Fear of falling: efficacy of virtual reality associated with serious games in elderly people

Virtual Reality Mental Health Interventions in Geriatric Care for Functional or Well-being Enhancement - A Scoping Review

PURPOSE

It has become common to use Virtual Reality (VR) for mental health interventions; however, its use in care of the elederly is limited, especially regarding mood and well-being. In this review, we summarize the results of current VR-based mental health interventions for this population.

METHODS

Peer-reviewed journal articles on immersive VR mental health intervention in seniors, published until 2022, were included.

RESULTS

There were 2697 results found in the database search, of which 40 articles met the inclusion criteria and were included in the final analysis. Most studies did not use an experimental design with randomized controlled trials and follow-up sessions. Function-oriented and entertainment-oriented intervention studies were categorized. VR-based geriatric mental interventions have grown rapidly since 2018, especially the number of interventions that promote wellbeing. The function-oriented interventions used active interactions with varied devices. Entertainment-oriented interaction was primarily passive, seldomly using hand controllers for moving activities. Generally, VR interventions improved the mental health of older adults.

CONCLUSION

Geriatric rehabilitation can benefit from this innovative technology to maintain cognitive functions and to improve the well-being of seniors. They have potential for use in aging care and in retirement homes. Future VR interventions may also involve promoting social interaction to combat loneliness among seniors.

Cognitive behavioural therapy and third-wave approaches for anxiety and related disorders in older people

BACKGROUND

Cognitive behavioural therapy (CBT) is the most researched psychological therapy for anxiety disorders in adults, and known to be effective in this population. However, it remains unclear whether these results apply to older adults, as most studies include participants between 18 and 55 years of age. This systematic review aims to provide a comprehensive and up-to-date synthesis of the available evidence on CBT and third wave approaches for older adults with anxiety and related disorders.

OBJECTIVES

To assess the effects of Cognitive Behavioural Therapy (CT, BT, CBT and third-wave CBT interventions) on severity of anxiety symptoms compared with minimal management (not providing therapy) for anxiety and related disorders in older adults, aged 55 years or over. To assess the effects of CBT and related therapies on severity of anxiety symptoms compared with other psychological therapies for anxiety and related disorders in older adults, aged 55 years or over.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled studies Register (CCMDCTR), CENTRAL, Ovid MEDLINE, Ovid Embase and Ovid PsycINFO to 21 July 2022. These searches were updated on 2 February 2024. We also searched the international studies registries, including Clinicalstudies.gov and the WHO International Clinical Trials Registry Platform (ICTRP), to identify additional ongoing and unpublished studies. These sources were manually searched for studies up to 12 February 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in older adults (≥ 55 years) with an anxiety disorder, or a related disorder, including obsessive compulsive disorder (OCD), acute stress disorder and post-traumatic stress disorder (PTSD), that compared CBT to either minimal management or an active (non-CBT) psychological therapy. Eligible studies had to have an anxiety-related outcome.

DATA COLLECTION AND ANALYSIS

Several authors independently screened all titles identified by the searches. All full texts were screened for eligibility according to our prespecified selection criteria. Data were extracted and the risk of bias was assessed using the Cochrane tool for RCTs. The certainty of evidence was evaluated using GRADE. Meta-analyses were performed for outcomes with quantitative data from more than one study.

MAIN RESULTS

We included 21 RCTs on 1234 older people allocated to either CBT or control conditions. Ten studies focused on generalised anxiety disorder; others mostly included a mix of clinical diagnoses. Nineteen studies focused on the comparison between CBT and minimal management. Key issues relating to risk of bias were lack of blinding of participants and personnel, and participants dropping out of studies, potentially due to treatment preference and allocation. CBT may result in a small-to-moderate reduction of anxiety post-treatment (SMD -0.51, 95% CI -0.66 to -0.36, low-certainty evidence). However, compared to this benefit with CBT immediately after treatment, at three to six months post-treatment, there was little to no difference between CBT and minimal management (SMD -0.29, 95% CI -0.59 to 0.01, low-certainty evidence). CBT may have little or no effect on clinical recovery/ improvement post-treatment compared to minimal management, but the evidence is very uncertain (RR 1.56, 95% CI 1.20 to 2.03, very low-certainty evidence). Results indicate that five people would need to receive treatment for one additional person to benefit (NNTB = 5). Compared to minimal management, CBT may result in a reduction of comorbid depression symptoms post-treatment (SMD -0.57, 95% CI -0.74 to -0.40, low-certainty evidence). There was no difference in dropout rates post-treatment, although the certainty of the evidence was low (RR 1.19, 95% CI 0.80 to 1.78). Two studies reported adverse events, both of which related to medication in the control groups (very low-certainty evidence, no quantitative estimate). Only two studies compared CBT to other psychological therapies, both of which only included participants with post-traumatic stress disorder. Low-certainty evidence showed no difference in anxiety severity post-treatment and at four to six months post-treatment, symptoms of depression post-treatment, and dropout rates post-treatment. Other outcomes and time points are reported in the results section of the manuscript.

AUTHORS' CONCLUSIONS

CBT may be more effective than minimal management in reducing anxiety and symptoms of worry and depression post-treatment in older adults with anxiety disorders. The evidence is less certain longer-term and for other outcomes including clinical recovery/improvement. There is not enough evidence to determine whether CBT is more effective than alternative psychological therapies for anxiety in older adults.

Effects of immersive virtual reality training on balance, gait and mobility in older adults: A systematic review and meta-analysis

OBJECTIVE

To examine whether immersive virtual reality (VR) can improve balance, gait, mobility and fear of falling in older people.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, ProQuest Central (Engineering and Computer Science) and reference lists of included articles.

STUDY SELECTION

Randomised controlled trials that administered immersive VR training and assessed balance, gait and mobility outcomes in older adults without neurological disorders (mean age ≥ 65). Primary outcomes were standing balance (e.g. postural sway), multi-item balance scales (e.g. Berg Balance Scale), gait (e.g. gait speed) and mobility (e.g. Timed Up and Go test). Secondary outcomes comprised measures of enjoyment, fear of falling, adherence (e.g. dropout rate), feasibility/usability and adverse effects (e.g. motion sickness).

RESULTS

Meta-analyses showed that immersive VR training significantly improved standing balance (SMD: 0.51, 95% CI: .15, 0.86, p = 0.005, I2 = 28% - 3 studies, n = 79) and performance on the Berg Balance Scale (MD: 2.36, 95% CI: 1.17, 3.56, p=0.0001, I2=0% - 4 studies, n = 190). No significant improvement in gait, mobility or fear of falling was found. Subgroup analyses revealed higher training doses (≥4.5 total hours) and VR interventions using non-head mounted displays were more likely to improve standing balance. No meta-analyses were conducted for enjoyment, adherence, feasibility/usability and adverse events.

CONCLUSIONS

The findings indicate immersive VR has beneficial effects on balance, but not gait, mobility or fear of falling. Further research is required to examine these outcomes in trials that also include quantitative measurements of enjoyment, adherence, clinical feasibility, usability and adverse effects.

Impact of virtual reality applications in the treatment of anxiety disorders: A systematic review and meta-analysis of randomized-controlled trials

BACKGROUND AND OBJECTIVES

Anxiety disorders are the most prevalent mental disorders worldwide. Virtual reality (VR) treatment approaches have increasingly been studied. Before clinical implementation, it is necessary to evaluate the treatment effect of VR applications. The objective is to evaluate the treatment effect of virtual reality applications in the treatment of anxiety disorders compared to conventional therapy.

METHODS

A systematic literature review with meta-analysis was conducted. Four databases were used to identify randomized controlled trials published between April 2011 and April 2021 which compare VR applications with non-VR interventions or waiting lists. Study characteristics, pre- and post-treatment data were extracted. Hedges g was calculated as effect size. Primary outcome was anxiety symptoms.

RESULTS

Data from 17 studies from 827 participants was extracted. The studies examined specific phobia (n = 9), social anxiety disorder (n = 4), agoraphobia (n = 2) and panic disorder (n = 2). 16 out of 17 studies used head-mounted displays as VR application. A non-significant effect size with significant heterogeneity was observed in favor of the use of VR applications in anxiety symptoms (g, 0.33; 95%-CI, -0.20-0.87). Compared to passive control groups, VR applications are associated significant with lower anxiety symptoms (g, 1.29; 95%-CI, 0.68-1.90).

LIMITATIONS

The study and patient characteristics varied between the individual studies which is reflected in a high statistical heterogeneity of the effect sizes.

CONCLUSIONS

The added value of VR applications over waiting-list or psychoeducation only control groups is obvious. VR applications can be used as part of the treatment of anxiety disorders, especially when conventional therapy is unavailable.

Rehabilitation in Older Adults Affected by Immobility Syndrome, Aided by Virtual Reality Technology: A Narrative Review

Individual mobility deficit in older adults induces a variety of medical conditions, diminishing their functional capacity in pursuing activities of daily living. In immobility syndrome patients, such conditions are prone further deterioration through a drastically reduced scope of physical activity, owing mostly to poor self-motivation and the monotonous character of conventional rehabilitation regimens. As evidenced by published research, virtual reality technology solutions in rehabilitation management actually add significantly to patients' self-motivation, while promoting their active involvement in therapy through visual, auditory, and kinaesthetic stimuli. Effective rehabilitation training aided by virtual reality solutions helps patients acquire specific physical and cognitive skills to be subsequently emulated in the real-world environment. The extra added advantage lies in facilitating such training within patients' own home environments, combined with online monitoring of their progress, when not personally supervised by a physiotherapist, which also boosts the overall cost effectiveness of the therapeutic management itself. This narrative review appears to be the very first one principally focused on critically comparing individual immobilisation with immobility syndrome, especially through the application of the Authors' own substantial hands-on therapeutic experience in managing various rehabilitation schemes, specifically aided by diverse virtual reality technology solutions.

Technologies in Home-Based Digital Rehabilitation: Scoping Review

BACKGROUND

Due to growing pressure on the health care system, a shift in rehabilitation to home settings is essential. However, efficient support for home-based rehabilitation is lacking. The COVID-19 pandemic has further exacerbated these challenges and has affected individuals and health care professionals during rehabilitation. Digital rehabilitation (DR) could support home-based rehabilitation. To develop and implement DR solutions that meet clients' needs and ease the growing pressure on the health care system, it is necessary to provide an overview of existing, relevant, and future solutions shaping the constantly evolving market of technologies for home-based DR.

OBJECTIVE

In this scoping review, we aimed to identify digital technologies for home-based DR, predict new or emerging DR trends, and report on the influences of the COVID-19 pandemic on DR.

METHODS

The scoping review followed the framework of Arksey and O'Malley, with improvements made by Levac et al. A literature search was performed in PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library. The search spanned January 2015 to January 2022. A bibliometric analysis was performed to provide an overview of the included references, and a co-occurrence analysis identified the technologies for home-based DR. A full-text analysis of all included reviews filtered the trends for home-based DR. A gray literature search supplemented the results of the review analysis and revealed the influences of the COVID-19 pandemic on the development of DR.

RESULTS

A total of 2437 records were included in the bibliometric analysis and 95 in the full-text analysis, and 40 records were included as a result of the gray literature search. Sensors, robotic devices, gamification, virtual and augmented reality, and digital and mobile apps are already used in home-based DR; however, artificial intelligence and machine learning, exoskeletons, and digital and mobile apps represent new and emerging trends. Advantages and disadvantages were displayed for all technologies. The COVID-19 pandemic has led to an increased use of digital technologies as remote approaches but has not led to the development of new technologies.

CONCLUSIONS

Multiple tools are available and implemented for home-based DR; however, some technologies face limitations in the application of home-based rehabilitation. However, artificial intelligence and machine learning could be instrumental in redesigning rehabilitation and addressing future challenges of the health care system, and the rehabilitation sector in particular. The results show the need for feasible and effective approaches to implement DR that meet clients' needs and adhere to framework conditions, regardless of exceptional situations such as the COVID-19 pandemic.

Adverse Effects of Virtual and Augmented Reality Interventions in Psychiatry: Systematic Review

BACKGROUND

Virtual reality (VR) and augmented reality (AR) are emerging treatment modalities in psychiatry, which are capable of producing clinical outcomes broadly comparable to those achieved with standard psychotherapies.

OBJECTIVE

Because the side effect profile associated with the clinical use of VR and AR remains largely unknown, we systematically reviewed available evidence of their adverse effects.

METHODS

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework across 3 mental health databases (PubMed, PsycINFO, and Embase) to identify VR and AR interventions targeting mental health diagnoses.

RESULTS

Of 73 studies meeting the inclusion criteria, 7 reported worsening clinical symptoms or an increased fall risk. Another 21 studies reported "no adverse effects" but failed to identify obvious adverse effects, mainly cybersickness, documented in their results. More concerningly, 45 of the 73 studies made no mention of adverse effects whatsoever.

CONCLUSIONS

An appropriate screening tool would help ensure that VR adverse effects are correctly identified and reported.

Visual feedback-dependent modulation of arousal, postural control, and muscle stretch reflexes assessed in real and virtual environments

Introduction

The mechanisms regulating neuromuscular control of standing balance can be influenced by visual sensory feedback and arousal. Virtual reality (VR) is a cutting-edge tool for probing the neural control of balance and its dependence on visual feedback, but whether VR induces neuromodulation akin to that seen in real environments (eyes open vs. closed or ground level vs. height platform) remains unclear.

Methods

Here we monitored 20 healthy young adults (mean age 23.3 ± 3.2 years; 10 females) during four conditions of quiet standing. Two real world conditions (eyes open and eyes closed; REO and REC) preceded two eyes-open virtual 'low' (ground level; VRL) and 'high' (14 m height platform; VRH) conditions. We measured arousal via electrodermal activity and psychosocial questionnaires rating perceived fear and anxiety. We recorded surface electromyography over the right soleus, medial gastrocnemius, and tibialis anterior, and performed force plate posturography. As a proxy for modulations in neural control, we assessed lower limb reflexive muscle responses evoked by tendon vibration and electrical stimulation.

Results

Physiological and perceptual indicators of fear and anxiety increased in the VRH condition. Background soleus muscle activation was not different across conditions; however, significant increases in muscle activity were observed for medial gastrocnemius and tibialis anterior in VRH relative to REO. The mean power frequency of postural sway also increased in the VRH condition relative to REO. Finally, with a fixed stimulus level across conditions, mechanically evoked reflexes remained constant, while H-reflex amplitudes decreased in strength within virtual reality.

Discussion

Notably, H-reflexes were lower in the VRL condition than REO, suggesting that these ostensibly similar visual environments produce different states of reflexive balance control. In summary, we provide novel evidence that VR can be used to modulate upright postural control, but caution that standing balance in analogous real and virtual environments may involve different neural control states.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

Appraising Virtual Technologies' Impact on Older Citizens' Mental Health-A Comparative between 360° Video and Virtual Reality

Aging populations across the world are facing a number of challenges in the context of health and healthcare. These challenges are driven by the aging process and the illnesses associated with aging. Healthcare for older people has become a point of concern with most health organizations, and this is particularly the case with palliative care. In this instance, the movement of the patient may be restricted to a room with no or limited access to the outdoors. This research focuses on the active integration of immersive technologies with healthcare. By addressing the problem of providing patients with the experience of being present in an outdoors space, the associated psychological and physiological benefits can be identified. In this mixed methods research paper, the impact of a crossover study to discern technology preferences in relation to immersive technologies among a sample of older people is reported. In addition, the study highlights factors that contribute to a meaningful immersive experience that can improve psychological and physiological wellbeing. The study identifies that there are two significant categorical aspects that contribute to such immersive experiences, technological aspects (including, for example, the weight of headsets, visual impairment, pixelation, and gamification) and emotive aspects (for example, joy, anger, and fear). The study suggests that older people prefer immersive Virtual Reality (VR) environments rather than 360 video experiences. This can be attributed to the greater flexibility in the provision of interactivity in virtual reality systems.

Effects of Serious Games on Depression in Older Adults: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Depression is a severe psychological concern that negatively affects health in older adults. Serious games applied in various fields are considered appropriate interventions, especially in mental health care. However, there is a lack of evidence regarding the effects of serious games on depression in older adults.

OBJECTIVE

This study aimed to investigate the characteristics and effectiveness of serious games for depression in older adults.

METHODS

A systematic review and meta-analysis of randomized controlled trials were conducted. In total, 5 electronic databases (PubMed, CINAHL, Embase, PsycINFO, and Cochrane Library) were searched to identify relevant studies published until July 6, 2021. A total of 2 reviewers independently conducted study selection, data extraction, and quality appraisals. The risk of bias in the included studies was assessed using the JBI Critical Appraisal Checklist. For the meta-analysis, the effect size was calculated as the standardized mean difference (SMD) by using a random effects model.

RESULTS

A total of 17 studies with 1280 older adults were included in the systematic review, and 15 studies were included in the meta-analysis. Serious game interventions were classified into 3 types: physical activity (PA), cognitive function, and both PA and cognitive function. The meta-analysis demonstrated that serious games reduced depression in older adults (SMD -0.54, 95% CI -0.79 to -0.29; P<.001). Serious games had a more significant effect size in community or home settings (SMD -0.61, 95% CI -0.95 to -0.26; P<.001) than in hospital settings (SMD -0.46, 95% CI -0.85 to -0.08; P=.02); however, the difference between groups was not significant. Among the types of games, games for PA (SMD -0.60, 95% CI -0.95 to -0.25; P<.001) and games for both (SMD -0.73, 95% CI -1.29 to -0.17; P=.01) had a significant effect on reducing depression in older adults. However, no significant correlations were observed between the duration or number of serious games and depression.

CONCLUSIONS

Serious games were beneficial in reducing depression in older adults. Regardless of the study setting, serious games appeared to reduce depression. Particularly, serious games including PA had a significant impact on reducing depression. Furthermore, high-quality randomized controlled trials are needed to establish substantial evidence for the effectiveness of serious games on depression in older adults.

TRIAL REGISTRATION

PROSPERO CRD42021242573; https://tinyurl.com/26xf7ym5.

A Virtual Reality Intervention to Reduce Dementia-Related Agitation Using Single-Case Design

OBJECTIVES

The primary objective of this study was to use a single-case design to evaluate the utility of a VR intervention to reduce agitation behaviors in two female participants with a diagnosis of dementia.

METHODS

A single-case research design with an ideographic approach was selected given the novelty of this intervention. A blended single case experimental design was used combining the Multiple-baseline design across individuals with a reversal design to examine the effects of VR nature scenes on agitation. Visual analysis was used to determine changes in mean, level, and latency of the behaviors.

RESULTS

For both participants, a significant decrease in their respective agitation behaviors was observed during intervention phases.

CONCLUSIONS

This study provides preliminary evidence of the utility of VR as a brief and effective intervention to decrease agitation in individuals with dementia.

CLINICAL IMPLICATIONS

These initial, promising results may help caregivers improve the quality of life for dementia patients. Further, the brevity of the intervention makes this a practical tool for care providers working in clinical settings. The primary objective of this study was to use a single-case design to evaluate the utility of a VR intervention to reduce agitation behaviors in two female participants with a diagnosis of dementia.

The effectiveness of exergames on fear of falling in community-dwelling older adults: a systematic review

ObjectivesFear of falling is common among older adults and can increase fall-risk through premature activity restriction. Exergames, an emerging tool in fall prevention, combine exercise with interactive and adaptive game elements. This review examines the extent to which exergame interventions reduce fear of falling among community-dwelling older adults. Method: Guided by the PRISMA methodology, we reviewed peer-reviewed studies that were published in English between 2006 and 2019 and employed a comparative design to test the effect of exergames on fear of falling in community-dwelling older adults. Two reviewers screened the literature and extracted data on the exergame platform, participants, study design, and results. A modified PEDro scale was used to assess study quality. Disagreements were resolved through discussion with the third reviewer. Results: Our literature search resulted in 23 eligible studies on exergame interventions where fear of falling was the primary or secondary outcome. Most interventions (35%) occurred within hospitals and were delivered via a Wii-based system (61%). Fear of falling was most commonly measured using the Falls Efficacy Scale, the Activities-specific Balance Scale and their modified versions. A total of 15 of the 23 studies reported statistically significant changes in fear of falling. Quality assessment showed 10 studies to be rated as 'good.' Conclusion: This review showed that exergame may have a positive effect in reducing fear of falling in community-dwelling older adults. The finding provides a direction for clinical practice in the research area of intervention on fear of falling in older adults.

Virtual reality and mental health in older adults: a systematic review

IMPORTANCE

Virtual reality (VR) is a promising tool with the potential to enhance care of cognitive and affective disorders in the aging population. VR has been implemented in clinical settings with adolescents and children; however, it has been less studied in the geriatric population.

OBJECTIVE

The objective of this study is to determine the existing levels of evidence for VR use in clinical settings and identify areas where more evidence may guide translation of existing VR interventions for older adults.

DESIGN AND MEASUREMENTS

We conducted a systematic review in PubMed and Web of Science in November 2019 for peer-reviewed journal articles on VR technology and its applications in older adults. We reviewed article content and extracted the number of study participants, study population, goal of the investigation, the level of evidence, and categorized articles based on the indication of the VR technology and the study population.

RESULTS

The database search yielded 1554 total results, and 55 articles were included in the final synthesis. The most represented study design was cross-sectional, and the most common study population was subjects with cognitive impairment. Articles fell into three categories for VR Indication: Testing, Training, and Screening. There was a wide variety of VR environments used across studies.

CONCLUSIONS

Existing evidence offers support for VR as a screening and training tool for cognitive impairment in older adults. VR-based tasks demonstrated validity comparable to some paper-based assessments of cognition, though more work is needed to refine diagnostic specificity. The variety of VR environments used shows a need for standardization before comparisons can be made across VR simulations. Future studies should address key issues such as usability, data privacy, and confidentiality. Since most literature was generated from high-income countries (HICs), it remains unclear how this may be translated to other parts of the world.

Virtual and augmented reality applications to improve older adults' quality of life: A systematic mapping review and future directions

Objective

The use of virtual reality and augmented reality to improve older adults' quality of life has rapidly increased in recent years. This systematic mapping review aimed to provide a comprehensive overview of existing research that identifies and classifies current virtual reality and augmented reality applications that enhance the quality of life of older adults to increase the understanding of the impact of these technologies.

Methods

To reach this objective, a systematic mapping review was conducted of the studies published between 2009 and 2020 in major scientific databases, such as IEEE Xplore, Web of Science, Scopus, and PubMed. A total of 57 studies were analyzed and classified into four main quality of life domains: physical, cognitive, psychological, and social well-being.

Results

The findings showed that virtual reality and augmented reality have found their places in many quality of life studies of older adults. Although virtual reality and augmented reality applications are notably growing in the physical and cognitive well-being domains in training and rehabilitation settings, they are still in the early stages of development in psychological and social well-being research as well as healthcare settings. Our findings also revealed that virtual reality games, particularly motion-based exergames, and 3D augmented reality systems are the most common virtual reality and augmented reality types among the reviewed studies. Moreover, balance and attention were the most prevalent physical and cognitive functions when using motion-based and immersive virtual reality exergames and augmented reality systems and games, respectively, while confidence and interaction were the most dominant psychological and social functions.

Conclusion

This mapping review provides a comprehensive overview of potential areas for further research in this field, thereby assisting researchers, technologists, and health practitioners in expanding this field of research.

Effect of virtual reality exercises on balance and fall in elderly people with fall risk: a randomized controlled trial

BACKGROUND

Deficient balance and fear of falling in elderly people can lead to disturbed daily activities, falling, and finally reduced quality of life. Therefore, evaluation of low-risk methods that might partially improve balance in this group of people is of utmost importance. The present study aimed to investigate the impact of Virtual Reality (VR) exercises based on Xbox Kinect on balance and fear of falling among elderly people.

METHODS

This clinical trial was performed on 60 elderly individuals living in nursing homes divided into two groups of control and Xbox. The participants in the intervention group received VR exercises based on Xbox Kinect in form of two 30-45-min sessions held on a weekly basis for 6 weeks. The individuals in the control group, on the other hand, received routine exercises of the nursing homes. The research tools used in this study included a demographic questionnaire, the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, and the Falling Efficacy Scale (FES).

RESULTS

The findings of the current study demonstrated that the scores of BBS and TUG test as the indices of balance among elderly people improved significantly in the Xbox group after the intervention (p < 0.001 for both BBS and TUG test). Moreover, the score of fear of falling diminished significantly in the intervention group compared to the control group (p < 0.001).

CONCLUSION

According to the results of the present investigation, 6 weeks of VR balance exercises could enhance balance and fear of falling among elderly people living in nursing homes.

TRIAL REGISTRATION

Code: IRCT20190727044347N1 , Date: 17-8-2019.

The Effect of Reminiscence Therapy Using Virtual Reality on Apathy in Residential Aged Care: Multisite Nonrandomized Controlled Trial

Background

Apathy is a frequent and underrecognized neurological disorder symptom. Reduced goal-directed behavior caused by apathy is associated with poor outcomes for older adults in residential aged care. Recommended nonpharmacological treatments include person-centered therapy using information and communication technology. Virtual reality (VR) in the form of head-mounted displays (HMDs) is a fully immersive technology that provides access to a wide range of freely available content. The use of VR as a therapy tool has demonstrated promise in the treatment of posttraumatic stress disorder and anxiety. In addition, VR has been used to improve conditions including depression, anxiety, cognitive function, and balance in older adults with memory deficits, Alzheimer disease, and Parkinson disease. Research using VR for the symptoms of apathy in older adults living in residential aged care facilities is limited.

Objective

This study aims to examine whether using HMDs as a tool for reminiscence therapy improves the symptoms of apathy compared with using a laptop computer and physical items with older adults living in residential aged care.

Methods

In this multisite trial, 43 participants were allocated to one of three groups: reminiscence therapy intervention using VR in the form of HMDs, reminiscence therapy using a laptop computer supplemented by physical items if required (active control), and a usual care (passive control) group. The primary outcome was apathy, and the secondary outcomes included cognition and depression. The side effects of using HMDs were also measured in the VR group.

Results

Mixed model analyses revealed no significant group interaction over time in outcomes between the VR and laptop groups (estimate=−2.24, SE 1.89; t₄₀=−1.18; P=.24). Pooled apathy scores in the two intervention groups compared with the passive control group also revealed no significant group interaction over time (estimate=−0.26, SE 1.66; t₄₀=−0.16; P=.88). There were no significant secondary outcomes. Most participants in the VR group stated that they would prefer to watch content in VR than on a flat screen (Χ²₂=11.2; P=.004), side effects from HMD use were negligible to minimal according to the Simulator Sickness Questionnaire cutoff scores.

Conclusions

Although there were no significant results in outcome measures, this study found that participants engaged in the research and enjoyed the process of reminiscing using both forms of technology. It was found that VR can be implemented in an aged care setting with correct protocols in place. Providing residents in aged care with a choice of technology may assist in increasing participation in activities. We cannot dismiss the importance of immediate effects while the therapy was in progress, and this is an avenue for future research.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12619001510134; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378564.

International Registered Report Identifier (IRRID)

RR2-DOI: 10.1136/bmjopen-2020-046030

Enhancement of Anticipatory Postural Adjustments by Virtual Reality in Older Adults with Cognitive and Motor Deficits: A Randomised Trial

BACKGROUND

Postural activities involved in balance control integrate the anticipatory postural adjustments (APA) that stabilize balance and posture, facilitating arm movements and walking initiation and allowing an optimal coordination between posture and movement. Several studies reported the significant benefits of virtual reality (VR) exercises in frail older adults to decrease the anxiety of falling and to induce improvements in behavioural and cognitive abilities in rehabilitation processes. The aim of this study was thus to test the efficiency of a VR system on the enhancement of the APA period, compared to the use of a Nintendo Wii system.

METHODS

Frail older adults (n = 37) were included in this study who were randomized and divided into a VR exercises group (VR group) or a control group using the Nintendo Wii system (CTRL group). Finally, 22 patients were included in the data treatment. APA were studied through muscular activation timings measured with electromyographic activities. The functional reach test, the gait speed, and the time up and go were also evaluated before and after a 3-week training phase.

RESULTS AND DISCUSSION

As the main results, the training phase with VR improved the APA and the functional reach test score along the antero-posterior axis. Together, these results highlight the ability of a VR training phase to induce neuromuscular adaptations during the APA period in frail older adults. Then, it underlines the effective transfer from learning carried out during the VR training movements to control balance abilities in a more daily life context.

Virtual Reality Rehabilitation and Exergames—Physical and Psychological Impact on Fall Prevention among the Elderly—A Literature Review

The present review is aimed at the effectiveness of virtual reality (VR) and exergames in the prevention of falls among the elderly. Falls become a significant problem in the aging population and lead to psychological, social, and physical impairment. Prevention of falls is crucial to the well-being of the elderly population and is one of the challenges of contemporary rehabilitation. Recently, in view of the threat of the SARS-CoV-2 pandemic, contactless methods of rehabilitation, including telerehabilitation, appear as valuable rehabilitation tools. This review is based on the PRISMA guidelines and was carried out in five databases: PubMed, Medline, Web of Science, Scopus, and PEDro. Twenty-one randomized controlled trials, focused on the application of VR and exergames in the prevention of falls, were included. This review suggests that VR training in rehabilitation appears to be a promising complement to traditional techniques of physiotherapy to improve specific physical outcomes. VR and exergames could be considered as a complement of standard physiotherapy and its possible continuation at home for elderly. However, further high-quality studies, with carefully designed protocols and proper blinding, are needed.

Immersive virtual reality is effective in the rehabilitation of older adults with balance disorders: A randomized clinical trial

QUESTION

What are the effects of immersive virtual reality (IVR) training compared to conventional physiotherapy on body balance and risk of falls in older adults with balance disorders?

DESIGN

A randomized controlled trial with two intervention arms, concealed allocation, per-protocol analysis, and blinded assessment.

PARTICIPANTS

Thirty-seven older adults with balance disorders and risk of falling.

INTERVENTION

Participants were randomized into two groups: a control group, which received balance training with conventional physiotherapy using multimodal circuit exercises, and an experimental group, which received balance training using immersive virtual reality. Both groups received 16 individual sessions, twice a week.

OUTCOME MEASURES

The primary outcome was functional balance. Secondary outcomes were static balance, gait speed, functional range, dizziness symptoms, and fear of falling. Safety was ensured by assessing any adverse events during the intervention.

RESULTS

After 16 sessions, in the intragroup analysis, the functional balance score in the experimental group increased by 3.00 (95% CI 1.42 to 4.57) and in the control group by 3.88 (95% CI 2.16 to 5.59). Both groups improved in assessments of sensory interaction and anterior reach. Only the experimental group presented increased mobility and reduced dizziness. After two months, there was a maintenance of gains in functional balance and a reduction of the gains in functional reach for both groups. In the intergroup comparison, there was no significant difference.

CONCLUSION

Immersive Virtual Reality training proved to be effective for balance-related outcomes, although it was not superior to conventional therapy.

TRIAL REGISTRATION

RBR-3tk7fw.

Do You Feel the Same as I Do? Differences in Virtual Reality Technology Experience and Acceptance Between Elderly Adults and College Students

Virtual reality (VR) has been widely applied in medical health areas and the entertainment and tourism industries, in which elderly people are a primary target. However, most studies on VR have focused on how people respond to this new technology and its effects on younger generations. Our study explored the differences in VR experience and acceptance between elderly adults and college students. A mixed method approach including both experiments and in-depth interviews was applied in this study. Our results show that elderly adults reported a higher level of telepresence and stronger emotional responses than young adults in VR viewing regardless of the VR device. The ways in which elderly people processed and evaluated VR content and devices were different from those of young people. Elderly people reported more positive attitudes toward the video they watched than young people, but this did not necessarily lead to more positive attitudes toward the viewing experience.

Virtual Reality Exercise as a Coping Strategy for Health and Wellness Promotion in Older Adults during the COVID-19 Pandemic

The December 2019 COVID-19 outbreak in China has led to worldwide quarantine, as recommended by local governments and the World Health Organization. Particularly affected are older adults (i.e., those aged ≥ 65 years) who are at elevated risk for various adverse health outcomes, including declines in motor ability and physical activity (PA) participation, increased obesity, impaired cognition, and various psychological disorders. Thus, given the secular increases in the older adult population, novel and effective intervention strategies are necessary to improve physical activity behaviors and health in this population. Virtual reality (VR)-integrated exercise is a promising intervention strategy, which has been utilized in healthcare fields like stroke rehabilitation and psychotherapy. Therefore, the purpose of this editorial is to synthesize recent research examining the efficacy and effectiveness of VR exercise in the promotion of favorable health outcomes among the older adults. Results indicate the application of VR exercise to facilitate improved physical outcomes (e.g., enhanced motor ability, reduced obesity), cognition and psychological outcomes. VR exercise has also been observed to be an effective intervention strategy for fall prevention in this population. Future research should employ more rigorous research designs to allow for a more robust quantitative synthesis of the effect of VR exercise on the preceding outcomes to elucidate which type(s) of VR-based PA interventions are most effective in promoting improved health outcomes among older adults. Findings from this study will better inform the development of technology-savvy PA programs for wellness promotion in older adults who practice social distancing and exercise from home under the unprecedented global health crisis.

The Role of Virtual Reality in Improving Health Outcomes for Community-Dwelling Older Adults: Systematic Review

Background

Virtual reality (VR) delivered through immersive headsets creates an opportunity to deliver interventions to improve physical, mental, and psychosocial health outcomes. VR app studies with older adults have primarily focused on rehabilitation and physical function including gait, balance, fall prevention, pain management, and cognition. Several systematic reviews have previously been conducted, but much of the extant literature is focused on rehabilitation or other institutional settings, and little is known about the effectiveness of VR apps using immersive headsets to target health outcomes among community-dwelling older adults.

Objective

The objective of this review was to evaluate the effectiveness of VR apps delivered using commercially available immersive headsets to improve physical, mental, or psychosocial health outcomes in community-dwelling older adults.

Methods

Peer-reviewed publications that included community-dwelling older adults aged ≥60 years residing in residential aged care settings and nursing homes were included. This systematic review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews of effectiveness evidence. The title of this review was registered with JBI, and the systematic review protocol was registered with the International Prospective Register of Systematic Reviews.

Results

In total, 7 studies that specifically included community-dwelling older adults were included in this review. VR apps using a head-mounted display led to improvements in a number of health outcomes, including pain management, posture, cognitive functioning specifically related to Alzheimer disease, and a decreased risk of falls. A total of 6 studies reported a statistically significant difference post VR intervention, and 1 study reported an improvement in cognitive function to reduce navigational errors. Only one study reported on the usability and acceptability of the interventions delivered through VR. While one study used a distraction mechanism for pain management, none of the studies used gaming technology to promote enjoyment.

Conclusions

Interventions to improve health outcomes through VR have demonstrated potential; however, the ability to synthesize findings by primary outcome for the older adult population is not possible. A number of factors, especially related to frailty, usability, and acceptability, also need to be explored before more substantial recommendations on the effectiveness of VR interventions for older adults can be made.

Trial Registration

PROSPERO CRD42019143504; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=143504

Virtual Reality for Anxiety Disorders: Rethinking a Field in Expansion

The principal aim to this chapter is to present the latest ideas in virtual reality (VR), some of which have already been applied to the field of anxiety disorders, and others are still pending to be materialized. More than 20 years ago, VR emerged as an exposure tool in order to provide patients and therapists with more appealing ways of delivering a technique that was undoubtedly effective but also rejected and thus underused. Throughout these years, many improvements were achieved. The first section of the chapter describes those improvements, both considering the research progresses and the applications in the real world. In a second part, our main interest is to expand the discussion of the new applications of VR beyond its already known role as an exposure tool. In particular, VR is enabling the materialization of numerous ideas that were previously confined to a merely philosophical discussion in the field of cognitive sciences. That is, VR has the enormous potential of providing feasible ways to explore nonclassical ways of cognition, such as embodied and situated information processing. Despite the fact that many of these developments are not fully developed, and not specifically designed for anxiety disorders, we want to introduce these new ideas in a context in which VR is experiencing an enormous transformation.

An Augmented Reality Game for Helping Elderly to Perform Physical Exercises at Home

People are living longer nowadays. Unfortunately, this positive tendency is marred by various age-related health issues, which people experience. Falling is one of the most serious and common of them. Falls negatively influences elderly’ everyday living and significantly decreases quality of their life. Physical exercises is a proven method for preventing falls. However, it is only effective when training is regular and exercise techniques are correct. This paper presents a prototype of an augmented reality exergame for elderly people to perform physical exercise at home. The research is focusing on developing a solution for both above-mentioned issues: augmentation with Microsoft Kinect and various sensors assists in creating a safe game environment, which can helps to perform exercises with right technique; gamification elements contribute to users’ motivation to train regularly. A user-centered design approach was adopted to guide the design and development iterative process. User testing of the first prototype was performed and demonstrated positive attitudes from participants. Feedback from user testing will be used for the next development iterations.

Optic flow improves step width and length in older adults while performing dual task

BACKGROUND

Dual-task paradigms are used to investigate gait and cognitive declines in older adults (OA). Optic-flow is a virtual reality environment where the scene flows past the subject while walking on a treadmill, mimicking real-life locomotion.

AIMS

To investigate cost of environment (no optic-flow v. optic-flow) while completing single- and dual-task walking and dual-task costs (DTC; single- v. dual-task) in optic-flow and no optic-flow environments.

METHODS

Twenty OA and seven younger adults (YA) walked on a self-paced treadmill in 3-min segments per task and both environments. Five task conditions included: no task, semantic fluency (category), phonemic fluency (letters), word reading, and serial-subtraction.

RESULTS

OAs had a benefit of optic-flow compared to no optic-flow for step width (p = 0.015) and step length (p = 0.045) during letters compared to the YA. During letters, OA experienced improvement in step width DTC; whereas YA had a decrement in step width DTC from no optic-flow to optic-flow (p = 0.038). During serial-subtraction, OA had less step width DTC when compared to YA in both environments (p = 0.02).

DISCUSSION

During letters, step width and step length improved in OA while walking in optic-flow. Also, step width DTC differed between the two groups. Sensory information from optic-flow appears to benefit OA. Letters relies more on verbal ability and word knowledge, which are preserved in aging. However, YA use a complex speech style during dual tasking, searching for complex words and an increased speed of speech.

CONCLUSIONS

OA can benefit from optic-flow by improving spatial gait parameters, specifically, step width, during dual-task walking.

The effectiveness of virtual reality training in reducing the risk of falls among elderly people

Background

Virtual reality (VR) training using modern game consoles is an innovative rehabilitation method for fall-prone elderly people. The aim of this study was to assess the effectiveness of VR training using the "Xbox 360 Kinect" in people over 60 years of age.

Materials and methods

The study involved 23 people, including 19 women and 4 men (mean age 75.74±8.09 years). The following functional tests were employed as research instruments: the 6-minute walking test (6MWT), the Dynamic Gait Index (DGI), the tandem stance test (TST), the tandem walk test (TWT), and the Beck Depression Inventory (BDI). A "spring hand dynamometer" was also used. The participants underwent 30-day VR training using an Xbox 360 Kinect. They trained 3 times a week, with each exercise lasting 30 minutes.

Results

The 6MWT (P<0.001), the DGI (P=0.008), the TST (P<0.001), the TWT (P=0.002), and the BDI (P<0.001) outcomes were significantly improved. There were differences in the results for the strength of the "pressing muscles" in the right (P=0.106) and left (P=0.043) hands of the participants. Both participants under 80 years of age and those aged 80 years and over had visibly better results on the 6MWT (P<0.001 and P=0.008, respectively), the TST (P<0.001 and P=0.008, respectively), and the BDI (P=0.003 and P=0.012, respectively).

Conclusion

Training based on VR increases the possibilities of motor training and can help reduce the risk of falls by improving the static and dynamic balance.

Integrated Exposure Therapy and Exercise Reduces Fear of Falling and Avoidance in Older Adults: A Randomized Pilot Study

OBJECTIVES

To evaluate the safety and acceptability of a novel 8-week intervention integrating exercise, exposure therapy, cognitive restructuring, and a home safety evaluation, conducted by a physical therapist, in reducing fear of falling and activity avoidance. To collect preliminary evidence of efficacy.

DESIGN

Randomized pilot study comparing the intervention to time- and attention-equivalent fall prevention education.

SETTING

Participants' homes.

PARTICIPANTS

42 older adults with disproportionate fear of falling (high fear, low to moderate objective fall risk).

MEASUREMENTS

Falls Efficacy Scale-International, modified Activity Card Sort, satisfaction, falls.

RESULTS

Relative to education, the intervention reduced fear of falling (d = 1.23) and activity avoidance (d = 1.02) at 8 weeks, but effects eroded over a 6-month follow-up period. The intervention did not increase falls, and participants rated the exercise, exposure therapy, and non-specific elements as most helpful.

CONCLUSIONS

An integration of exercise and exposure therapy may help older adults with disproportionate fear of falling, but modifications to the intervention or its duration may be needed to maintain participants' gains.

An Interdisciplinary Intervention for Fear of Falling: Lessons Learned from Two Case Studies

This article describes two case studies using an interdisciplinary intervention for homebound older adults who experience fear of falling, resulting in debility and isolation. The patients discussed received separate home visits from a physical therapist (two and four visits) and psychologist (six and eight visits) and intervention components included an initial assessment of physical ability, prescription of home exercise program, exposure therapy, and cognitive restructuring. Both patients reported satisfaction with the fear of falling intervention and showed improved ability to walk, both in distance and in requiring less assistance. These findings suggest significant positive treatment effects can be achieved through interdisciplinary exposure-based interventions aimed at reducing unrealistic fear of falling and associated avoidance behaviors. Similar interventions should be considered for more systematic evaluation of effects and mechanisms of change as well as inclusion in interdisciplinary treatment planning.

Anxiety in Later Life

The spectrum of anxiety disorders occurring in later life is diverse and includes the same disorders that occur with younger adults-such as generalized anxiety disorder, panic disorder, specific phobias, and social anxiety disorder-but also unique presentations, including a fear of falling and the anxiety often seen in various neurocognitive disorders. Therefore, diagnosis and treatment are arguably more challenging in older populations. In addition, many older adults have subthreshold symptoms that can benefit from proper management. This article summarizes the literature on anxiety disorder presentations in later life and offers key recommendations to assist clinicians working with this growing population.