People have the right to accept or refuse medical treatment provided they give voluntary, prior and informed consent. When capacity to consent is impaired, autonomy can be preserved through a clear, legally valid advance directive. Cognitive impairments, such as dementia, increase the risk of compromised capacity to consent. This study examines the prevalence of advance directives among patients at German memory clinics and explores predictors influencing their presence, focusing on compliance with informed consent standards. Using an observational cross-sectional design, 289 outpatients were assessed. Data included the presence of advance directives, circumstances of their creation and the patient characteristics age, gender, education, cognitive status, physical and mental health, need for autonomy in medical decision-making and health literacy. Descriptive statistics were calculated, and multivariable logistic regression models were applied to analyze the data. The results indicate that age is the strongest predictor for the presence of advance directives. Beyond age, specific events or experiences, rather than personal traits, may prompt individuals to create advance directives.

The UN Convention on the Rights of Persons with Disabilities, and the reformed guardianship law in Germany, require that persons with a disability, including people with dementia in Alzheimer’s disease (PwAD), are supported in making self-determined decisions. This support is achieved through communication. While content-related communication is a deficit of PwAD, relational aspects of communication are a resource. Research in supported decision-making (SDM) has investigated the effectiveness of different content-related support strategies for PwAD but has only succeeded in improving understanding, which, although one criterion of capacity to consent, is not sufficient to ensure overall capacity to consent. The aim of the ‘spatial intervention study’ of the DECIDE project is to examine an innovative resource-oriented SDM approach that focuses on relational aspects. We hypothesise that talking to PwAD in their familiar home setting (as opposed to a clinical setting) will reduce the complexity of the decision-making process and enhance overall capacity to consent. People with a suspected or confirmed diagnosis of dementia in Alzheimer’s disease will be recruited from two memory clinics (N = 80). We will use a randomised crossover design to investigate the intervention effect of the decision-making place on capacity to consent. Besides reasoning capacity, which is part of overall capacity to consent and will be the primary outcome, various secondary outcomes (e.g., other aspects of capacity to consent, subjective task complexity, decisional conflict) and suspected moderating or mediating variables (e.g., meaning of home, demographic characteristics) will be assessed. The results of the study will be used to develop a new SDM strategy that is based on relational resources for PwAD. If a change in location achieves the anticipated improvement in capacity to consent, future research should focus on implementing this SDM strategy in a cost-effective manner in clinical practice. Trial registration: DRKS00030799 .

Any medical treatment that interferes with physical integrity requires the informed consent of a patient capable of such consent. For people with dementia, the capacity to consent is questioned even in the early course of the disease. Particularly diagnostic instruments like the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) often deny people with dementia the capacity to consent because of high confounding of the results with patients' verbal abilities. To date, it remains unclear whether not only verbal but also nonverbal communication is associated with assessments of capacity to consent. The current study investigates associations between patients' verbal and nonverbal communication behaviors as assessed by the measure for Communication Behavior in People with Dementia in Ambulant Settings (CODEMamb) and capacity to consent as assessed by the MacCAT-T. We expected the strongest positive associations for verbal communication behaviors compared to nonverbal communication behaviors. Data of N = 43 patients with dementia (n = 8 capable of consent) were collected at two different German psychiatric clinics. The results show small to moderate correlations between the overall scores of CODEMamb and MacCAT-T. As expected, correlations were strongest for the verbal CODEMamb subscale. The results support current findings on the dependency of the MacCAT-T on verbal communication. Based on the findings, the discussion addresses how people with dementia can be enabled to make self-determined medical treatment decisions.

Companion-type social robots are expected to support elders socially and emotionally. Whilst studies show promising results, ethical concerns have also been raised. Yet, there are only a few studies that investigate ethical issues empirically. The current study investigates elders' expectations about the companion-type robot Pleo and how much these were fulfilled after prolonged interaction through an ethical lens, thereby also targeting in differences between elders living independently and with assistance. In the study, N = 33 elders living with and without assistance in the community or in nursing homes interacted with the robot dinosaur Pleo as it suited them in their home environment for two weeks. Expectations regarding a) the robot's capabilities, and b) the robot's impact on elders' lives were assessed beforehand by means of open-ended interview questions. After two weeks, elders rated the fulfillment of their individual expectations on a 7-point scale. Overall experiences as recorded interview after the interaction period were also evaluated. The results show that elders expected the robot to behave almost like a living being. Whilst, overall, participants expected some therapeutic effects, elders living with assistance anticipated to derive fun and enjoyment from the robot. Negative effects like undue responsibility, fading of enjoyment, or anger and frustration were not uncommon. The results are discussed in the light of their ethical implications.

Everybody has the right to decide whether to receive specific medical treatment or not and to provide their free, prior and informed consent to do so. As dementia progresses, people with Alzheimer’s dementia (PwAD) can lose their capacity to provide informed consent to complex medical treatment. When the capacity to consent is lost, the autonomy of the affected person can only be guaranteed when an interpretable and valid advance directive exists. Advance directives are not yet common in Germany, and their validity is often questionable. Once the dementia diagnosis has been made, it is assumed to be too late to write an advance directive. One approach used to support the completion of advance directives is ‘Respecting Choices’®—an internationally recognised, evidence-based model of Advance Care Planning (ACP), which, until now, has not been evaluated for the target group of PwAD. This study’s aims include (a) to investigate the proportion of valid advance directives in a memory clinic population of persons with suspected AD, (b) to determine the predictors of valid advance directives, and (c) to examine whether the offer of ACP can increase the proportion of valid advance directives in PwAD. We intend to recruit at least N = 250 participants from two memory clinics in 50 consecutive weeks. Of these, the first 25 weeks constitute the baseline phase (no offer of ACP), the following 25 weeks constitute the intervention phase (offer of ACP). The existence and validity of an advance directive will be assessed twice (before and after the memory clinic appointment). Moreover, potential predictors of valid advance directives are assessed. The results of this study will enhance the development of consent procedures for advance directives of PwAD based on the ACP/Respecting Choices (R) approach. Therefore, this project contributes towards increasing the autonomy and inclusion of PwAD and the widespread acceptance of valid advance directives in PwAD. Trial Registration DRKS, DRKS00026691, registered 15th of October 2021, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML TRIAL_ID=DRKS00026691

Although companion-type robots are already commercially available, little interest has been taken in identifying reasons for inter-individual differences in their acceptance. Elders’ age-related perceptions of both their own self (self-image) and of the general older robot user (user image) could play a relevant role in this context. Since little is known to date about elders’ companion-type robot user image, it is one aim of this study to investigate its age-related facets, concentrating on possibly stigmatizing perceptions of elder robot users. The study also addresses the association between elders’ age-related self-image and robot acceptance: Is the association independent of the user image or not? To investigate these research questions, N = 28 adults aged 63 years and older were introduced to the companion-type robot Pleo. Afterwards, several markers of robot acceptance were assessed. Actual and ideal self- and subjective robot user image were assessed by a study-specific semantic differential on the stereotype dimensions of warmth and competence. Results show that participants tended to stigmatize elder robot users. The self-images were not directly related to robot acceptance, but affected it in the context of the user image. A higher fit between self- and user image was associated with higher perceived usefulness, social acceptance, and intention to use the robot. To conclude, elders’ subjective interpretations of new technologies play a relevant role for their acceptance. Together with elders’ individual self-images, they need to be considered in both robot development and implementation. Future research should consider that associations between user characteristics and robot acceptance by elders can be complex and easily overlooked.

It has been questioned by researchers in robotics as well in the general public to what extent companion-type robots can support the elderly with the fulfillment of their psychological and social needs. Although these robots have already been used in care settings in Germany, research has referred little to this practical experience in order to analyze their impact and benefit. To start to close this gap, the current article reports on the current use of companion-type robots in care settings, on the effects reported by professional caregivers as well as on the role of psychosocial needs in the acceptance and use of companion-type robots by the elderly. In the first study, 30 professional caregivers with experience in the use of the robot seal Paro in care settings were interviewed regarding Paro's application and the observed effects on their clients. In the second study, three case examples are presented from an interaction study in which vulnerable elderly persons had the robot dinosaur Pleo at their disposal for a maximum period of 15 days. Paro is used very flexibly in a variety of settings and with a broad range of user groups (study 1). The reported psychosocial effects were mainly positive but short term. The case examples (study 2) show that psychosocial needs can both foster or hinder robot acceptance and use. They also emphasize the important role of caregivers in the interaction between the elderly and emotional robots in the context of eldercare. The beneficial and ethical use of companion-type robots in care settings demands a high commitment on the part of the caregivers. Given this prerequisite, emotional robots can be a valuable therapeutic tool.

Sowohl im wissenschaftlichen Kontext wie auch in der Gesellschaft wird darüber diskutiert, ob emotionale Roboter ältere Menschen bei der Erfüllung psychischer und sozialer Bedürfnisse unterstützen können. Sie werden in deutschen Pflegeeinrichtungen bereits eingesetzt, jedoch wurde zur Analyse von Nutzen und Wirkung der Roboter kaum auf diese Praxiserfahrung zurückgegriffen. Der vorliegende Beitrag ist daher eine erste empirische Erfahrungsanalyse zur Nutzung emotionaler Roboter im Pflegekontext. Darin werden der momentane Einsatz und die durch Pflegende berichteten Wirkungen erfasst sowie die Bedeutung psychosozialer Bedürfnisse für die Akzeptanz und Nutzung emotionaler Roboter dargestellt.

This study aims at investigating the relevance of psychosocial functioning for the acceptance of social robots by elder people in the context of everyday functioning. It was assumed that the level of psychosocial functioning either hinders or promotes robot acceptance, depending on the fit between elder people’s level of everyday functioning and the demands imposed by the robot (user–technology fit). To investigate this assumption, two social robots imposing different demands on the user, i.e., the easy-to-handle therapeutic robot Paro (low demands) and the less intuitive telepresence robot Giraff (high demands), were introduced successively to \(N=29\) cognitively and physically healthy elder people. To implement different levels of user–technology fit, participants rated their intention to use each robot for both a scenario of high and a scenario of low everyday functioning. Psychosocial functioning was assessed with emotional loneliness, depressive mood and life satisfaction as indicators of psychological well-being, and social support as indicator of social resources. Results show that lower social support was associated with higher acceptance of the less intuitive robot Giraff in the high everyday functioning scenario (adequate user–technology fit). In the low everyday functioning scenario (poor fit), however, lower psychological well-being was associated with lower acceptance of Giraff. For the rather intuitive robot Paro (adequate user–technology fit regardless of the level of everyday functioning), lower life satisfaction was associated with lower acceptance in both everyday functioning scenarios. The findings show the importance of psychosocial variables for the acceptance of social robots by elder people and underline the relevance of the fit between user and technology. Moreover, they suggest a more intense consideration of complex psychological mechanisms and individual user characteristics in research on robot acceptance by elder people.

Emotional robots become increasingly important in future health care scenarios in an aging world. The field, however, still lacks both clear theoretical and methodological underpinnings. The present chapter therefore aims to provide an integrative perspective on current research and theories in emotional robotics. Using the example of the seal robot Paro the chapter, firstly, psychologically describes specific phases of how a human-robot relationship develops over time (biologically driven relationship initiation phase, behavior-dependent relationship maintenance phase). Secondly, determinants of positive and negative emotions-evoking human-animal and human-robot interaction are reviewed from a lifespan approach.