Aging Medicine and Healthcare. doi:10.33879/AMH.2020.066-2001.003 [In Press, March 27, 2020]

Aging Medicine and Healthcare
https://www.agingmedhealthc.com

Case Report

Effects of Teleoperated Humanoid Robot
Application in Older Adults with Neurocognitive
Disorders in Taiwan: A Report of Three Cases
Liang-Yu Chen1,2,4, Hidenobu Sumioka3, Li-Ju Ke5, Masahiro Shiomi3, *Liang-Kung Chen1,2,4
1Aging and Health Research Center, National Yang-Ming University, Taipei, Taiwan
Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
3Advanced Telecommunications Research Institute International, Kyoto, Japan
4
Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
5uAge Day Care Center, Taipei Veterans General Hospital, Taipei, Taiwan
2

ABSTRACT*Correspondence
Prof. Liang-Kung Chen
Center for Geriatrics andGerontology, Taipei Veterans
General Hospital, Taipei,
TaiwanE-mail:lkchen2@vghtpe.gov.tw
Received 26 January 2020
Accepted 2 February 2020

Keywords
Dementia, neurocognitive
disorder, neuropsychiatric
symptom, Telenoid, uncanny
valley.

Rising prevalence of major neurocognitive disorders (NCDs) is associated witha great variety of care needs and care stress for caregivers and families. A
holistic care pathway to empower person-centered care is recommended, andnon-pharmacological strategies are prioritized to manage neuropsychiatric
symptoms (NPS) of people with NCDs. However, limited formal services,
shortage of manpower, and unpleasant experiences related to NPS ofthese patients often discourage caregivers and cause the care stress andpsychological burnout. Telenoid, a teleoperated humanoid robot, is a newtechnology that aims to improve the quality of life and to reduce the severityof NPS for persons with major NCDs by facilitating meaningful connection
and social engagement. Herein, we presented 3 cases with major NCDs in
a day care center in Taiwan who experienced interaction with the Telenoid.
Overall, no fear neither distressed emotional response was observed during
their conversation, neither worsening of delusion or hallucination after
interaction with Telenoid. The severity of NCDs seemed to affect the verbal
communication and the attention during conversation with Telenoid. Other
factors, such as hearing impairment, insomnia, and environmental stimuli,
may also hinder the efficacy of Telenoid in long-term care settings. Further
studies with proper study design are needed to evaluate the effects ofTelenoid application on older adults with major NCDs.
ISSN 2663-8851/Copyright © 2020, Asian Association for Frailty and Sarcopenia and Taiwan
Association for Integrated Care. Published by Full Universe Integrated Marketing Limited.

1. INTRODUCTION

82 million in 2030, and 152 million by 2050.2 In Taiwan,
the prevalence of major NCDs was 8.04%, and 18.76%
for minor NCDs among the community-dwelling older
adults, and the prevalence may be higher among thosewith frailty and multimorbidities.3 In the average of
8-10 years of life expectancy after diagnosis, persons
with major NCDs have more care needs related totheir cognitive impairment, and frequent transition of

Rising prevalence of major neurocognitive disorders(NCDs) poses a great impact on physical, psychological,
social, and economic dimensions on persons withdiseases, caregivers, families, and whole society. 1
Globally, it is estimated that 50 million people wereaffected by major NCDs in 2015, which may become1Aging Medicine and Healthcare. doi:10.33879/AMH.2020.066-2001.003 [In Press, March 27, 2020]

care needs due to neuropsychiatric symptoms as well
as disability. A holistic, person-centered care pathway
to empower patients is always recommended to
improve those negative aspects related to NCDs, suchas insecurity, low dignity, depression, and few social
engagements.1,4experiences on applying teleoperated humanoid
robots among older participants with major NCD, toevaluate the subsequent influences on their NPS, toelucidate if any negative response related to uncanny
valley hypothesis, and to explore the possibly
affecting factors on successful application of robot
technology in daily practices.

Neuropsychiatric symptoms (NPS), which over 90%
of patients with major NCDs may develop at any
stage over the disease course, substantially increased
the risks of premature institutionalization, functional
disability, cognitive decline, and even mortality for
persons with major NCDs.5 Aggression, delusion, andhallucination of agitated/psychotic clusters often leadto mistreatment and inappropriate care managementsby physical or chemical restrains. Anxiety, nihilistic
ideation, lack of initiatives, and psychomotor slowingof depressive/apathic clusters may worsen theconditions of social isolation and even mistreatment
or neglect. 5 Among family caregivers and staff oflong-term care facilities, NPS are highly associatedwith physical care stress and psychological burnout
due to the inability to cope with those problems.6
In addition to physical injuries coming from violent
behaviors related to NPS, caregivers also foundhaving higher risk of cardiovascular diseases, probably
due to chronic inflammation and sympathetic
overactivation. Moreover, over a third of caregivers
reported depressive symptoms and about a halfof care-givers reported anxiety due to emotional
stress and psychological frustration. 6 Despite that
non-pharmacological approaches are prioritizedin the management of NPS, caregivers are often
discouraged due to enormous care stress andpsychological burnout, especially when the formal
services and manpower are limited.

2. CASE PRESENTATION
Three service recipients who received day careservices at the uAge Day Care Center, Taipei Veterans
Hospital, were invited for participation during July
15, 2018 and July 15, 2019. All participants received
day care services with confirmed diagnosis for major
NCDs, including Parkinson’s disease dementia,
Alzheimer’s disease, and vascular dementia. Written
informed consent were obtained after fully explanation
to all participants and their families. Demographic
characteristics, subtypes of major NCDs, chronic
conditions, and regular medications were collected
for all participants. Each participant would havemutual interaction with a staff of day care center insession 1, with their family in session 2, with humanoid
robot operated by that staff in session 3, and finallythe robot operated by their family in session 4. Eachsession allowed a free conversation during ordinarysocial interaction with the maximum of 20 minutes.
On the final day, additional group session was
arranged for all participants and Telenoid operated bystaff to evaluate the interaction pattern and possible
learning effect during ordinary conversation. The
time distribution of participants’ and partners’ talking
were recorded individually to calculate a time ratio ofparticipant/partner. The attention paid on the partnerwith eye-to-eye contact was also estimated during
each session. Neuropsychiatric symptom assessment
by 12-items Neuropsychiatric Inventory (NPI) in
Chinese version was performed on each individual
before and 48 hours after mutual interaction.10 This
study was approved by the institutional review boardof the Taipei Veterans General Hospital (IRB-VGHTPE
No. 2018-07-020B).

Teleoperated humanoid robot is a new technologythat improves the quality of life and relieve the severityof NPS of patients with major NCDs by facilitating
meaningful connection and social engagement.7 This
teleoperated design allows the caregivers keeping
conversation as usual at a more relaxing atmospherewithout worrying NPS and violence, and the humanlike appearance of teleoperated humanoid robot
promotes the initiatiation of communication withpersons with major NCDs.8 Animal-like robots provide
companionship as pet to comfort the NPS of older
adults with major NCDs. However, the teleoperated
humanoid robot reduces users’ potential emotional
stress, and facilitates mutual interaction from family
members through wireless connection system athomes, offices, or even when they are on vacations.
Nevertheless, the “uncanny valley hypothesis” argues
that the human-like appearance might provoke thefeeling of dislike and the risk for delirium, delusion,and even worsened NPS, especially among older
persons with cognitive impairment.9

Telenoid R4, a teleoperated, humanoid robot thatdeveloped by Osaka University and the Advanced
Telecommunications Research Institute International,
was employed for mutual interaction (Figure 1).
It was covered by pleasant soft vinyl skin, sized
approximately 50 cm in length, weighted 3.5 kgs, andcould transmit a remote operator’s voice based on an
intact Wifi environment. Its physical movements weregenerated based on voice of the operator, using an
online speech-driven head motion system.11 Equippedwith six independent actuators of eyeballs, mouth,neck, and both arms, Telenoid could also perform
predefined behaviors, such as greeting or hugs using
Graphical User Interface (GUI) buttons on the laptop
screen (Figure 2). The application experiences among
the elderly living in senior homes in Denmark and

The purpose of this study was to explore the2Aging Medicine and Healthcare. doi:10.33879/AMH.2020.066-2001.003 [In Press, March 27, 2020]

Figure 1. Telenoid R4.

Figure 2. Illustration of teleoperating system.

Japan reported positive response through mutualinteraction via Telenoid both for the elderly and thefamilies.8,12

was 0 in session 3 & 4. No changes in NPI score wasdisclose at 48 hours after interaction.

Interestingly, after a good sleep prior to the groupsession, she became more curious about participantP articipant 1 is a 78-year-old lady diagnosed
1’s interaction with Telenoid, and paid more attention
Parkinson’s disease dementia with Clinical Dementia
with a smile, and learned how to interact with
Rating (CDR) of 1, i.e. mild severity. NeuropsychiatricTelenoid in group conversation. The performance was
symptoms observed in the day care center, includingmuch better than that at individual’s session, and it
delusion, hallucination, dysphoria, anxiety, aberrant
was supposed group session would do help throughbehaviors, and sleep disorders with the total NPI
connecting with their previous life experience orscore 32 and regular use of quetiapine 25 mg every
learning pattern of mutual interaction.
night. She always kept smiling with good eye contact
over 95% of time during interaction with her partner
Participant 3 is an 86-year-old gentleman withof each session. High initiative was observed during
vascular dementia and his CDR was 2 (moderate
conversation, but lower time ratio of participant/severity). There were neuropsychiatric symptoms
partner was found when the Telenoid was operatedof hallucination, agitation, dysphoria, disinhibition,by staff rather than by family (Table 1). The participant
irritability, aberrant behaviors, and sleep disorders
was also very interested on Telenoid with hugging,touching, dressing and kissing during
interaction. She presented more euphoric
Table 1. Distribution of conversation time and attention of participants.
and more talkative after those sessions, but
no worsening of NPS neither increased care
Conversation Time ofConversation Ratio
Attention on
Participant (Seconds)(Participant/Partner)
Partner (%)
stress on family after 48 hours.
Participant 2 is an 85-year-old lady
diagnosed with Alzheimer’s disease with
her CDR of 2 (moderate severity). There
were neuropsychiatric symptoms of apathy
and fair intake at usual with total NPI score
11 and regular consumption of donepezil
10 mg every day. The participant would
keep eye contact for over 80% of time withstaff in session 1, but tended to respondby gestures and non-verbal language morethan spoken sentences. Her attention was
easily distracted by external stimuli during
each session, and became tired soon due
to insomnia at previous night. She looked
confused, inpatient, and unfamiliar with
Telenoid in session 3 & 4 and did not haveany verbal response to it. Even the partner
spent about 5 minutes in each session,
the conversation time of participant wasless than 2 minutes in session 1 & 2, andParticipant 1, female, 78 years old, with Parkinson’s disease dementia, CDR=1, NPI=32*Session 1

588

1.87

> 95

Session 2

484

1.71

> 95

Session 3

357

1.28

> 95

Session 4

475

1.93

> 95

Participant 2, female, 85 years old, with Alzheimer’s disease, CDR=2, NPI=11
Session 1

117

0.29

90

Session 2

78

0.20

50

Session 30

00

Session 40

00Participant 3, male, 86 years old, with vascular dementia, CDR=2, NPI=64
Session 1

481

6.33

90

Session 2

328

1.91

90

##

Session 3

27

0.10

20

Session 4###

334

2.39

30

CDR: clinical dementia rating; NPI: neuropsychiatric inventory.
*Partner of each session: 1: staff; 2: family; 3: Telenoid by staff; 4: Telenoid by family.
Partner: group session with family assistant and Telenoid by staff.
###
Partner: group session with staff assistant and Telenoid by family.
##

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Aging Medicine and Healthcare. doi:10.33879/AMH.2020.066-2001.003 [In Press, March 27, 2020]

with total NPI score 64 but not in use of any
antipsychotic agent. The participant would keep eye
contact for over 80% of time with staff and family
during conversation with high initiative, but theinteraction was partially interfered by his hearing
impairment that the staff and family needed talking
in a shorter distance with louder voice for better
understanding. The voice from Telenoid was not wellheard by the participant, he paid less attention on
Telenoid and turned to the staff for further talking insession 3 & 4. No influence was found on NPI scores
before and 48 hours after interaction.

demonstration of nonverbal language by robot needmore sophisticated design. As evidence reported
in current studies, the application of Telenoid might
be more effective among older adults with retained
ability for verbal communication. Meanwhile, it wasalso important to minimize all possible interferingfactors on physical, psychological, and environmental
aspects before mutual interactions, such as insomnia,
hearing impairment, and lack of gesture response that
presented among the participants. Gender difference
might also affect the response of Telenoid application.
The male participant showed less interested inTelenoid talking and dressing due to lacking such
experience of playing doll in childhood, therefore alinkage with life experience should be considered on
robot-care application in the future.

3. DISCUSSION
To the best of our knowledge, this is the first study
to evaluate the hypothesis of uncanny valley by NPIscores before and 48 hours after Telenoid interaction
among participants with major NCDs. Mutualinteraction with human-like robot did not evoke a
response of fear or dislike during the process, andno NPS worsening was noted after the trial. One
participant was found more talkative and euphoric
with minimal disturbance of sleep, but those NPS did
not worsen nor increase the care burden on family.
Although NPI had been evaluated in the previous
study on Telenoid application in Japan, the NPI scores
were tested in 6 months interval as routine evaluationand not actually represented the influence of uncanny
valley. 8 Experiences from the three participants
partially confir med the feasibility of Telenoid
application on older peoplee with major NCDs.

4. CONLUSION
Teleoperated humanoid robot provides a feasible
strategy to establish mutual interaction between older
adults with major NCDs and caregivers at elsewhere.
No fear or dislike response to its human-likeappearance was observed during their interaction.
Improvement in social connection and stabilizationin mood status were noted, but the ability ofcommunication may confound the interaction. Further
study with larger scale is needed to evaluate theefficacy of Telenoid applications.
CONFLICTS OF INTEREST STATEMENT
The authors declare that they have no competinginterest.

As presented in this study, participants 1 & 3with agitated/psychotic NPS had better mutualinteraction with Telenoid than participant 2 withdepressive/apathic NPS. Although agitated/psychotic
NPS have been reported as the most difficult
symptoms for caregivers and may lead to premature
institutionalization, 13 observation from this study
implied the potential of retain their autonomy anda possibility for active social connection. However,very limited data were available to evaluate therelationship between social interaction, clinicaloutcome, and different subtypes of NPS at present.

Funding Resources
This research was funded by JST CREST Grant
Number JPMJCR18A1, Japan.
Acknowledgement
We appreciate all efforts and assistance fromthe Telenoid robot team of Osaka University andAdvanced Telecommunications Research Institute, as
well as staff of uAge Day Care Center, Taipei Veterans
General Hospital.

Although NPS was not worsened after Telenoid
interaction, the severity of major NCDs hindered
the fluency of mutual communication. According
to previous studies, the application of telepresence
robot helped to improve social connection and tostabilize the mood among persons with major NCDs.7
However, participants with more advanced severityof NCDs were found progressively losing theirability on verbal communication, mostly responding
conversations by gestures or nonverbal language, andhaving difficulty when paying attention on specifictopics for a longer duration.14 Therefore, the principles
for choosing potential candidates, the strategies
as individual or group interaction, and the possible

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