Developing a virtual reality for people with dementia in nursing homes based on their psychological needs: a feasibility study

The number of people with dementia is rapidly increasing due to the aging of the global population. According to Alzheimer’s Disease International, in 2018, there were 50 million individuals with dementia globally, which represents a 6% increase from 2015 [1]. In South Korea, the prevalence of dementia in persons 65 years and older, as of 2018, was 10.1%, and the number has continued to increase [2].

Patients with dementia experience cognitive dysfunction and various behavioral and psychological symptoms, such as nervousness, depression, psychosis, yelling, and violence [3, 4]. Due to their loss of social and communication skills and limitations in their ability to undertake physical activity, patients with dementia experience issues in their relationships with others. This can exacerbate negative emotions and behavioral and psychological issues in older patients with dementia [5, 6]. The behavioral and psychological symptoms of dementia (BPSD) are one of the most significant reasons why those with dementia receive early admission into nursing facilities [7]. The early institutionalization into a nursing home leads to higher social costs and a lower quality of life for patients with dementia and their families [8].

Interventions that decrease BPSD include non-pharmacological interventions that focus primarily on reducing and removing the psychosocial or environmental risk factors associated with behavioral and psychological symptoms [9] and therapeutic approaches, such as recall therapy, horticultural therapy, music therapy, art therapy, animal-assisted therapy, and physical exercise [10‐12]. However, it is difficult to apply existing non-pharmacological interventions to patients with dementia and decreased cognitive function. The application of these interventions is restricted due to a lack of trained professionals [13]. To overcome these restrictions, multisensory virtual reality (VR) platforms may be used to improve cognitive function and rehabilitation in patients with dementia, as VR platforms are advanced, adaptable, and easy-to-use [14‐18]. VR refers to technologies that allow people to experience realistic situations or environments that are difficult to experience in reality [19, 20]. In particular, immersive VR can be used to focus on certain sensory stimuli and has been reported to facilitate positive emotions and improvements in their emotional state, interpersonal interactions, and communication [21‐23].

The motivation to use VR may differ between individuals based on individual interests and preferences, aside from maladjustment to VR [13]. The psychological needs of people with dementia include comfort, identity, attachment, occupation, and inclusion [24]. While studies on patient-centered dementia care have considered these needs [25‐28], very few studies have developed activities or interventions for dementia patients that consider their psychological needs.

This study involved three phases. The objective of the first phase was to confirm the activities that alleviate BPSD and classify these activities based on the patients’ psychological needs. The objective of the second phase was to develop VR platform environments based on the patients’ psychological needs and test whether it alleviates BPSD. The objective of the final phase was to evaluate the participants’ VR immersion, preferences and interactions with VR, and tolerance for VR.

The purpose of this study was (1) to develop a VR intervention program based on the psychological needs of patients residing in South Korean nursing facilities, (2) to test whether this VR intervention alleviates BPSD, and (3) to confirm the utilization of VR in patients with dementia. This program aims to improve the patients’ quality of life and provide effective care models for health professionals.

The VR program was designed to meet the participants’ psychological needs by securing their emotional immersion and engagement in accordance with the preferences and emotions of South Koreans. Comfort needs were most frequently suggested as a way to alleviate the patients’ behavioral and psychological symptoms. Patients with dementia maintain their identity through love and comfort, which provides them with a greater sense of well-being [34, 35]. Patients with dementia obtain happiness and enjoyment by engaging in meaningful activities, such as various leisure activities, social participation, and work-related activities, which improve the individual’s sense of autonomy and identity [36, 37]. When their psychological needs were satisfied, their anxiety and behavioral psychological symptoms decreased [38, 39], and such reductions have been effective in reducing the need for neuroleptics [16]. Additionally, this VR environment provides a multimedia platform that can facilitate the storage and retrieval of memories and simulate multisensory experiences. This could be used to create a therapeutic environment for alleviating BPSD.

The VR content developed in this study was applied to patients with dementia, and the evaluations were subsequently obtained from the participants’ immersion, preference, interaction, and tolerance for VR. The participants’ feedback was consistent with previous results demonstrating that patients with dementia participated more keenly in activities that reflected their individual preferences [35] and activities that they could recall and reminisce about [40‐43]. A high degree of preference and immersion were confirmed among the participants, demonstrating the usability of the VR intervention program. This indicates that it is important for VR platforms to present a familiar environment, given the historical and cultural backgrounds of patients with dementia. Furthermore, intervention programs that reflect familiarity and various emotional stimuli can increase immersion and contribute to active interactions by helping the participants reminisce and recall the past [44].

Manera et al. [15, 45] reported that older individuals with mild cognitive disorders or Alzheimer’s disease had higher levels of satisfaction and reported less anxiety, discomfort, and fatigue with image-based VR exercises compared to paper and pencil exercises. The results of these studies indicate that well-developed VR content can be effectively applied to patients with dementia and mild cognitive impairment and can result in positive outcomes [46].

Despite these promising results, the usability problems of the VR system developed in this study need to be solved. In terms of the experience length, this varied from 5 to 15 min. This was because the participants chose different themes, and their interaction pace varied. The theme “street of memories” was selected the most, which included an elementary school, an alleyway, and a homely house. The theater and coffee house were selected the least. Considering that the participants’ mean age was 85.80 years, watching movies in the theater and drinking coffee in a café might not be preferred activities for these participants. Therefore, historical and cultural characteristics should be considered to develop immersive VR programs [47].

In this feasibility study, there were issues related to the assistance required to use the VR: the weight of the HMD (Samsung HMD Odyssey Windows Mixed Reality Headset and Wireless controllers 630 g), controlling the visual acuity, and capturing the participants’ hand movements via leap motion. The participants displayed difficulties operating the VR with hand movements mostly likely because of the decreased hand movement and cognitive functions of the older patients [48]. The patients complained of limited vision while wearing the HMD as they are cut off from the outside world; they also complained about the heavy weight of the displays [20]. The weight of the HMD is 590 g, which is relatively lighter than other HMDs; even lighter HMDs for older patients will be released in the future (e.g., HP Reverb G2). The VR environment requires active movement and the use of visual and auditory senses. This may be limited in older people with dementia since they typically experience reduced visual and auditory capacity, resulting in decreased accuracy and attention [5]. The results of this study indicate that the participants experienced some difficulties due to their diminished sensory capacity. This should inform the design, implementation, and evaluation of similar technologies or interventions. For instance, physical functions, such as visual acuity and hand power, and the weight of the HMD should be considered for the use of VR technology with dementia patients.

In the current study, VR sickness varied with two participants complaining about dizziness or nausea during the VR immersion. The VR intervention program test was implemented while the participants were seated, which decreased the effort required to maintain their posture. Clearer images and accurate motion tracking can reduce VR sickness [49, 50], and content requiring less movement [51] is less likely to lead to VR sickness. Although these symptoms are temporary [52], researchers and developers need to pay attention to this issue.

This feasibility study aimed to uncover the strengths and weaknesses of VR interventions. The findings demonstrate that it is feasible to use VR with patients with dementia but did not demonstrate the efficacy of VR to reduce BPSD. Further research should be conducted based on rigorous experimental design to build more evidence for VR intervention programs. High-quality methodological and experimental studies are required to demonstrate the effectiveness of randomized controlled trials and should be designed to include a control group of dementia patients as a long-term intervention program in a nursing home.

Typically, VR platforms have been underutilized in healthcare services for groups such as patients with chronic diseases or people with disabilities [53]. This is the first study to develop VR interventions for dementia patients by considering their psychological needs. Overall, this study has demonstrated that VR could increase immersion, preference, interaction, and tolerance, but such effects vary with the nature of the task. Moreover, unlike previous studies, this study demonstrated that a low demand VR environment that facilitates the storage and retrieval of preferred memories could permit the implementation of strategies to facilitate patients’ interactions. While VR-based programs have issues, such as high costs, difficulty in operating the system, space constraints, and low portability [54, 55], the VR program employed in this study increased the convenience and safety of use by using simple interactive motions, such as pointing one’s hand in the desired direction and avoiding the need for large and complex hardware.