A succinct overview of virtual reality technology use in Alzheimer's disease

Effects of font size, stroke, and background on the legibility of Chinese characters in virtual reality for the elderly

To investigate the legibility of Chinese characters' font size, text background opacity, and font stroke for the elderly in virtual reality, we recruited old and young participants to conduct experiments with VR and used eye-tracking technology to record the data of task completion time and error rate. After analysis, we concluded that the minimum recognition font size for the elderly is 30 dmm, and the best font size is 60 dmm, which is 20 and 40 dmm for young people. The font style has a significant effect on old people (p = 0.000*). Besides, for font sizes smaller than 20 dmm and bigger than 50 dmm, text with strokes and over 50% semi-transparent backgrounds can improve legibility for the elderly. With a suitable font size, the influence of font style on the elderly is not significant. These conclusions can provide a reference for the elderly-oriented Chinese font design in VR.

The Technology to Enhance Patient Motivation in Virtual Reality Rehabilitation: A Review

Virtual reality (VR) technology has experienced a steady rise and has been widely applied in the field of rehabilitation. The integration of VR technology in rehabilitation has shown promising results in enhancing their motivation for treatment, thereby enabling patients to actively engage in rehab training. Despite the advancement, there is a dearth of comprehensive summary and analysis on the use of VR technology to enhance patient motivation in rehabilitation. Thus, this narrative review aims to evaluate the potential of VR technology in enhancing patient motivation during motor rehabilitation training. This review commences with an explanation of how enhancing motivation through the VR rehabilitation system could improve the efficiency and effectiveness of rehabilitation training. Then, the technology was analyzed to improve patient motivation in the present VR rehabilitation system in detail. Furthermore, these technologies are classified and summarized to provide a comprehensive overview of the state-of-the-art approaches for enhancing patient motivation in VR rehabilitation. Findings showed VR rehabilitation training utilizes game-like exercises to enhance the engagement and enjoyment of rehabilitation training. By immersing patients in a simulated environment with multisensory feedback, VR systems offer a unique approach to rehabilitation that can lead to improved patient motivation. Both ultimately lead to improved patient outcomes, which is not typically achievable with traditional rehabilitation methods. The review concludes that VR rehabilitation presents an opportunity to improve patient motivation and adherence to long-term rehabilitation training. However, to further enhance patient self-efficacy, VR rehabilitation should integrate psychology and incorporate methods. Moreover, it is necessary to build a game design theory for rehabilitation games, and the latest VR feedback technology should also be introduced.

Use of Virtual Reality and Augmented Reality Technologies to Support Resilience and Skill-Building in Caregivers of Persons With Dementia: A Scoping Review

Dementia presents a growing public health challenge with most affected individuals living at home, placing significant responsibility on their caregivers. Various interventions, from traditional support groups and education programs to emerging technologies, and more specifically virtual reality (VR) and augmented reality (AR), aim to enhance caregiver skills. While VR/AR shows promise in educating and fostering empathy among caregivers and healthcare professionals, its overall effectiveness and practicality in older adults and dementia care warrant further exploration. This review aimed to summarize currently available VR and AR interventions tailored for family caregivers of persons living with dementia (PLWD) in home or clinical settings, including their level of effectiveness, and to compile a summary of features that contributed to technology acceptance in family caregivers of PLWD. We conducted a systematic search in OVID PsychInfo, CINAHL, Google Scholar, and ERIC, as well as CADTH's Grey Matters, OpenGrey, National Technical Information Service, OAIster, and Health Quality Ontario, to comprehensively summarize the existing evidence underscoring the role of VR and AR in supporting education, resilience-building, and skills training for family caregivers of PLWD. The search terms were built with the assistance of a research librarian and involved synonyms for VR, AR, and dementia. Two screeners conducted a rigorous screening and data extraction to analyze and summarize findings. Studies were included if they focused on family caregivers engaging in interventions utilizing a three-dimensional VR environment and/or Metaverse for group learning in psychotherapeutic modalities such as psychoeducation, therapy, communication, and skill-building. The primary outcome of the studies was assessing measures of well-being (e.g., quality of life, communication, interaction, personhood) and learning outcomes for caregivers, while the secondary outcomes focused on identifying barriers and facilitators influencing the acceptability of VR/AR among dementia caregivers. Content analysis and descriptive statistics were used to summarize key trends in technology and evidence effectiveness and acceptability. Of the 1,641 articles found, 112 were included, with six articles meeting inclusion for analysis. Studies differed in duration and frequency of data collection, with interventions varying from single events to months-long programs, often employing home-based approaches using VR or online platforms. No study used AR. Usability issues and unclear benefits of use were identified as factors that hinder technology acceptance for dementia caregivers. However, technologies demonstrated engaging user experiences, fostering skill-building, confidence, and competence among caregivers. Positive psychological effects were also observed, facilitated by immersive VR and AR interventions, resulting in improved caregiver empathy and reduced stress, depression, and loneliness. VR and AR interventions for family caregivers of PLWD show the potential to enhance empathy and skills and reduce stress. Challenges such as technological limitations and user inexperience issues persist. Home-based VR training aligns with caregiver comfort but lacks focus on financial aspects and cultural competencies. Co-design approaches offer solutions by addressing user concerns and promoting end-user engagement or empowerment.

Facilitators, barriers and impacts to implementing dementia care training for staff in long-term care settings by using fully immersive virtual reality: a scoping review protocol

INTRODUCTION

The rapid growth of the ageing population underscores the critical need for dementia care training among care providers. Innovative virtual reality (VR) technology has created opportunities to improve dementia care training. This scoping review will specifically focus on the barriers, facilitators and impacts of implementing fully immersive VR training for dementia care among staff in long-term care (LTC) settings.

METHODS AND ANALYSIS

We will follow the Joanna Briggs Institute's scoping review methodology to ensure scientific rigour. We will collect literature of all languages with abstracts in English from CINAHL, Medline, Scopus, Embase, Web of Science and ProQuest database until 31 December 2023. Grey literature from Google Scholar and AgeWell websites will be included. Inclusion criteria encompass papers involving paid staff (Population), fully immersive VR training on dementia care (Concept) and LTC settings (Context). Literature referring only to non-paid caregivers, non-fully immersive VR or other chronic diseases will be excluded. Literature screening, data extraction and analysis will be conducted by two reviewers separately. We will present a narrative summary with a charting table on the main findings.

ETHICS AND DISSEMINATION

This work does not require ethics approval, given the public data availability for this scoping review. Through a comprehensive overview of the current evidence regarding impacts, barriers and facilitators on this topic, potential insights and practical recommendations will be generated to support the implementation of VR training to enhance staff competence in LTC settings. The findings will be presented in a journal article and shared with practitioners on the frontline.

The use of virtual reality as a perspective-taking manipulation to improve self-awareness in Alzheimer's disease

Lack of awareness of symptoms or having a condition referred to as anosognosia is a common feature of individuals with Alzheimer's Disease (AD). Previous literature on AD reported difficulties in evaluating self-abilities, often showing underestimation of limitations. There is increasing evidence that the perspective through which information is presented may moderate the performance appraisal and that anosognosia in AD might be a consequence of a deficit in assuming a third-person perspective. In this context, some studies showed that subjects may better recognize self-and other-difficulties when exposed to a third-person perspective. Considering the variety of approaches aiming to investigate the lack of awareness, there is still a scarcity of methods that provide great ecological validity and consider more than one facet of awareness, thus failing to offer more accurate evaluations of daily experiences. The present paper primarily addresses the theme of the multidimensional character of awareness of abilities in AD and the effect of perspective-taking on its trajectories. The focus turns to virtual reality as a promising tool for a greater evaluation of perspective-taking and self-awareness. Particularly, these systems offer the possibility to involve users in cognitive and sensorimotor tasks that simulate daily life conditions within immersive and realistic environments, and a great sense of embodiment. We propose that virtual reality might allow a great level of complexity, veracity, and safety that is needed for individuals with AD to behave according to their actual abilities and enable to explore the liaison between the subject's viewpoint, performance, and self-evaluation. In addition, we suggest promising clinical implications of virtual reality-based methods for individualized assessments, investigating specific impacts on subjects' life and possible improvements in their awareness.

In too deep? A systematic literature review of fully-immersive virtual reality and cybersickness among older adults

BACKGROUND

Virtual reality technology holds great promise in improving the health and well-being of older adults; however, this technology is associated with potential risks that may outweigh the benefits. The purpose of this systematic review is to synthesize and critique the existing literature on fully-immersive virtual reality interventions for older adults and the associated risk of cybersickness.

METHODS

We searched eight databases for studies that utilized fully-immersive virtual reality, stated the population as older adults, provided outcomes related to cybersickness, and were written or translated into the English language. Our search generated 332 articles, 39 of which were selected for inclusion in this systematic synthesis and appraisal.

RESULTS

We found that the majority of studies utilized a one-time session. The studies generally had weak sample generalizability and methodological design, but strong data collection and participant retention. The studies nearly all used the Simulator Sickness Questionnaire to measure cybersickness, but the scoring for the Simulator Sickness Questionnaire varied or was not mentioned. Most included studies reported only minor cybersickness among older adult participants.

CONCLUSION

Researchers might conclude that the benefits of virtual reality interventions outweigh the risk of cybersickness in this population. Going forward, researchers should concentrate on the efficacy of virtual reality interventions among older adults, using larger samples and randomized controlled study design, along with measuring dosage effects.

Customized virtual reality naturalistic scenarios promoting engagement and relaxation in patients with cognitive impairment: a proof-of-concept mixed-methods study

Being immersed in a natural context has a beneficial and pervasive impact on well-being. Virtual Reality (VR) is a technology that can help expose people to naturalistic scenarios virtually, overcoming obstacles that prevent them from visiting real natural environments. VR could also increase engagement and relaxation in older adults with and without cognitive impairment. The main aim of this study is to investigate the feasibility of a customized naturalistic VR scenario by assessing motion-sickness effects, engagement, pleasantness, and emotions felt. Twenty-three individuals with a diagnosis of cognitive impairment living in a long-term care home participated in our study. At the end of the entire VR experimental procedure with older adults, five health staff operators took part in a dedicated assessment phase focused on evaluating the VR procedure's usability from their individual perspectives. The tools administered were based on self-reported and observational tools used to obtain information from users and health care staff professionals. Feasibility and acceptance proved to be satisfactory, considering that the VR experience was well-tolerated and no adverse side effects were reported. One of the major advantages emerged was the opportunity to deploy customized environments that users are not able to experience in a real context.Trial Registration: National Institute of Health (NIH) U.S. National Library of Medicine, ClinicalTrials.gov NCT05863065 (17/05/2023).

Current development of biosensing technologies towards diagnosis of mental diseases

The biosensor is an instrument that converts the concentration of biomarkers into electrical signals for detection. Biosensing technology is non-invasive, lightweight, automated, and biocompatible in nature. These features have significantly advanced medical diagnosis, particularly in the diagnosis of mental disorder in recent years. The traditional method of diagnosing mental disorders is time-intensive, expensive, and subject to individual interpretation. It involves a combination of the clinical experience by the psychiatrist and the physical symptoms and self-reported scales provided by the patient. Biosensors on the other hand can objectively and continually detect disease states by monitoring abnormal data in biomarkers. Hence, this paper reviews the application of biosensors in the detection of mental diseases, and the diagnostic methods are divided into five sub-themes of biosensors based on vision, EEG signal, EOG signal, and multi-signal. A prospective application in clinical diagnosis is also discussed.

Assessing Virtual Reality Spaces for Elders Using Image-Based Sentiment Analysis and Stress Level Detection

Seniors, in order to be able to fight loneliness, need to communicate with other people and be engaged in activities to keep their minds active to increase their social capital. There is an intensified interest in the development of social virtual reality environments, either by commerce or by academia, to address the problem of social isolation of older people. Due to the vulnerability of the social group involved in this field of research, the need for the application of evaluation methods regarding the proposed VR environments becomes even more important. The range of techniques that can be exploited in this field is constantly expanding, with visual sentiment analysis being a characteristic example. In this study, we introduce the use of image-based sentiment analysis and behavioural analysis as a technique to assess a social VR space for elders and present some promising preliminary results.

A systematic review: Virtual-reality-based techniques for human exercises and health improvement

Virtual Reality (VR) has emerged as a new safe and efficient tool for the rehabilitation of many childhood and adulthood illnesses. VR-based therapies have the potential to improve both motor and functional skills in a wide range of age groups through cortical reorganization and the activation of various neuronal connections. Recently, the potential for using serious VR-based games that combine perceptual learning and dichoptic stimulation has been explored for the rehabilitation of ophthalmological and neurological disorders. In ophthalmology, several clinical studies have demonstrated the ability to use VR training to enhance stereopsis, contrast sensitivity, and visual acuity. The use of VR technology provides a significant advantage in training each eye individually without requiring occlusion or penalty. In neurological disorders, the majority of patients undergo recurrent episodes (relapses) of neurological impairment, however, in a few cases (60-80%), the illness progresses over time and becomes chronic, consequential in cumulated motor disability and cognitive deficits. Current research on memory restoration has been spurred by theories about brain plasticity and findings concerning the nervous system's capacity to reconstruct cellular synapses as a result of interaction with enriched environments. Therefore, the use of VR training can play an important role in the improvement of cognitive function and motor disability. Although there are several reviews in the community employing relevant Artificial Intelligence in healthcare, VR has not yet been thoroughly examined in this regard. In this systematic review, we examine the key ideas of VR-based training for prevention and control measurements in ocular diseases such as Myopia, Amblyopia, Presbyopia, and Age-related Macular Degeneration (AMD), and neurological disorders such as Alzheimer, Multiple Sclerosis (MS) Epilepsy and Autism spectrum disorder. This review highlights the fundamentals of VR technologies regarding their clinical research in healthcare. Moreover, these findings will raise community awareness of using VR training and help researchers to learn new techniques to prevent and cure different diseases. We further discuss the current challenges of using VR devices, as well as the future prospects of human training.

Influence of Hand Tracking in Immersive Virtual Reality for Memory Assessment

Few works analyze the parameters inherent to immersive virtual reality (IVR) in applications for memory evaluation. Specifically, hand tracking adds to the immersion of the system, placing the user in the first person with full awareness of the position of their hands. Thus, this work addresses the influence of hand tracking in memory assessment with IVR systems. For this, an application based on activities of daily living was developed, where the user must remember the location of the elements. The data collected by the application are the accuracy of the answers and the response time; the participants are 20 healthy subjects who pass the MoCA test with an age range between 18 to 60 years of age; the application was evaluated with classic controllers and with the hand tracking of the Oculus Quest 2. After the experimentation, the participants carried out presence (PQ), usability (UMUX), and satisfaction (USEQ) tests. The results indicate no difference with statistical significance between both experiments; controller experiments have 7.08% higher accuracy and 0.27 ys. faster response time. Contrary to expectations, presence was 1.3% lower for hand tracking, and usability (0.18%) and satisfaction (1.43%) had similar results. The findings indicate no evidence to determine better conditions in the evaluation of memory in this case of IVR with hand tracking.

Addressing Cognitive Function and Psychological Well-Being in Chronic Kidney Disease: A Systematic Review on the Use of Technology-Based Interventions

Patients with chronic kidney disease (CKD) are at risk of both a gradual decline in cognitive function and an increase in psychological distress. This includes symptoms of anxiety, depression, and sleep disturbances, all of which are factors that have been associated with increased morbidity and mortality. In response, we are now seeing that interventions based on new digital technologies are increasingly used in order to optimize patients' quality of life. Systematic research of the literature on electronic databases (MEDLINE/PubMed, Scopus, Web of Science, and PsycInfo/ProQuest) covering the period from 2012 to 2022 was conducted in order to methodically review the existing evidence regarding the implementation and effectiveness of technology-based interventions in the management of cognitive and psychological well-being symptoms in patients with CKD. A total of 739 articles were retrieved, 13 of which are included in the present review. All the studies focused on the usability, acceptability, and feasibility of technology-based interventions aimed at psychological symptoms, with no studies targeting cognitive functioning. Technology-based interventions offer feelings of safety, fun, and satisfaction, and they also have the potential to improve CKD patients' health outcomes regarding their psychological well-being. The diverseness of technologies allows an approximation towards the identification of those types of technologies most frequently used, as well as the symptoms targeted. There was considerable heterogeneity in the types of technologies used for interventions in so few studies, making it difficult to draw conclusive findings with regard to their efficiency. In order to adequately assess the technology-based health interventions effect, future lines of research should consider designing non-pharmacological treatments for the improvement of cognitive and psychological symptoms in this type of patient.

Vestibular cognition assessment system: Tablet-based computerized visuospatial abilities test battery

Introduction

The vestibular system is anatomically connected to extensive regions of the cerebral cortex, hippocampus, and amygdala. However, studies focusing on the impact of vestibular impairment on visuospatial cognition ability are limited. This study aimed to develop a mobile tablet-based vestibular cognitive assessment system (VCAS), enhance the dynamic and three-dimensional (3D) nature of the test conditions, and comprehensively evaluate the visuospatial cognitive ability of patients with vestibular dysfunction.

Materials and methods

First, the VCAS assessment dimensions (spatial memory, spatial navigation, and mental rotation) and test content (weeding, maze, card rotation, and 3D driving tests) were determined based on expert interviews. Second, VCAS was developed based on Unity3D, using the C# language and ILruntime hot update framework development technology, combined with the A* algorithm, prime tree algorithm, and dynamic route rendering. Further, the online test was built using relevant game business logic. Finally, healthy controls (HC) and 78 patients with vertigo (VP) were recruited for the VCAS test. The validity of VCAS was verified using the test results of random controls.

Results

In the weeding test, the HC group had a significantly longer span and faster velocity backward than did the VP group. In the 12 × 12 maze, statistically significant differences in step and time were observed between the two groups, with VP taking longer time and more steps. In the mental rotation task, no significant difference was observed between the two groups. Similarly, no significant difference was found in the performance of the two groups on maps 2, 3, and 4 in the 3D driving task.

Discussion

Thus, impaired visuospatial cognition in patients with vestibular dysfunction is primarily related to spatial memory and navigation. VCAS is a clinically applicable visuospatial cognitive ability test for VP.

Biosensors toward behavior detection in diagnosis of alzheimer’s disease

In recent years, a huge number of individuals all over the world, elderly people, in particular, have been suffering from Alzheimer’s disease (AD), which has had a significant negative impact on their quality of life. To intervene early in the progression of the disease, accurate, convenient, and low-cost detection technologies are gaining increased attention. As a result of their multiple merits in the detection and assessment of AD, biosensors are being frequently utilized in this field. Behavioral detection is a prospective way to diagnose AD at an early stage, which is a more objective and quantitative approach than conventional neuropsychological scales. Furthermore, it provides a safer and more comfortable environment than those invasive methods (such as blood and cerebrospinal fluid tests) and is more economical than neuroimaging tests. Behavior detection is gaining increasing attention in AD diagnosis. In this review, cutting-edge biosensor-based devices for AD diagnosis together with their measurement parameters and diagnostic effectiveness have been discussed in four application subtopics: body movement behavior detection, eye movement behavior detection, speech behavior detection, and multi-behavior detection. Finally, the characteristics of behavior detection sensors in various application scenarios are summarized and the prospects of their application in AD diagnostics are presented as well.

Virtual Reality Intervention for Managing Apathy in People With Cognitive Impairment: Systematic Review

Background

Apathy is common in people with cognitive impairment. It leads to different consequences, such as more severe cognitive deficits, rapid functional decline, and decreased quality of life. Virtual reality (VR) interventions are increasingly being used to manage apathy in individuals with cognitive impairment. However, reports of VR interventions are scattered across studies, which has hindered the development and use of the interventions.

Objective

This study aimed to systematically review existing evidence on the use of VR interventions for managing apathy in people with cognitive impairment with regard to the effectiveness, contents, and implementation of the interventions.

Methods

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. The PubMed, Embase, CINAHL, and PsycINFO databases were systematically searched for experimental studies published up to March 13, 2022, that reported the effects of VR interventions on apathy in older adults with cognitive impairment. Hand searching and citation chasing were conducted. The results of the included studies were synthesized by using a narrative synthesis. Their quality was appraised by using the Effective Public Health Practice Project quality assessment tool. However, because the VR interventions varied in duration, content, and implementation across studies, a meta-analysis was not conducted.

Results

A total of 22 studies were identified from the databases, of which 6 (27%) met the inclusion criteria. Of these 6 studies, 2 (33%) were randomized controlled trials, 1 (17%) was a controlled clinical trial, and 3 (50%) were quasi-experimental studies. Individual studies showed significant improvement in apathy and yielded within-group medium to large effect sizes. The level of immersion ranged from low to high. Minor adverse effects were reported. The VR content mostly included natural scenes, followed by city views and game-based activities. A background soundtrack was often used with natural scenes. Most (5/6, 83%) of the studies were conducted in a residential care setting and were implemented by health care professionals or researchers. Safety precautions were taken in most (5/6, 83%) of the studies.

Conclusions

Although preliminary evidence shows that VR interventions may be effective and feasible for alleviating apathy in people with cognitive impairment, the methodological limitations in the included studies make it difficult to reach a firm conclusion on these points. The implementation of the interventions was highlighted and discussed. More rigorous studies are encouraged.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42021268289; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021268289

Application of Real and Virtual Radial Arm Maze Task in Human

Virtual Reality (VR) emerges as a promising technology capable of creating different scenarios in which the body, environment, and brain are closely related, proving enhancements in the diagnosis and treatment of several spatial memory deficits. In recent years, human spatial navigation has increasingly been studied in interactive virtual environments. However, navigational tasks are still not completely adapted in immersive 3D VR systems. We stipulate that an immersive Radial Arm Maze (RAM) is an excellent instrument, allowing the participants to be physically active within the maze exactly as in the walking RAM version in reality modality. RAM is a behavioral ecological task that allows the analyses of different facets of spatial memory, distinguishing declarative components from procedural ones. In addition to describing the characteristics of RAM, we will also analyze studies in which RAM has been used in virtual modality to provide suggestions into RAM building in immersive modality.

Virtual Reality Technology in Cognitive Rehabilitation Application: A Bibliometric Analysis (Preprint)

Background

In recent years, with the development of computer science and medical science, virtual reality (VR) technology has become a promising tool for improving cognitive function. Research on VR-based cognitive training has garnered increasing attention.

Objective

This study aimed to investigate the application status, research hot spots, and emerging trends of VR in cognitive rehabilitation over the past 20 years.

Methods

Articles on VR-based cognitive rehabilitation from 2001 to 2021 were retrieved from the Web of Science Core Collection. CiteSpace software was used for the visual analysis of authors and countries or regions, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Keywords were clustered using the gCLUTO software.

Results

A total of 1259 papers were included. In recent years, research on the application of VR in cognitive rehabilitation has been widely conducted, and the annual publication of relevant literature has shown a positive trend. The main research areas include neuroscience and neurology, psychology, computer science, and rehabilitation. The United States ranked first with 328 papers, and Italy ranked second with 140 papers. Giuseppe Riva, an Italian academic, was the most prolific author with 29 publications. The most frequently cited reference was “Using Reality to Characterize Episodic Memory Profiles in Amnestic Mild Cognitive Impairment and Alzheimer’s Disease: Influence of Active and Passive Encoding.” The most common keywords used by researchers include “virtual reality,” “cognition,” “rehabilitation,” “performance,” and “older adult.” The largest source of research funding is from the public sector in the United States.

Conclusions

The bibliometric analysis provided an overview of the application of VR in cognitive rehabilitation. VR-based cognitive rehabilitation can be integrated into multiple disciplines. We conclude that, in the context of the COVID-19 pandemic, the development of VR-based telerehabilitation is crucial, and there are still many problems that need to be addressed, such as the lack of consensus on treatment methods and the existence of safety hazards.

Immersive Virtual Reality-Based Cognitive Intervention for the Improvement of Cognitive Function, Depression, and Perceived Stress in Older Adults With Mild Cognitive Impairment and Mild Dementia: Pilot Pre-Post Study

Background

The incidence of dementia is increasing annually, resulting in varying degrees of adverse effects for individuals, families, and society. With the continuous development of computer information technology, cognitive interventions are constantly evolving. The use of immersive virtual reality (IVR) as a cognitive intervention for older adults with mild cognitive impairment (MCI) and mild dementia (MD) is promising, although only few studies have focused on its use.

Objective

The Chinese virtual supermarket (CVSM) IVR system was developed to provide a comprehensive and individual cognitive intervention program for older patients with MCI and MD. The aim of this study was to explore the feasibility and clinical effectiveness of this 5-week IVR-based cognitive intervention.

Methods

A pretest-posttest study design was conducted with 31 older adults with MCI and MD from August 2020 to January 2021. All participants participated in a 5-week immersive virtual cognitive training program using the CVSM system. Feasibility was assessed as the incidence and severity of cybersickness symptoms and participant satisfaction based on questionnaires conducted after the intervention. Clinical effectiveness was evaluated using neuropsychological assessments, including several commonly used measures of cognitive function, depression, perceived stress, and activities of daily living. Measurements were obtained at baseline and after the intervention period.

Results

A total of 18 patients with MCI (mean age 82.94 [SD 5.44] years; 12 females) and 13 patients with MD (mean age 85.7 [SD 4.67] years, 10 females) participated in this pilot study. Both groups showed significant improvements in all cognitive function measurements (P<.001). The MD group had a significantly greater improvement in general cognitive function compared to the MCI group in Montreal Cognitive Assessment Scale, Symbol Digit Modalities Test, Shape Trail Test, and Auditory Verbal Learning Test. Furthermore, an intervention effect was observed in the improvement of perceived stress (P=.048 for MD group, P=.03 for MCI group ).

Conclusions

The use of the CVSM system may be effective in enhancing the cognitive function of patients with MCI and MD, including general cognitive function, memory, executive function, and attention. IVR technology enriches cognitive intervention approaches and provides acceptable, professional, personalized, and interesting cognitive training for older adults with cognitive impairment.

Trial Registration

ClinicalTrials ChiCTR2100043753; https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2100043753

Effect of virtual reality exercise on interventions for patients with Alzheimer's disease: A systematic review

Virtual reality (VR) interventions are increasingly being used in rehabilitating and treating patients with neurological disorders. This study aimed to explore the effects of VR exercise interventions for patients with Alzheimer's disease (AD). A systematic review of the published literature on randomized controlled trials of VR technology applied to patients with AD was conducted using the preferred reporting entry for systematic reviews and Meta-analysis guidelines. Descriptive analyses were performed to assess the quality of the studies in terms of the characteristics of the included studies, samples, diagnoses, types of VR technologies, subjective and objective levels of immersion, and quality of studies. Eight studies were included, including a pooled sample of 362 patients with AD. A systematic review showed that most studies focused on patients with AD's cognitive and physical functions. The main finding was that VR interventions could help improve cognitive and physical balance in patients with AD. However, future studies should emphasize design and use well-accepted assessment tools to validate the effects of VR interventions further.

Virtual Reality Applications in Medicine During the COVID-19 Pandemic: Systematic Review (Preprint)

Background

Virtual reality can play an important role during the COVID-19 pandemic in the health care sector. This technology has the potential to supplement the traditional in-hospital medical training and treatment, and may increase access to training and therapies in various health care settings.

Objective

This systematic review aimed to describe the literature on health care–targeted virtual reality applications during the COVID-19 crisis.

Methods

We conducted a systematic search of the literature on the PsycINFO, Web of Science, and MEDLINE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search string was as follows: “[(virtual reality)] AND [(COVID-19) OR (coronavirus) OR (SARS-CoV-2) OR (healthcare)].” Papers published in English after December 2019 in peer-reviewed journals were selected and subjected to the inclusion and exclusion criteria. We used the Mixed Methods Appraisal Tool to assess the quality of studies and the risk of bias.

Results

Thirty-nine studies met the inclusion criteria. Seventeen studies showed the usefulness of virtual reality during the COVID-19 crisis for reducing stress, anxiety, depression, and pain, and promoting physical activity. Twenty-two studies revealed that virtual reality was a helpful learning and training tool during the COVID-19 crisis in several areas, including emergency medicine, nursing, and pediatrics. This technology was also used as an educational tool for increasing public understanding of the COVID-19 pandemic. Different levels of immersion (ie, immersive and desktop virtual reality), types of head-mounted displays (ie, PC-based, mobile, and standalone), and content (ie, 360° videos and photos, virtual environments, virtual reality video games, and embodied virtual agents) have been successfully used. Virtual reality was helpful in both face-to-face and remote trials.

Conclusions

Virtual reality has been applied frequently in medicine during the COVID-19 pandemic, with positive effects for treating several health conditions and for medical education and training. Some barriers need to be overcome for the broader adoption of virtual reality in the health care panorama.

Trial Registration

International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) INPLASY202190108; https://inplasy.com/inplasy-2021-9-0108/

Building Embodied Spaces for Spatial Memory Neurorehabilitation with Virtual Reality in Normal and Pathological Aging

Along with deficits in spatial cognition, a decline in body-related information is observed in aging and is thought to contribute to impairments in navigation, memory, and space perception. According to the embodied cognition theories, bodily and environmental information play a crucial role in defining cognitive representations. Thanks to the possibility to involve body-related information, manipulate environmental stimuli, and add multisensory cues, virtual reality is one of the best candidates for spatial memory rehabilitation in aging for its embodied potential. However, current virtual neurorehabilitation solutions for aging and neurodegenerative diseases are in their infancy. Here, we discuss three concepts that could be used to improve embodied representations of the space with virtual reality. The virtual bodily representation is the combination of idiothetic information involved during virtual navigation thanks to input/output devices; the spatial affordances are environmental or symbolic elements used by the individual to act in the virtual environment; finally, the virtual enactment effect is the enhancement on spatial memory provided by actively (cognitively and/or bodily) interacting with the virtual space and its elements. Theoretical and empirical findings will be presented to propose innovative rehabilitative solutions in aging for spatial memory and navigation.

Brain-Computer Interfaces Systems for Upper and Lower Limb Rehabilitation: A Systematic Review

In recent years, various studies have demonstrated the potential of electroencephalographic (EEG) signals for the development of brain-computer interfaces (BCIs) in the rehabilitation of human limbs. This article is a systematic review of the state of the art and opportunities in the development of BCIs for the rehabilitation of upper and lower limbs of the human body. The systematic review was conducted in databases considering using EEG signals, interface proposals to rehabilitate upper/lower limbs using motor intention or movement assistance and utilizing virtual environments in feedback. Studies that did not specify which processing system was used were excluded. Analyses of the design processing or reviews were excluded as well. It was identified that 11 corresponded to applications to rehabilitate upper limbs, six to lower limbs, and one to both. Likewise, six combined visual/auditory feedback, two haptic/visual, and two visual/auditory/haptic. In addition, four had fully immersive virtual reality (VR), three semi-immersive VR, and 11 non-immersive VR. In summary, the studies have demonstrated that using EEG signals, and user feedback offer benefits including cost, effectiveness, better training, user motivation and there is a need to continue developing interfaces that are accessible to users, and that integrate feedback techniques.

Intelligent Sensing Technologies for the Diagnosis, Monitoring and Therapy of Alzheimer's Disease: A Systematic Review

Alzheimer's disease is a lifelong progressive neurological disorder. It is associated with high disease management and caregiver costs. Intelligent sensing systems have the capability to provide context-aware adaptive feedback. These can assist Alzheimer's patients with, continuous monitoring, functional support and timely therapeutic interventions for whom these are of paramount importance. This review aims to present a summary of such systems reported in the extant literature for the management of Alzheimer's disease. Four databases were searched, and 253 English language articles were identified published between the years 2015 to 2020. Through a series of filtering mechanisms, 20 articles were found suitable to be included in this review. This study gives an overview of the depth and breadth of the efficacy as well as the limitations of these intelligent systems proposed for Alzheimer's. Results indicate two broad categories of intelligent technologies, distributed systems and self-contained devices. Distributed systems base their outcomes mostly on long-term monitoring activity patterns of individuals whereas handheld devices give quick assessments through touch, vision and voice. The review concludes by discussing the potential of these intelligent technologies for clinical practice while highlighting future considerations for improvements in the design of these solutions for Alzheimer's disease.

A Scoping Review of Cognitive Training in Neurodegenerative Diseases via Computerized and Virtual Reality Tools: What We Know So Far

Most prevalent neurodegenerative diseases such as Alzheimer's disease, frontotemporal dementia, Parkinson's disease and multiple sclerosis are heterogeneous in their clinical profiles and underlying pathophysiology, although they typically share the presence of cognitive impairment that worsens significantly during the course of the disease. Viable pharmacological options for cognitive symptoms in these clinical conditions are currently lacking. In recent years, several studies have started to apply Computerized Cognitive Training (CCT) and Virtual Reality (VR) tools to try and contrast patients' cognitive decay over time. However, no in-depth literature review of the contribution of these promising therapeutic options across main neurodegenerative diseases has been conducted yet. The present paper reports the state-of-the-art of CCT and VR studies targeting cognitive impairment in most common neurodegenerative conditions. Our twofold aim is to point out the scientific evidence available so far and to support health professionals to consider these promising therapeutic tools when planning rehabilitative interventions, especially when the access to regular and frequent hospital consultations is not easy to be provided.

Virtual Reality in Neurorehabilitation: An Umbrella Review of Meta-Analyses

Neurological disorders are a leading cause of death and disability worldwide. Can virtual reality (VR) based intervention, a novel technology-driven change of paradigm in rehabilitation, reduce impairments, activity limitations, and participation restrictions? This question is directly addressed here for the first time using an umbrella review that assessed the effectiveness and quality of evidence of VR interventions in the physical and cognitive rehabilitation of patients with stroke, traumatic brain injury and cerebral palsy, identified factors that can enhance rehabilitation outcomes and addressed safety concerns. Forty-one meta-analyses were included. The data synthesis found mostly low- or very low-quality evidence that supports the effectiveness of VR interventions. Only a limited number of comparisons were rated as having moderate and high quality of evidence, but overall, results highlight potential benefits of VR for improving the ambulation function of children with cerebral palsy, mobility, balance, upper limb function, and body structure/function and activity of people with stroke, and upper limb function of people with acquired brain injury. Customization of VR systems is one important factor linked with improved outcomes. Most studies do not address safety concerns, as only nine reviews reported adverse effects. The results provide critical recommendations for the design and implementation of future VR programs, trials and systematic reviews, including the need for high quality randomized controlled trials to test principles and mechanisms, in primary studies and in meta-analyses, in order to formulate evidence-based guidelines for designing VR-based rehabilitation interventions.

Making Art Therapy Virtual: Integrating Virtual Reality Into Art Therapy With Adolescents

In recent years, the field of art therapy has sought to adapt traditional treatment approaches to today’s innovative technological environments when working with adolescent “digital natives.” In their clinic, art therapists often struggle with lack of cooperation when treating adolescents during sessions. This article presents two case studies that explore how Virtual Reality (VR) technology can be combined with traditional art therapy to treat adolescents suffering from anxiety and social difficulties. It is suggested that this type of technology may lead to a better understanding of the needs of adolescents by adopting their vantage point and hence better outcomes.

Age-related impairment of navigation and strategy in virtual star maze

Background

Although it is well known that aging impairs navigation performance, the underlying mechanisms remain largely unknown. Egocentric strategy requires navigators to remember a series of body-turns without relying on the relationship between environmental cues. Previous study suggested that the egocentric strategy, compared with non-egocentric strategy, was relatively unimpaired during aging. In this study, we aimed to examine strategy use during virtual navigation task and the underlying cognitive supporting mechanisms in older adults.

Methods

Thirty young adults and thirty-one older adults were recruited from the local community. This study adapted star maze paradigm using non-immersive virtual environment. Participants moved freely in a star maze with adequate landmarks, and were requested to find a fixed destination. After 9 learning trials, participants were probed in the same virtual star maze but with no salient landmarks. Participants were classified as egocentric or non-egocentric strategy group according to their response in the probe trial.

Results

The results revealed that older adults adopting egocentric strategy completed the navigation task as accurate as young adults, whereas older adults using non-egocentric strategy completed the navigation task with more detours and lower accuracy. The relatively well-maintained egocentric strategy in older adults was related to better visuo-spatial ability.

Conclusions

Visuo-spatial ability might play an important role in navigation accuracy and navigation strategy of older adults. This study demonstrated the potential value of the virtual star maze in evaluating navigation strategy and visuo-spatial ability in older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02034-y.

Administering Virtual Reality Therapy to Manage Behavioral and Psychological Symptoms in Patients With Dementia Admitted to an Acute Care Hospital: Results of a Pilot Study

BACKGROUND

As virtual reality (VR) technologies become increasingly accessible and affordable, clinicians are eager to try VR therapy as a novel means to manage behavioral and psychological symptoms of dementia, which are exacerbated during acute care hospitalization, with the goal of reducing the use of antipsychotics, sedatives, and physical restraints associated with negative adverse effects, increased length of stay, and caregiver burden. To date, no evaluations of immersive VR therapy have been reported for patients with dementia in acute care hospitals.

OBJECTIVE

This study aimed to determine the feasibility (acceptance, comfort, and safety) of using immersive VR therapy for people living with dementia (mild, moderate, and advanced) during acute care hospitalization and explore its potential to manage behavioral and psychological symptoms of dementia.

METHODS

A prospective, longitudinal pilot study was conducted at a community teaching hospital in Toronto. The study was nonrandomized and unblinded. A total of 10 patients aged >65 years (mean 86.5, SD 5.7) diagnosed with dementia participated in one or more research coordinator-facilitated sessions of viewing immersive 360° VR footage of nature scenes displayed on a Samsung Gear VR head-mounted display. This mixed-methods study included review of patient charts, standardized observations during the intervention, and pre- and postintervention semistructured interviews about the VR experience.

RESULTS

All recruited participants (N=10) completed the study. Of the 10 participants, 7 (70%) displayed enjoyment or relaxation during the VR session, which averaged 6 minutes per view, and 1 (10%) experienced dizziness. No interference between the VR equipment and hearing aids or medical devices was reported.

CONCLUSIONS

It is feasible to expose older people with dementia of various degrees admitted to an acute care hospital to immersive VR therapy. VR therapy was found to be acceptable to and comfortable by most participants. This pilot study provides the basis for conducting the first randomized controlled trial to evaluate the impact of VR therapy on managing behavioral and psychological symptoms of dementia in acute care hospitals.

Harnessing the Spatial Foundation of Mind in Breaking Vicious Cycles in Anxiety, Insomnia, and Depression: The Future of Virtual Reality Therapy Applications

Mental Illnesses, particularly anxiety, insomnia, and depression often involve vicious cycles which are self-perpetuating and can trap one into a more chronic state. For example in the case of insomnia, sympathetic overactivity, intrusive thoughts, and emotional instability due to sleep loss can perpetuate further sleep loss the next night and so on. In this article, we put forward a perspective on breaking these vicious cycles based on preeminent theories in global and spatial cognition, that the foundation of the conscious mind is a spatial coordinate system. Based on this we discuss the potential and future of virtual reality therapeutic applications which utilize massive virtual spaces along with biofeedback designed to help break perpetual cycles in depression, anxiety, and insomnia. "Massive spaces" are those which are truly expansive such as when looking to the clear night sky. These virtual realities may take the form of a night sky, fantastical cosmic scenes, or other scenes such as mountain tops. We also hope to inspire research into such a spatial foundation of mind, use of perceived massive spaces for therapy, and the integration of biofeedback into virtual therapies.

Virtual reality to promote wellbeing in persons with dementia: A scoping review

Virtual Reality (VR) technologies have increasingly been considered potentially valuable tools in dementia-related research and could serve as non-pharmacological therapy to improve quality of life (QoL) and wellbeing for persons with dementia (PwD). In this scoping review, we summarize peer-reviewed articles published up to Jan-21, 2021, on the use of VR to promote wellbeing in PwD. Eighteen manuscripts (reporting on 19 studies) met the inclusion criteria, with a majority published in the past 2 years. Two reviewers independently coded the articles regarding A) intended clinical outcomes and effectiveness of the interventions, B) study sample (characteristics of the participants), C) intervention administration (by whom, what setting), D) experimental methods (design/instruments), and E) technical properties of the VR-systems (hardware/devices and software/content). Emotional outcomes were by far the most common objectives of the interventions, reported in seventeen (89.5%) of the included articles. Outcomes addressing social engagement and personhood in PwD have not been thoroughly explored using VR. Based on the positive impact of VR, future opportunities lie in identifying special features and customization of the hardware/software to afford the most benefit to different sub-groups of the target population. Overall, this review found that VR represents a promising tool for promoting wellbeing in PwD, with positive or neutral impact reported on emotional, social, and functional aspects of wellbeing.

A Survey of Alzheimer's Disease Early Diagnosis Methods for Cognitive Assessment

Dementia is a syndrome that is characterised by the decline of different cognitive abilities. A high rate of deaths and high cost for detection, treatments, and patients care count amongst its consequences. Although there is no cure for dementia, a timely diagnosis helps in obtaining necessary support, appropriate medication, and maintenance, as far as possible, of engagement in intellectual, social, and physical activities. The early detection of Alzheimer Disease (AD) is considered to be of high importance for improving the quality of life of patients and their families. In particular, Virtual Reality (VR) is an expanding tool that can be used in order to assess cognitive abilities while navigating through a Virtual Environment (VE). The paper summarises common AD screening and diagnosis techniques focusing on the latest approaches that are based on Virtual Environments, behaviour analysis, and emotions recognition, aiming to provide more reliable and non-invasive diagnostics at home or in a clinical environment. Furthermore, different AD diagnosis evaluation methods and metrics are presented and discussed together with an overview of the different datasets.

Analyzing large Alzheimer's disease cognitive datasets: Considerations and challenges

Recent data-sharing initiatives of clinical and preclinical Alzheimer's disease (AD) have led to a growing number of non-clinical researchers analyzing these datasets using modern data-driven computational methods. Cognitive tests are key components of such datasets, representing the principal clinical tool to establish phenotypes and monitor symptomatic progression. Despite the potential of computational analyses in complementing the clinical understanding of AD, the characteristics and multifactorial nature of cognitive tests are often unfamiliar to computational researchers and other non-specialist audiences. This perspective paper outlines core features, idiosyncrasies, and applications of cognitive test data. We report tests commonly featured in data-sharing initiatives, highlight key considerations in their selection and analysis, and provide suggestions to avoid risks of misinterpretation. Ultimately, the greater transparency of cognitive measures will maximize insights offered in AD, particularly regarding understanding the extent and basis of AD phenotypic heterogeneity.

The Impact of a Multitasking-Based Virtual Reality Motion Video Game on the Cognitive and Physical Abilities of Older Adults

This study demonstrates how playing a well-designed multitasking motion video game in a virtual reality (VR) environment can positively impact the cognitive and physical health of older players. We developed a video game that combines cognitive and physical training in a VR environment. The impact of playing the game was measured through a four-week longitudinal experiment. Twenty healthy older adults were randomly assigned to either an intervention group (i.e., game training) or a control group (i.e., no contact). Participants played three 45-min sessions per week completing cognitive tests for attention, working memory, reasoning and a test for physical balance before and after the intervention. Results showed that compared to the control group, the game group showed significant improvements in working memory and a potential for enhancing reasoning and balance ability. Furthermore, while the older adults enjoyed playing the video game, ability enhancements were associated with their intrinsic motivation to play. Overall, cognitive training with multitasking VR motion video games has positive impacts on the cognitive and physical health of older adults.

Virtual Reality in the Assessment, Understanding and Treatment of Mental Health Disorders

Computer scientists usually describe virtual reality (VR) as a set of fancy hardware and software technologies. However, psychology and neuroscience are starting to consider VR as the most advanced form of human-computer interaction allowing individuals to act, communicate and become present in a computer-generated environment. In this view, the feeling of "being there" experienced during a VR experience can become a powerful tool for personal change: it offers a dynamic and social world where individuals can live and share a specific experience. For this reason, the use of VR in mental health shows promise: different researches support its clinical efficacy for conditions including anxiety disorders, stress-related disorders, obesity and eating disorders, pain management, addiction and schizophrenia. However, more research is needed to transform the promises of VR in a real clinical tool for mental health. This Special Issue aims to present the most recent advances in the mental health applications of VR, as well as their implications for future patient care.

Cognitive Training Using Fully Immersive, Enriched Environment Virtual Reality for Patients With Mild Cognitive Impairment and Mild Dementia: Feasibility and Usability Study

Background

Cognitive training using virtual reality (VR) may result in motivational and playful training for patients with mild cognitive impairment and mild dementia. Fully immersive VR sets patients free from external interference and thus encourages patients with cognitive impairment to maintain selective attention. The enriched environment, which refers to a rich and stimulating environment, has a positive effect on cognitive function and mood.

Objective

The aim of this study was to investigate the feasibility and usability of cognitive training using fully immersive VR programs in enriched environments with physiatrists, occupational therapists (OTs), and patients with mild cognitive impairment and mild dementia.

Methods

The VR interface system consisted of a commercialized head-mounted display and a custom-made hand motion tracking module. We developed the virtual harvest and cook programs in enriched environments representing rural scenery. Physiatrists, OTs, and patients with mild cognitive impairment and mild dementia received 30 minutes of VR training to evaluate the feasibility and usability of the test for cognitive training. At the end of the test, the usability and feasibility were assessed by a self-report questionnaire based on a 7-point Likert-type scale. Response time and finger tapping were measured in patients before and after the test.

Results

Participants included 10 physiatrists, 6 OTs, and 11 patients with mild cognitive impairment and mild dementia. The mean scores for overall satisfaction with the program were 5.75 (SD 1.00) for rehabilitation specialists and 5.64 (SD 1.43) for patients. The response time of the dominant hand in patients decreased after the single session of cognitive training using VR, but this was not statistically significant (P=.25). There was no significant change in finger tapping in either the right or left hand (P=.48 and P=.42, respectively). None of the participants reported headaches, dizziness, or any other motion sickness after the test.

Conclusions

A fully immersive VR cognitive training program may be feasible and usable in patients with mild cognitive impairment and mild dementia based on the positive satisfaction and willingness to use the program reported by physiatrists, OTs, and patients. Although not statistically significant, decreased response time without a change in finger tapping rate may reflect a temporary increase in attention after the test. Additional clinical trials are needed to investigate the effect on cognitive function, mood, and physical outcomes.

Effects of a virtual group cycling experience on people living with dementia: A mixed method pilot study

Social isolation and sedentary behaviour are common in residential aged care facilities (also known as nursing homes or long-term care). Use of new technologies such as virtual and augmented reality are currently under investigation for their potential to provide exciting and engaging activities for older people in residential aged care facilities. However, there is limited evidence on whether these technologies can promote physical activity in a small group setting for people with cognitive impairment. Using mixed methods, we examined the use of a virtual cycling experience in a sample of 10 participants with cognitive impairment living in residential aged care facilities. In a randomised crossover design, participants engaged in a 25-minute, self-paced, facilitated seated virtual cycling experience and a time-matched seated physical activity session in groups of five. All participants completed a brief pre- and post-intervention mood questionnaire. Video analysis was used for both conditions to compare levels of environmental stimulation, apathy and engagement using both the Person–Environment Apathy Rating Scale and the Engagement of a Person with Dementia Scale. A thematic analysis of semi-structured interviews following the virtual cycling experience was also performed. No differences were observed between conditions for all outcomes except for environmental stimulation, where there was a lower response in the intervention than the control condition ( p = 0.032). This was primarily driven by lower scores for the virtual cycling experience than control in physical accessibility ( p = 0.012). Participants reported the virtual cycling experience to be immersive and challenging and reminisced about cycling earlier in life. The activity manager observed that the virtual cycling experience was an overall positive experience and emphasised benefits of safety screening and preparation prior to the activities. The findings of this study support the use of the virtual cycling experience as an immersive and engaging alternative to usual activities, which might encourage higher levels of physical activity in residential aged care facilities.

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

The Effect of a Virtual Reality-Based Intervention Program on Cognition in Older Adults with Mild Cognitive Impairment: A Randomized Control Trial

This study aimed to investigate the association between a virtual reality (VR) intervention program and cognitive, brain and physical functions in high-risk older adults. In a randomized controlled trial, we enrolled 68 individuals with mild cognitive impairment (MCI). The MCI diagnosis was based on medical evaluations through a clinical interview conducted by a dementia specialist. Cognitive assessments were performed by neuropsychologists according to standardized methods, including the Mini-Mental State Examination (MMSE) and frontal cognitive function: trail making test (TMT) A & B, and symbol digit substitute test (SDST). Resting state electroencephalogram (EEG) was measured in eyes open and eyes closed conditions for 5 minutes each, with a 19-channel wireless EEG device. The VR intervention program (3 times/week, 100 min each session) comprised four types of VR game-based content to improve the attention, memory and processing speed. Analysis of the subjects for group-time interactions revealed that the intervention group exhibited a significantly improved executive function and brain function at the resting state. Additionally, gait speed and mobility were also significantly improved between and after the follow-up. The VR-based training program improved cognitive and physical function in patients with MCI relative to controls. Encouraging patients to perform VR and game-based training may be beneficial to prevent cognitive decline.

Usability Issues of Clinical and Research Applications of Virtual Reality in Older People: A Systematic Review

Aging is a condition that may be characterized by a decline in physical, sensory, and mental capacities, while increased morbidity and multimorbidity may be associated with disability. A wide range of clinical conditions (e.g., frailty, mild cognitive impairment, metabolic syndrome) and age-related diseases (e.g., Alzheimer's and Parkinson's disease, cancer, sarcopenia, cardiovascular and respiratory diseases) affect older people. Virtual reality (VR) is a novel and promising tool for assessment and rehabilitation in older people. Usability is a crucial factor that must be considered when designing virtual systems for medicine. We conducted a systematic review with Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines concerning the usability of VR clinical systems in aging and provided suggestions to structure usability piloting. Findings show that different populations of older people have been recruited to mainly assess usability of non-immersive VR, with particular attention paid to motor/physical rehabilitation. Mixed approach (qualitative and quantitative tools together) is the preferred methodology; technology acceptance models are the most applied theoretical frameworks, however senior adapted models are the best within this context. Despite minor interaction issues and bugs, virtual systems are rated as usable and feasible. We encourage usability and user experience pilot studies to ameliorate interaction and improve acceptance and use of VR clinical applications in older people with the aid of suggestions (VR-USOP) provided by our analysis.

Virtual Reality Single-Port Sleeve Gastrectomy Training Decreases Physical and Mental Workload in Novice Surgeons: An Exploratory Study

BACKGROUND

Novice surgeons experience high levels of physical and mental workload during the early stages of their curriculum and clinical practice. Laparoscopic sleeve gastrectomy is the first bariatric procedure worldwide. Feasibility and safety of single-port sleeve gastrectomy (SPSG) has been demonstrated. An immersive virtual reality (VR) simulation was developed to provide a repetitive exercise to learn this novel technique. The primary objective of this study was to evaluate the impact of the VR training tool on mental and physical workload in novice surgeons. The secondary objective included an evaluation of the VR simulator.

METHODS

A monocentric-controlled trial was conducted. Ten participants were divided into two groups, the VR group and the control group (without VR training). Surgery residents participated in a first real case of SPSG and a second case 1 month later. The VR group underwent a VR training between the two surgeries. Mental and physical loads were assessed with self-assessment questionnaires: NASA-TLX, Borg scale, and manikin discomfort test. The VR simulator was evaluated through presence, cybersickness, and usability questionnaires.

RESULTS

This study showed a decrease of the mental demand and effort dimensions of NASA-TLX between the first and the second surgery in the VR group (P < .05). During the second surgery, a marginally significant difference was shown concerning the mental demand between the two groups. Postural discomfort of the VR group decreased with practice (P < .01), mainly between the first and the second surgery (P < .05). Furthermore, participants characterized the VR simulator as realistic, usable, and very useful to learned surgery.

CONCLUSION

This exploratory study showed an improvement in mental and physical workload when novice surgeons trained with VR (repetitive practice, gesture improvement, reduction of stress, etc.). Virtual reality appears to be a promising perspective for surgical training.

Causal Inference in Generalizable Environments: Systematic Representative Design

Causal inference and generalizability both matter. Historically, systematic designs emphasize causal inference, while representative designs focus on generalizability. Here, we suggest a transformative synthesis - Systematic Representative Design (SRD) - concurrently enhancing both causal inference and "built-in" generalizability by leveraging today's intelligent agent, virtual environments, and other technologies. In SRD, a "default control group" (DCG) can be created in a virtual environment by representatively sampling from real-world situations. Experimental groups can be built with systematic manipulations onto the DCG base. Applying systematic design features (e.g., random assignment to DCG versus experimental groups) in SRD affords valid causal inferences. After explicating the proposed SRD synthesis, we delineate how the approach concurrently advances generalizability and robustness, cause-effect inference and precision science, a computationally-enabled cumulative psychological science supporting both "bigger theory" and concrete implementations grappling with tough questions (e.g., what is context?) and affording rapidly-scalable interventions for real-world problems.

Assessing Saccadic Eye Movements With Head-Mounted Display Virtual Reality Technology

As our society is ageing globally, neurodegenerative disorders are becoming a relevant issue. Assessment of saccadic eye movement could provide objective values to help to understand the symptoms of disorders. HTC Corporation launched a new virtual reality (VR) headset, VIVE Pro Eye, implementing an infrared-based eye tracking technique together with VR technology. The purpose of this study is to evaluate whether the device can be used as an assessment tool of saccadic eye movement and to investigate the technical features of eye tracking. We developed a measurement system of saccadic eye movement with a simple VR environment on Unity VR design platform, following an internationally proposed standard saccade measurement protocol. We then measured the saccadic eye movement of seven healthy young adults to analyze the oculo-metrics of latency, peak velocity, and error rate of pro- and anti-saccade tasks: 120 trials in each task. We calculated these parameters based on the saccade detection algorithm that we have developed following previous studies. Consequently, our results revealed latency of 220.40 ± 43.16 ms, peak velocity of 357.90 ± 111.99°/s, and error rate of 0.24 ± 0.41% for the pro-saccade task, and latency of 343.35 ± 76.42 ms, peak velocity of 318.79 ± 116.69°/s, and error rate of 0.66 ± 0.76% for the anti-saccade task. In addition, we observed pupil diameter of 4.30 ± 1.15 mm (left eye) and 4.29 ± 1.08 mm (right eye) for the pro-saccade task, and of 4.21 ± 1.04 mm (left eye) and 4.22 ± 0.97 mm (right eye) for the anti-saccade task. Comparing between the descriptive statistics of previous studies and our results suggests that VIVE Pro Eye can function as an assessment tool of saccadic eye movement since our results are in the range of or close to the results of previous studies. Nonetheless, we found technical limitations especially about time-related measurement parameters. Further improvements in software and hardware of the device and measurement protocol, and more measurements with diverse age-groups and people with different health conditions are warranted to enhance the whole assessment system of saccadic eye movement.

Use of Immersive Virtual Reality in the Assessment and Treatment of Alzheimer's Disease: A Systematic Review

BACKGROUND

Immersive virtual reality (iVR) allows seamless interaction with simulated environments and is becoming an established tool in clinical research. It is unclear whether iVR is acceptable to people with Alzheimer's disease (AD) dementia or useful in their care. We explore whether iVR is a viable research tool that may aid the detection and treatment of AD.

OBJECTIVES

This review examines the use of iVR in people with AD or mild cognitive impairment (MCI).

METHODS

Medline, PsycINFO, Embase, CINAHL, and Web of Science databases were searched from inception. PRISMA guidelines were used with studies selected by at least two researchers.

RESULTS

Nine studies were eligible for inclusion. None reported any issues with iVR tolerability in participants with MCI and AD on assessment or treatment tasks. One study demonstrated capability for detecting prodromal AD and correlated with neuroanatomical substrates. Two studies showed iVR to have high accuracy in differentiating participants with AD from controls but were not hypothesis driven or with adequate controls measures. In a small validation study and two longitudinal case studies, iVR cognitive training was positively rated but did not demonstrate reliable benefit.

CONCLUSION

iVR is emerging as a viable method of assessing older adults and people with AD. Strongest benefits were seen when closely integrated with theoretical models of neurodegeneration and existing screening methods. Further randomized controlled trials integrated with clinical populations are required. This will consolidate the power of iVR for assessment of MCI and clarify treatment efficacy beyond current applications in physical rehabilitation.

A systematic review of the use of virtual reality and its effects on cognition in individuals with neurocognitive disorders

Introduction

Virtual reality (VR) interventions are increasingly used in individuals with brain injuries. The objective of this study was to determine the effects of VR on overall cognitive functioning in individuals with neurocognitive disorders (NCDs).

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of the published literature on immersive and nonimmersive VR technologies targeting cognition in minor and major NCDs was conducted: (PROSPERO registration number: CRD42019121953).

Results

A total of 22 studies were included in the review, for an aggregated sample of 564 individuals with NCDs. Most of the studies were conducted on patients who had stroke (27.3%), followed by mild cognitive impairment (22.7%) and Alzheimer's disease (13.6%). VR interventions used for cognitive rehabilitation suggested to improve cognition (e.g. memory, dual tasking, and visual attention), and secondarily to psychological functioning (e.g. reduction of anxiety, higher levels of well-being, and increased use of coping strategies).

Conclusion

VR interventions are useful to improve cognition and psychological symptoms in NCDs.

Non-Immersive Virtual Reality for Rehabilitation of the Older People: A Systematic Review into Efficacy and Effectiveness

: Objective: the objective of this review is to analyze the advances in the field of rehabilitation through virtual reality, while taking into account non-immersive systems, as evidence have them shown to be highly accepted by older people, due to the lowest "cibersikness" symptomatology.

DATA SOURCES

a systematic review of the literature was conducted in June 2019. The data were collected from Cochrane, Embase, Scopus, and PubMed databases, analyzing manuscripts and articles of the last 10 years.

STUDY SELECTION

we only included randomized controlled trials written in English aimed to study the use of the virtual reality in rehabilitation. We selected 10 studies, which were characterized by clinical heterogeneity.

DATA EXTRACTION

quality evaluation was performed based on the Physioterapy Evidence Database (PEDro) scale, suggested for evidence based review of stroke rehabilitation. Of 10 studies considered, eight were randomized controlled trials and the PEDro score ranged from four to a maximum of nine.

DATA SYNTHESIS

VR (Virtual Reality) creates artificial environments with the possibility of a patient interaction. This kind of experience leads to the development of cognitive and motor abilities, which usually positively affect the emotional state of the patient, increasing collaboration and compliance. Some recent studies have suggested that rehabilitation treatment interventions might be useful and effective in treating motor and cognitive symptoms in different neurological disorders, including traumatic brain injury, multiple sclerosis, and progressive supranuclear palsy.

CONCLUSIONS

as it is shown by the numerous studies in the field, the application of VR has a positive impact on the rehabilitation of the most predominant geriatric syndromes. The level of realism of the virtual stimuli seems to have a crucial role in the training of cognitive abilities. Future research needs to improve study design by including larger samples, longitudinal designs, long term follow-ups, and different outcome measures, including functional and quality of life indexes, to better evaluate the clinical impact of this promising technology in healthy old subjects and in neurological patients.

The effectiveness of virtual reality for people with mild cognitive impairment or dementia: a meta-analysis

BACKGROUND

Virtual Reality (VR) is increasingly used in health-related fields and interventions using VR have the potential to be powerful tools in patient management. The aim of this study was to synthesize the effects of VR interventions for people with mild cognitive impairment (MCI) or dementia.

METHODS

Electronic databases were searched to identify studies that used an experimental design to investigate VR intervention outcomes for patients with MCI or dementia. Studies were excluded if the intervention did not focus on VR, if relevant quantitative outcomes were not reported, or if the intended study purpose was assessment or diagnosis. Data were extracted and analyzed from studies that met criteria. To synthesize the intervention effect sizes (ES), we used random effects models to accommodate heterogeneity in the main effect and sub-group analyses. To identify the potential reason for heterogeneity and compare ES according to the moderator variables, subgroup analyses were conducted based on study characteristics and intervention outcomes.

RESULTS

Data from eleven studies that met eligibility criteria were analyzed. VR intervention delivered to participants with MCI or dementia produced small to medium effects (ES = 0.29, CI = 0.16, 0.42). The ES for studies using semi-immersive technology (ES = 0.37, CI = 0.25, 0.49) was greater than the studies using full-immersive VR (ES = 0.03, CI = -0.14, 0.21). The results showed small-to-medium effects for VR interventions affecting key outcome variables such as cognition (ES = 0.42, CI = 0.24, 0.60) and physical fitness (ES = 0.41, CI = 0.16, 0.65).

CONCLUSION

VR interventions, particularly of the semi-immersive type, are useful for people with MCI or dementia. These results should contribute to the establishment of practical guidelines for VR interventions for patients with cognitive decline.

Virtual Enactment Effect on Memory in Young and Aged Populations: a Systematic Review

BACKGROUND

Spatial cognition is a critical aspect of episodic memory, as it provides the scaffold for events and enables successful retrieval. Virtual enactment (sensorimotor and cognitive interaction) by means of input devices within virtual environments provides an excellent opportunity to enhance encoding and to support memory retrieval with useful traces in the brain compared to passive observation.

METHODS

We conducted a systematic review with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines concerning the virtual enactment effect on spatial and episodic memory in young and aged populations. We aim at giving guidelines for virtual enactment studies, especially in the context of aging, where spatial and episodic memory decline.

RESULTS

Our findings reveal a positive effect on spatial and episodic memory in the young population and promising outcomes in aging. Several cognitive factors (e.g., executive function, decision-making, and visual components) mediate memory performances. Findings should be taken into account for future interventions in aging.

CONCLUSIONS

The present review sheds light on the key role of the sensorimotor and cognitive systems for memory rehabilitation by means of a more ecological tool such as virtual reality and stresses the importance of the body for cognition, endorsing the view of an embodied mind.

Acceptance of immersive head-mounted virtual reality in older adults

Immersive virtual reality has become increasingly popular to improve the assessment and treatment of health problems. This rising popularity is likely to be facilitated by the availability of affordable headsets that deliver high quality immersive experiences. As many health problems are more prevalent in older adults, who are less technology experienced, it is important to know whether they are willing to use immersive virtual reality. In this study, we assessed the initial attitude towards head-mounted immersive virtual reality in 76 older adults who had never used virtual reality before. Furthermore, we assessed changes in attitude as well as self-reported cybersickness after a first exposure to immersive virtual reality relative to exposure to time-lapse videos. Attitudes towards immersive virtual reality changed from neutral to positive after a first exposure to immersive virtual reality, but not after exposure to time-lapse videos. Moreover, self-reported cybersickness was minimal and had no association with exposure to immersive virtual reality. These results imply that the contribution of VR applications to health in older adults will neither be hindered by negative attitudes nor by cybersickness.

An Impairment of Prospective Memory in Mild Alzheimer's Disease: A Ride in a Virtual Town

Objective: Research suggests that prospective memory (PM) is impaired from the very early stages of Alzheimer's disease (AD). We sought to further characterize this impairment in patients with mild AD, using a virtual reality (VR) task to provide ecological assessment of PM. Methods: Fifteen cognitively normal older individuals (76.47 years old ± 4.14, MMSE: 28.80 ± 1.21), and 17 patients with mild AD (79.29 years old ± 4.45, MMSE: 22.82 ± 2.83) were asked to recall the prospective and retrospective components of seven intentions in a virtual town task. Six intentions were event-based, where the prospective cue was either highly (three intentions) or weakly (three intentions) associated with the retrospective component. The remaining intention was time-based. All participants completed a neuropsychological assessment of episodic memory, semantic memory and executive functioning. Non-parametric tests were used to compare the two groups on the different intentions types and components. Correlations between cognition and PM scores were then realized to further understand the cognitive correlates of the PM impairment in patients with AD. Results: Overall, patients with Alzheimer disease recalled fewer intentions than controls, with the retrospective component and time-based intentions being the most challenging for them. The strength of the association between the prospective and retrospective components, however, had no effect on their performance. Event-based PM impairment, as well as deficit in the recall of prospective component correlated with memory and executive functions performance. Conclusion: PM is impaired in AD. Both automatic and controlled processes of PM retrieval are disturbed. This study also confirms the reliability of VR for assessing complex cognitive functions such as PM.