3 ways that VR can benefit elders who need cognitive care

[In the mid-2000s, my mother and grandmother both showed symptoms of cognitive impairment; from afar I struggled to provide for their support, frustrated and frightened by the lack of non-pharmaceutical options to enhance their quality of life. At the time, I’d been helping business people in different fields to use virtual reality, and I decided to immerse myself in the field of aging services with an intention to promote the use of tech-enabled tools that could engage and comfort elders and care partners. For that reason I recently conducted a literature review — part of coursework at UMass Boston — and I offer this summary to fellow future and current elders, especially clinical tech innovators, VR developers, and care providers looking to build products and platforms. All data sources are listed in the bibliography following the article.]

You may have heard that digital therapeutics (DTx) using virtual reality (VR) applications have been proven to decrease symptoms (without side effects) of PTSD, anxiety, and pain.

When considering how to help someone living with cognitive impairment, you wouldn’t necessarily think, "VR!" Yet this particular group of people desperately needs non-pharmaceutical approaches to reduce psychological and behavioral symptoms such as agitation, apathy, and anxiety — because NO pharmaceutical treatments can do it well, or at least without nasty side effects. Could virtual reality serve as one such approach?

The aforementioned medical uses of VR have been validated through thousands of clinical trials over the past 20 years, but all those population samples consisted of young or middle-aged people.

Recently, however, some 500 research studies of VR usage among adults ages 65+ have been completed. A nearly equal number of similar studies are in progress. Many high-ranking journals have published gerontological VR research reports – mostly from small, single-site, feasibility tests and pilot studies – showing the benefits of VR-based treatments for older people, including those with diseases such as Alzheimer’s and Parkinson’s and those who live in residential care and rehab hospital settings. This is a super relevant population segment; older adults in this situation “often experience reduced mobility, sometimes resulting in confinement indoors and isolation, which can introduce or aggravate symptoms of depression, anxiety, loneliness, and apathy” (Appel et al.).

In search of clinical evidence for VR helping these elder populations, I analyzed eight journal reports, including a systematic review of 26 other studies, all published since 2016. I’ll quote them here; full citations appear below.

While we await the results of longitudinal, large-sample studies, we can look to these early studies to identify the types of VR applications that potentially can benefit impaired elders today. VR app devs, please take note!

Evidence-based applications

Three areas emerge as proven use cases of VR for people with cognitive impairment:?therapeutic recreation; cognitive assessment; and cognitive training.

1. Therapeutic recreation …

Involves activities designed to boost quality of life and psychological well-being, and may facilitate social interaction. Many research studies have shown the potential for therapeutic VR-based experiences to reduce anxiety. With its ability to mimic physical reality, for example, VR offers people a chance to “visit” locations and events they no longer can physically access, enabling reminiscence therapy to encourage engagement and relaxation, and emphasize one’s sense of self and life experience.

Another valuable recreational therapy for this population involves interaction with our natural environment. Studies indicate that virtual nature settings could substitute when physical settings are inaccessible. A 2018 pilot study researched how a virtual forest experience might affect mood states, apathy, and engagement of assisted-living residents with dementia (Moyle et al.). “Visiting” a virtual forest improved residents’ alertness, encouraged interaction, and prompted responses indicating pleasure. One adult child observed, “Mum was able to control the movement [in the virtual scene]. It means she’s got control of something in her life. What other control has she really got?”

Another small study of the impact of VR nature settings involved assisted-living residents with cognitive impairment ranging from mildly to severely impaired (Brimelow et al.). All 13 participants preferred scenes of animals and waterscapes — particularly farmyard, underwater, beach, and penguins — above other natural environments. One participant reported the penguin scenery easiest to observe because of the scene’s black and white imagery.

To explore the potential for VR nature scenes to reduce anxiety and depressive symptoms, a 2020 study (Appel et al.) evaluated tolerability, comfort, and ease of use among 66 people with cognition ranging from normal to severely impaired. Appel’s team showed that this approach is feasible and safe, with a positive impact on mood and alertness.

Since engagement has been shown to improve quality of life and functional abilities (Cohen-Mansfield et al.; Manera et al.), VR shows potential for offering positive, engaging, interactive activities customized for the individual interests of people with cognitive impairment.

Ideally, realistic simulations of gorgeous environments ranging from relaxing to thrilling will implement universal design to benefit impaired audiences.

In the meantime, today’s commercially available VR environments depict an array of settings, and developers continue to introduce virtual environments, from soothing riverboat rides to tours of the world’s natural and human wonders, that can promote mental stimulation or relaxation. Commercial VR service providers are fine-tuning the functionality to add features such as the ability to create virtual experience “playlists.”

2. Cognitive assessment…

Vital for detecting the presence of impaired cognition to enable intervention as early as possible. Impaired spatial memory often is the first symptom of cognitive impairment (Burgess et al.; Coughlan et al.). Neuropsych practitioners may appreciate the potential for VR to offer standardized spatial environments for assessing cognitive performance. VR can mimic authentic situations that simulate real-life spatial memory challenges – such as navigating a familiar neighborhood -- from the comfort of a controlled testing environment. One research team (Davis et al.) modeled their virtual test environment to resemble the participants’ own assisted-living facility. Evidence also shows the ability to use VR to screen other cognitive domains including learning and memory, perceptual-motor function, and executive function. VR promises to be an exciting modality supporting early diagnosis of cognitive impairment.

3. Cognitive training…

Provides mental stimulation through structured activities that may reduce symptoms in patients diagnosed with cognitive impairment. VR is already in use as a rehab tool for people with certain types of impaired cognition, such as traumatic brain injury. Research shows that “brain game” apps offering motivational, playful aspects are used more frequently and for longer periods, so we’re now seeing the emergence of VR-based brain games for cognitive training. Short-term effects of VR training on patients with severe spatial memory deficits showed that patients improved during successive VR trials. Likewise, a report of an RCT at UCSF supports a VR concept for intervention to improve long-term memory in older adults.

In a similar experiment (Maggio et al.), researchers tested the impact of VR-based cognitive rehab (CR) for Parkinson’s disease patients with impaired executive functioning and visuospatial ability. Comparing conventional CR with VR-based CR for patients with mild to moderate impairment, they showed “VR-CR” can improve cognitive and behavioral function. It’s possible the exercise performed in VR “helps patients develop knowledge of movement outcome (knowledge of results) and knowledge of the quality of the movements (knowledge of performance), with a greater impact on rehabilitation outcomes, including cognitive ones.”

Evidence suggests these studies measure procedural skill-learning for a single task — rather than improving general spatial memory function and capacity to complete other tasks. We hope that researchers will study the impact of long-term VR CR and/or the extent to which it can result in improved performance of daily living activities.

Clinical protocols

To best implement VR-based cognitive treatment, we need clinical protocols -- recommended dosage, frequency of use, facilitation, etc. -- that have been shown to elicit meaningful effects. Yet each research study implemented its own unique protocol. That said, most of the observed VR sessions in the analyzed studies involved 30 minutes or less time inside the headset, most for 15-20 minutes, which is consistent with current recommendations for headset use by healthy adults.

All the studies of recreation therapy implemented facilitators to guide participants, providing vital social contact. Studies of VR-based rec therapy show that facilitation encourages positive verbal and non-verbal interactions among groups of elders and caregivers. The most successful clinical protocols for VR-based recreation therapy involved group- or 1:1-interaction in relatively brief sessions (15-20 minutes), regardless of the participants’ cognitive condition.

In terms of usage protocols for VR-based reminiscence therapy, with the broad availability of immersive audio-visual experiences (travel, nature, music and dance), care partners suggest asking elders a couple of standardized open-ended questions about the images of a personal-favorite location or landmark, rather than asking a general question about specific memories.

Are more insights regarding clinical protocols needed? Yes! Who else around here is discussing protocol for VR in cognitive care? Let’s share what we learn about this. Please consider commenting or reaching out!

More clinical research, please

Each of these single-site tests concluded with a call for more research. Most of the caregivers involved in these studies suggest that successful VR use depends on selecting content appropriate to each participant's level of cognitive impairment and physical?functioning.?For example, some caregivers observed that quiet nature scenes with no interactive elements were not engaging for elders with mild cognitive impairment, while certain scenes with multiple?motion elements and transitions, especially jump cuts, were not engaging for people with moderate to advanced impairment.

Conclusion

VR-based therapeutic recreation appears to be a safe and well-tolerated activity for cognitively impaired elders. This is important “because any activities that might decrease behavioral and psychological symptoms of dementia may help decrease psychotropic medication use” (Ferguson et al.).

Researchers consistently observe that VR is a natural medium for engagement, and engagement with rehab is shown to lead to increased adherence to treatment plans. One challenge in cognitive training design, the Manera research team concludes, is how to engage apathetic participants, and “should be considered as a clinical and research priority.”

VR-based tools enable clinicians to precisely control and reproduce the creation, administration, and measurement of assessment tasks in realistic virtual environments – facilitating ecologically valid VR-based cognitive testing.

VR also is promising because, like music, its content can be personalized or “curated” to suit individual interests. Findings show that customization encourages engagement, leading to longer training sessions and improved collaboration with care partners. An activity programmed to match a person’s interests is important to that person’s sense of agency, identity, and well-being. Research findings highlight the need for greater variability in the availability and choice of VR environments to accommodate personalization and improve engagement.

Ultimately, our society will benefit when transdisciplinary teams of researchers, technologists, clinicians, and older adults collaborate on design and implementation (with medical prescriptions, ideally) of VR tools so aging services providers and caregivers can operationalize effective, non-pharmacological interventions.

VR dev community, we have an unprecedented global opportunity for our community to enhance care for others.

Thank you to Carleigh Berryman for editorial review.

#eldercare #caregiving #virtualreality #aging #assistedliving #alzheimersdisease #parkinsonsdisease #dementiacare #cognitiveassessment #cognitive #digitaltherapeutics

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