in the research project. To protect participants’ privacy, the hospital introduced potential participants to a researcher in person, without providing the researchers access to their names or any other personal data until participants gave their consent. To avoid making participants feel obligated to join the research project, the invitation was delivered verbally by the researcher rather than by their healthcare provider. Participants were assured that their decision to participate or not would not affect their access to any health services. All participants were clinically assessed by the psychologists at the day hospital to determine their ability to understand the information related to the study. This evaluation was carried out by trained professionals who assessed each individual’s capacity to make informed decisions, in accordance with accepted criteria for evaluating decision-making competence. Only those individuals who demonstrated sufficient cognitive ability to understand the nature of the study, its risks and benefits, and their right to withdraw were invited to participate in the study.

Regarding withdrawal from the study, participants were explicitly informed that they could leave the research at any time, without needing to justify their decision and without any negative consequences for their medical care or their relationship with the research team. This right was periodically reinforced throughout the study, and a simple procedure was established to communicate this decision, either verbally or through a family member/caregiver.

2.3. Data Analysis

The recorded interviews were transcribed verbatim by the authors. The thematic analysis process was carried out using Microsoft Excel [17], based on six-step inductive thematic analysis: (a) becoming familiar with the data; (b) generating initial codes; (c) searching for themes; (d) reviewing themes; (e) defining and naming the themes; and (f) producing the report [18]. To ensure reliability and validity in this qualitative research, several rigor strategies were applied, following methodological recommendations from the literature [19,20]. These included data triangulation (interviews, observations, and field notes), the involvement of external researchers in the analysis, a rigorous thematic coding process, and detailed contextual descriptions to support transferability.

In addition, methodological decisions were thoroughly documented to ensure confirmability, and a reflexive stance was maintained throughout the process to minimize potential bias.

The researchers continuously read the interview transcripts to gain an overall understanding of the content. Next, the transcripts were analyzed, and the initial codes were continuously combined and compared with the data throughout the process. Then, the codes were reviewed and classified into emerging themes and subthemes. Modifications were made to the themes and subthemes to make them more inclusive through discussions among the authors. Ultimately, four main themes were developed that reflected the content of the interviews.

Several strategies were employed to ensure the reliability of the data. Two researchers conducted daily and persistent observations to fully understand the older adults during the robotherapy sessions and their interactions with the robot cat [18,21]. The observations helped identify behavioral patterns that participants did not always verbalize, and allowed for a better contextualization of their verbal responses. For example, in several cases where participants expressed indifference toward the robot during interviews, the field notes revealed consistent affectionate behaviors (such as stroking the robot, smiling at it, or speaking to it), suggesting a deeper level of emotional engagement than was verbally reported. These observations contributed to the interpretation of the themes and helped reduce potential biases in the self-reported data.

Two external researchers independently analyzed the data to enhance the credibility of the findings [22]. Additionally, an audit trail was maintained for the coding and categorization of qualitative data during the analytical process to ensure the rigor of the research [23].

2.4. Challenges in Conducting Interviews with People with Dementia

While the experiences of individuals with dementia provide valuable insights for research and practice, involving them in the interview process can be challenging due to their specific conditions and symptoms. This may hinder their ability to participate in an interview session for an adequate period of time. Common issues during interviews included comprehension and fatigue. Several strategies were implemented to support participants. First, reminiscence can trigger memories and encourage participants to share information [24]. Therefore, the researchers presented videos of the robotherapy sessions and brought the robot cat to the interview to help participants recall their experiences. Second, the interview questions were modified to be concise and direct, tailored for individuals with dementia. The interview questions were slightly adjusted following an initial pilot phase, during which the first interviews were conducted with a small group of participants. This phase allowed us to evaluate the clarity, relevance, and sensitivity of the interview guide. Based on this experience, some questions were reformulated to enhance understanding among participants with mild cognitive impairment and to encourage richer and more spontaneous responses.

Direct questions are recommended as they are more easily verbalized by individuals with limited expressive abilities [25]. The researchers offered participants the option to continue or stop the interview when they felt tired or showed signs of fatigue. Flexibility was also suggested by adjusting the length of the interview for each participant and offering the option of multiple short interviews [26].

2.5. Robotherapy Procedure

The robotherapy intervention was conducted over eight weeks, with sessions held weekly and lasting approximately 45 min each. The JFA robots were used, and they resemble cats in size and shape, making them appealing and familiar to participants. Their bodies are covered with soft fur that mimics the feel of a real animal, providing a sense of comfort and companionship (Figure 1).

The sessions took place in a quiet, familiar room within the day care center managed by the Acufade Association, ensuring a safe and comfortable environment. Each session involved two participants with mild dementia, a JFA robot, and two therapists. The therapists were occupational therapists and clinical psychologists with specific experience in geriatric care and dementia. Prior to the study, both participated in a 6 h training workshop on robotherapy protocols, ethical considerations, and appropriate techniques for interacting with robotic pets. Each session followed a structured format, starting with a welcome and orientation (5–10 min), where therapists introduced the robot and explained the session’s purpose. This was followed by free interaction (15–20 min), where participants engaged with the robot, with occasional therapist intervention to promote verbal interaction. In the guided activities (10–15 min), therapists encouraged conversation about the robot to stimulate reminiscence or emotional expression. The session concluded with a brief reflection (5–10 min), where participants shared their feelings and impressions in a calm manner.

2.6. Ethical Considerations

The Acufade Association, an organization in Tenerife working with older adults and individuals with cognitive impairment, provided the setting, participants, and professional support for the robotherapy sessions. The study received ethical approval from Acufade’s research department and the manager of the day centers. Participants and their caregivers signed informed consent, and verbal consent was obtained from participants during each session, in line with the ethical principles of the Declaration of Helsinki.

Although the study was not reviewed by a university ethics committee, it adhered to the established ethical standards. A protocol was also in place to intervene in case of distress, with trained personnel offering emotional support and notifying family members when necessary.

3. Results

3.1. Characteristics of the Participants

Table 1. Characteristics of the participants (n = 13).

Variables	Median (Interquartile Range)/ Frequency (%)
Age, years	80 (4)
Gender	Women, 13 (100)
Mini-Mental State Examination score, points	20 (2)
Dementia type	Alzheimer’s (61.53) Unspecified (38.46)
Pet preference	Dog (53.38) Cat (46.15)
With or without pets at home?	(76.92) No (23.07)

presents the demographic information of the study participants. All participants attended the day hospital from 9:00 a.m. to 5:00 p.m. and had an average age of 81.6 years. Additionally, all participants were women. The Mini-Mental State Examination (MMSE) was used to assess the level of cognitive decline, providing an objective and standardized measurement of the participants’ cognitive status.

3.2. Findings

Based on the analysis of participant data (

Table 2. Main themes, subthemes, and codes.

Themes	Subthemes	Codes
Therapeutic effects of robotherapy	Positive effects	− Relaxation − Mood improvement − Cognitive training − Increased social interaction
	Negative effects	− Feeling childish (stuffed animal)
Preferences for the type of activities during robotic therapy sessions	Social interaction group activities	− Creative and playful sessions with the robot cat
	Individual activities with the robot	− Personalized sessions
Interaction with the robot cat	Positive attitude with the robot cat	− Appearance of the robot cat − Interactive behavior with the robot cat
Technological characteristics of the robot cat	Technological advances of the robot cat	− Functions such as walking − Robot cat tail movement

), four main themes were identified:

(1)

Therapeutic effects of robotherapy;

(2)

Preferences for the type of activities during robotic therapy sessions;

(3)

Interaction with the robot cat;

(4)

Technological characteristics of the robot cat.

The overall results revealed that older women with mild dementia experienced positive therapeutic effects from robotherapy, including relaxation and the evocation of positive emotions. However, they also mentioned negative effects, such as feeling infantilized when using animal robots that resemble stuffed animals.

When it comes to preferences for activities during robotherapy, participants ranked social interaction activities and individual activities with the robot as their top priorities. The study also found that older people with dementia had a positive attitude towards using the JFA robot cat, particularly in terms of its appearance and interactive behaviors. However, participants expressed that they expected the robot to have more advanced technological features and offer additional functions, such as walking. Each theme is explained in more detail below, and all quotes have been translated from Spanish to English.

3.3. Theme 1: Therapeutic Effects of Robotherapy

The following theme highlights the experiences of participants during robot therapy sessions involving the use of a robotic cat. It explores both the positive and negative therapeutic effects reported by the participants. Individuals with mild dementia mentioned experiencing positive effects, feeling relaxed and calm. One participant shared, “I usually go to the hospital feeling nervous, but after this activity, I feel relaxed and eager to participate in other activities” (Participant 5). Other participants mentioned that attending the robotherapy sessions improved their mood and overall well-being, making them feel uplifted throughout the day in the day hospital. One participant stated, “They are very enjoyable activities; I feel happy when I participate” (Participant 2).

Some participants also mentioned that engaging in robotherapy activities using the robot cat made them think, enhancing their cognitive activity through memory and attention. One participant stated, “The therapist asked me what my cat ate and where he slept. She also asked me if this cat looked like my cat. That made me think. It helps me with my memory” (Participant 6). Additionally, other participants mentioned that using the robot cat sparked conversations between the participants in robotherapy and other elderly individuals from the day hospital who had not taken part in the sessions. This led to increased social interaction among day hospital colleagues. One participant mentioned, “…my friend waits for me to finish the activity with the robot so I can tell her how it went… we always laugh together…” (Participant 4).

During robot therapy sessions, participants with mild dementia reported negative experiences using the robot cats. They felt infantilized and described the robot cats as resembling a child’s stuffed animal. One participant remarked, “This cat is like my grandson’s stuffed animal. I feel like I’m playing with his stuffed animal…” (Participant 8)

3.4. Theme 2: Preferences for the Type of Activities During Robotic Therapy Sessions

Participants underwent robot therapy interventions in small groups, with two patients and one therapist attending sessions for 50 min twice a week over eight weeks. The participants had varying preferences for the activities during the robotherapy sessions. Some preferred group activities to engage with their peers. They expressed enjoyment in using the robot cat with other older adults, as it encouraged social participation and interaction. One participant mentioned, “What I enjoyed about this activity was laughing with my partner and using the cat between the two of us. We both went together to walk the cat and strolled through the garden” (Participant 10). However, some participants expressed a preference for personalized activities with the robot cat, highlighting the importance of individualized robotic therapy sessions with dedicated attention from a clinical professional. One participant mentioned, “I would have preferred the sessions to be individual… I feel more comfortable with the therapist” (Participant 3).

Additionally, other participants emphasized their preference for tailored robotherapy sessions with the robot cat, considering individual characteristics, preferences, and interests. One participant explained, “I wanted to continue grooming the cat, as I was having difficulty holding the brush and doing it slowly, while my partner was faster… I think it would be better for me to attend alone with the therapist” (Participant 3).

3.5. Theme 3: Interaction with the JFA Robot Cat

Many participants noted that the robot cat had a positive impact during the robotic therapy sessions. They thought the JFA robot cat was cute, with soft fur and a very realistic meow. They also felt that the robot cat was similar in weight and size to a real cat and, at times, seemed just like a real cat. One participant said, “The cat has very soft fur and is very pretty… It looks like a real cat.” (Participant 1). Additionally, some participants mentioned that they enjoyed positive interactions with the robot cat, finding the robotic therapy sessions very fun and enjoyable. One participant said, “What I like most about this activity is the cat” (Participant 9).

3.6. Theme 4: Technological Characteristics of the JFA Robot Cat

During the usability test with the JFA robot cat, participants felt that the technological features were limited. They expected the robot cat to walk or have more interactive features, such as blinking eyes, turning its head from right to left, and moving its tail. One participant expressed, “the cat always makes the same movements; it would be good if it walked or moved its tail…” (Participant 13).

4. Discussion

The study found that interactions between older people with mild dementia and robot cats can have significant benefits during robotherapy interventions, highlighting a preference for group and individual activities with the robot, emphasizing features such as the robot’s fur and meow. However, some participants were not fully satisfied with the robotherapy interventions, feeling that they could be seen as infantilizing the older person through the use of the robot cat. Furthermore, during the interaction with the JFA robot cat they perceived a lack of advanced technological features, expecting more functions.

Previous studies, which align with our findings, have demonstrated that robotherapy provides benefits such as relaxation, improved mood, and reduced symptoms of depression in older adults with dementia [27,28]. The improvement in mood is associated with the use of robot animals. Interacting with robot cats can evoke positive emotions through petting or touching the robot. This can lead to the release of neurotransmitters such as oxytocin, which has stress-relieving effects and increases pain threshold [29,30].

The use of robot animals can evoke memories of time spent with pets, improving mood. Other studies have shown that robotic pets can help elicit memories, providing benefits for reminiscence, especially during individual robotherapy sessions [31,32]. This aligns with the feedback we gathered from the lived interactions of older adults with mild dementia. The interaction with robot cats in the study demonstrated that older adults can experience a sense of emotional connection and companionship, countering loneliness and isolation. Furthermore, these interactions can stimulate communication and encourage active participation in activities, contributing to overall well-being. By providing responses and behaviors that mimic real animals, robot cats can help older adults feel calmer and more relaxed, fostering a positive environment during robotherapy sessions.

In line with our findings gathered from the experiences of older adults, previous studies have indicated that robotherapy with robot animals also has positive effects on cognitive training and can increase social interactions among older adults with dementia. Some studies have shown that older adults who participated in group therapy sessions with a robot animal were more likely to interact socially with each other when the robot was present, compared to when they did not interact with the robot [33,34].

The robotherapy sessions in this study involved groups of two older adults with dementia, where they interacted with the JFA robot cat. Participants expressed their preferences on how robotherapy interventions should be implemented, emphasizing the importance of personalizing activities according to their individual interests and needs. Many highlighted that the sessions should include a variety of activities that promote both social interaction and personal enjoyment, as well as the option to adjust the duration and pace of the sessions to maximize their comfort and engagement. This aligns with findings from several studies suggesting that robotherapy activities can be tailored to the individual preferences of older adults with dementia. This includes considering the duration and frequency of robot-assisted interventions [35,36]. Furthermore, some authors suggest that there is no one-size-fits-all approach to robotherapy, and variations in the types of activities—both individual and group—can exist [16,37].

The participants in the study had a positive perception of the JFA robot cat, particularly its soft fur, orange color, and meowing sound. It was found that the interactive features of the robot cat were crucial for the success of the robotherapy sessions. This could explain why robotic pets are more appealing to users compared to non-interactive stuffed animals. Furthermore, the robot cat’s ability to respond to petting and vocalizations created a sense of emotional connection, fostering an atmosphere of trust and warmth during the sessions. This interactivity not only enhanced the participants’ experience but also contributed to their emotional well-being, promoting greater engagement and enjoyment in the robotherapy activities [30]. In contrast, other authors point out that the interactive features of the JFA robot cat may have negative effects. Users may perceive the robotic animal as a living creature, leading to emotional distress due to unmet needs or a lack of feeding [10,38].

In the section on Technological Characteristics of the Robot Cat, participants reported some negative interactions regarding the technological capabilities of the JFA robot cat, despite their overall positive experiences with it. They mentioned its limited functionalities and expressed expectations for the cat to walk or move its tail, which they believed would have enhanced the sense of interaction and realism during the robotherapy sessions. In previous studies, users also anticipated more technological features from the robot during robotherapy sessions [39], which led to feelings of rejection [40]. This aligns with the findings of the study by [11], which noted that users expected the JFA robot cat to have additional technological functions, resulting in boredom and decreased interest among older adults with dementia [41].

Understanding these issues is crucial for informing the future development of social robots and ensuring their technological resilience during robotherapy sessions, thereby enhancing current interactions and treatments through this technology.

This study has limitations as it collected opinions solely from older women. Also, the delivery of this therapy in a single location—Tenerife, Spain—makes it difficult to generalize the results to other contexts and cultures. Additionally, it is important to note that the treatment was conducted with only one type of robot, highlighting the need for future research that utilizes other types of social robots to support the findings.

5. Conclusions

This study provides valuable insights into the use of robotherapy interventions, highlighting their benefits and the interactions with robotic animals. It emphasizes the potential to enhance relaxation, mood, cognitive training, and social connections among older adults with dementia in day hospitals. However, it also notes that robotic animals can evoke feelings of infantilism during therapy sessions and points out areas for improvement in the technological features of the JFA robot cat.

Our findings indicate that the JFA robot cat encouraged greater participation in robotherapy activities among older adults with dementia by fostering positive interactions and due to the provision of flexibility during sessions.

The qualitative findings are promising for informing healthcare professionals about the benefits of incorporating robotherapy with robotic animals into daily practice based on user experiences. Additionally, these insights will assist researchers and developers in understanding how older adults with dementia perceive the design and technological features of potential robots for therapy sessions. Future research is needed to evaluate design preferences for robotic pets intended for use by older adults with dementia.