Use of a Robotic Cat to Treat Terminal Restlessness: A Case Study

Introduction

Terminal restlessness is a particularly distressing form of delirium that usually occurs in the last several days or hours of dying patients. It is often characterized by anguish (spiritual, emotional, or physical), restlessness, and cognitive decline. Terminal restlessness is distressing because it appears to have a direct negative impact on the dying process when the goals of care are often comfort, dignity, and respect at the end of life.^1,2 This process becomes magnified in dying patients with any end-stage disease. Benzodiazepines and antipsychotics are often used for pharmacological symptom management, however, their clinical effectiveness and potential side effects are variable and often ineffective.

Nonpharmacological strategies, which are often overlooked, are very important as potentially modifiable behavior concerns may be identified before active symptom expression and addressed before their manifestation.^3–5 In a recent study, six major risk factors for acute delirium were identified, including sleep deprivation, immobilization, dehydration, cognitive impairment, and hearing and visual impairment. ⁶ In addition, research has generally shown that live animal therapy is useful as a therapeutic modality in care facilities for the elderly and those with dementia.^7–11 Reduction in anxiety and restlessness has been shown with the use of this therapy. ¹⁰ However cost, property damage, zoonotic infections, fear of the animal, and injury to staff and family may be potential harms.

In an attempt to focus on a unique nonpharmacological option in a dying patient with end-stage Alzheimer's dementia and terminal restlessness, a robotic cat (“Joy for All,” Ageless Innovation) was used. Benefits of reduced anxiety and decreased need for pharmacological therapy were seen. Our success in using this modality may lead to further enhanced research in the use of this tool under similar clinical circumstances.

Case Description

A 90-year-old veteran was originally admitted to our Veterans Affairs Community Living Center in September 2018 with a diagnosis of Alzheimer's Dementia with a Functional Assessment Staging Tool (FAST) score of 6C. Medical comorbidities included hypertension, coronary artery disease, and iron-deficient anemia. Early in his admission the veteran exhibited mild-to-moderate aggressive verbal behavior toward staff, especially in the early evenings. This was addressed with discussions with the veteran and his family, along with the enhanced use of natural light and music. Emotional and spiritual support from our social worker and chaplain was also provided. Unfortunately, about a month later, the veteran's psychiatric health and behavioral issues further declined and his FAST Scale score progressed to 7C. Specific psychiatric behaviors included striking staff during meal times, cursing, and refusal to participate in communal activities. His very minimal verbal communication skills and need for assistance with all activities of daily living became commonplace and were also magnified by staffing limitations.

Following these clinical changes, goals-of-care conversations were held with his family (wife and three children) on two different occasions and ultimately a focus on comfort was agreed upon. Due to his significant physical and mental decline, the medical team felt his prognosis was six months or less and hospice admission in our unit was offered and accepted by the family. Unfortunately, his aggressive physical behavior continued and made daily feeding, toileting, and medical care very challenging. Initially scheduled lorazepam 0.5 mg orally every six hours was added to his haloperidol 1 mg orally every four hours as-needed for his terminal restlessness, with minimal therapeutic effect. In an attempt to not escalate pharmacological treatment, other treatment modalities were considered. Our Veterans Affairs Community Living Center had recently purchased four “Joy For All” robotic cats to be tried in dementia patients with agitated behavior, poorly responsive to medication. In addition, recent reviews in the literature using an FDA-approved robotic seal (PARO) had shown promise in reducing stress and anxiety in this population and its success in reducing the need for psychoactive medications.^12–14 At this time, it was decided to begin a trial of using the robotic cat, which provided a significant positive clinical response. In addition to continuing the present medications and behavior therapy, our veteran's physical aggression almost completely disappeared within 24 hours as he stroked the cat, watched it move, and heard it purr. Sadly, over the ensuing week, the veteran continued to physically decline and entered the dying process. He began choking on his diet and hypopharyngeal secretions could be heard on close physical examination. He was provided a private room closer to the nurses' station for enhanced observation, and family notified that death appeared imminent.

Even as he became totally bed bound over the last three days of life, the use of the robotic cat negated the need for his scheduled benzodiazepine, although as-needed liquid haloperidol 1 mg orally every two hours was made available for his symptom flares. The cat remained on the veteran's bed during the last 24 hours of his life. During this time frame, he did not require any medication for terminal restlessness. His family was grateful for the staff support and minimization of the need for medication as they were able to witness a respectful and peaceful death of their loved one.

Discussion

Terminal restlessness is commonly seen in end-of-life care. Its symptomatology is often distressing to the patient, family, and staff. Recognition of this entity triggers therapeutic attempts to alleviate patient and family anxiety, as well as minimize physical symptoms. In addition, many facilities, ours included, do not allow physical restraints. Pharmacological and nonpharmacological therapies have been advocated if preventive modalities have not been successful.

In this case study, the use of the “Joy For All” robotic cat was employed to minimize terminal restlessness in this patient dying with end-stage Alzheimer's dementia. This modality was used as more conventional medical treatments were minimally successful and family and staff were open to a novel therapeutic approach. ¹⁵ Our veteran's mental status rapidly declined as he entered the dying process and developed terminal restlessness. The family was desirous of maintaining active interaction with their loved one, and had previously seen the calming effect of this robotic cat on other dementia patients in our secure unit. We chose to try our robotic cat in this clinical circumstance despite a lack of literature support. Although we had not previously used the robotic cat in end-of-life care, we chose it due to its availability in our ward, relative inexpensiveness, ease of use for the patient, and soothing effects seen with some of our other dementia patients.

Robotic cats can be helpful for a variety of reasons.^16–18 They are comforting by being able to respond to the patient's touch, which may be distracting and help refocus the agitation. The robotic cats also have the ability to close their eyes and purr in response to touch due to built-in sensors to motion. Realistic soft fur and looks seem to enhance the clinical and social benefits. In addition, the cost has now become less of an issue as most of these robotic cats are less than one hundred dollars. This eases the financial burden for facilities and/or families and hopefully increases availability. There are no obvious “side effects” compared with pharmacological modalities. Staff care time and maintenance of the robot are also minimal.

It is noteworthy that a three-year study dubbed ARIES (Affordable Robotic Intelligence for Elderly Support) was started in 2017 as a collaboration of the National Science Foundation and Brown University to develop a product that can enhance comfort and assistance for older patients. ¹⁹ The “Joy For All” companion pets (cat and dog), equipped with artificial intelligence, will be used for this research with the goal of helping the elderly with everyday tasks.

Conclusion

Although live-animal therapy, as well as therapy with a robotic seal (PARO), has been studied in the literature, little has been written regarding the potential value of a robotic cat in dementia patients at the end of life with terminal restlessness. The use of pet therapy, including robotic animals, may have a significantly positive effect in the care of the elderly and end-of-life patients. The use of robotic cats may enhance the patient's duration and quality of life and his/her potential ability to interact with loved ones before entering the active dying process. In addition, these robotic cats may have a role in terminal restlessness as they can have positive physical and emotional effects that can supplement pharmacological therapy. Further research for the use of this modality is warranted with a goal of improving the quality of life for elderly and dementia patients.