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Introduction: Several recent studies have pointed out that early impairment of executive functions (EFs) in Parkinson’s Disease (PD) may be a crucial marker to detect patients at risk for developing dementia. The main objective of this study was to compare the performances of PD patients with mild cognitive impairment (PD-MCI) with PD patients with normal cognition (PD-NC) and a control group (CG) using a traditional assessment of EFs and the Virtual Multiple Errands Test (VMET), a virtual reality (VR)-based tool. In order to understand which subcomponents of EFs are early impaired, this experimental study aimed to investigate specifically which instrument best discriminates among these three groups. Materials and methods: The study included three groups of 15 individuals each (for a total of 45 participants): 15 PD-NC; 15 PD-MCI, and 15 cognitively healthy individuals (CG). To assess the global neuropsychological functioning and the EFs, several tests (including the Mini Mental State Examination (MMSE), Clock Drawing Test, and Tower of London test) were administered to the participants. The VMET was used for a more ecologically valid neuropsychological evaluation of EFs. Results: Findings revealed significant differences in the VMET scores between the PD-NC patients vs. the controls. In particular, patients made more errors in the tasks of the VMET, and showed a poorer ability to use effective strategies to complete the tasks. This VMET result seems to be more sensitive in the early detection of executive deficits because these two groups did not differ in the traditional assessment of EFs (neuropsychological battery). Conclusion: This study offers initial evidence that a more ecologically valid evaluation of EFs is more likely to lead to detection of subtle executive deficits.
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published: 05 December 2014
doi: 10.3389/fnbeh.2014.00405
Virtual multiple errands test (VMET): a virtual reality-based
tool to detect early executive functions deficit in
Parkinsons disease
Pietro Cipresso1*, Giovanni Albani2,Silvia Serino1,Elisa Pedroli1,Federica Pallavicini1,
Alessandro Mauro2and Giuseppe Riva1,3
1Applied Technology for Neuro-Psychology Lab, IRCCS Istituto Auxologico Italiano, Milano, Italy
2Division of Neurology and Neurorehabilitation, IRCCS Istituto Auxologico Italiano, Oggebbio, Italy
3Department of Psychology, Università Cattolica del Sacro Cuore, Milano, Italy
Edited by:
Nuno Sousa, University of Minho,
Reviewed by:
Lynne Ann Barker, Sheffield Hallam
University, UK
Nicholas Morton, Rotherham,
Doncaster and South Humber
Mental Health NHS Foundation
Trust, UK
Pietro Cipresso, Applied Technology
for Neuro-Psychology Lab, IRCCS
Istituto Auxologico Italiano, Via
Ariosto, 13, Milano, 20145, Italy
Introduction: Several recent studies have pointed out that early impairment of executive
functions (EFs) in Parkinson’s Disease (PD) may be a crucial marker to detect patients
at risk for developing dementia. The main objective of this study was to compare the
performances of PD patients with mild cognitive impairment (PD-MCI) with PD patients
with normal cognition (PD-NC) and a control group (CG) using a traditional assessment of
EFs and the Virtual Multiple Errands Test (VMET), a virtual reality (VR)-based tool. In order
to understand which subcomponents of EFs are early impaired, this experimental study
aimed to investigate specifically which instrument best discriminates among these three
Materials and methods: The study included three groups of 15 individuals each (for a total
of 45 participants): 15 PD-NC; 15 PD-MCI, and 15 cognitively healthy individuals (CG). To
assess the global neuropsychological functioning and the EFs, several tests (including the
Mini Mental State Examination (MMSE), Clock Drawing Test, and Tower of London test)
were administered to the participants. The VMET was used for a more ecologically valid
neuropsychological evaluation of EFs.
Results: Findings revealed significant differences in the VMET scores between the PD-NC
patients vs. the controls. In particular, patients made more errors in the tasks of the VMET,
and showed a poorer ability to use effective strategies to complete the tasks. This VMET
result seems to be more sensitive in the early detection of executive deficits because
these two groups did not differ in the traditional assessment of EFs (neuropsychological
Conclusion: This study offers initial evidence that a more ecologically valid evaluation of
EFs is more likely to lead to detection of subtle executive deficits.
Keywords: virtual reality, executive function, VMET, psychometric assessment, Parkinson’s disease, mild cognitive
The umbrella term “executive function” (EF) refers to a broad set
of high-level cognitive abilities used to regulate actions (Burgess
and Simons, 2005; Chan et al., 2008; Otero and Barker, 2013).
These cognitive abilities range from the capacity to problem
solve, plan, sustain attention, utilize internal/external feedback,
multitasking and cognitive flexibility and ability to deal with
novelty (Damasio, 1995; Stuss et al., 1995; Grafman and Litvan,
1999; Burgess et al., 2000; Miller and Cohen, 2001; Strauss
et al., 2006; Stuss, 2007; Chan et al., 2008; Goldberg, 2009).
Impairment of EF is extremely common in neurological patients,
specifically in those presenting with frontal pathology (Bechara
et al., 1994; Stuss et al., 1995; Burgess and Shallice, 1996a,b;
Dreher et al., 2008; Barker et al., 2010; Morton and Barker, 2010;
Cole et al., 2013). Although EFs are thought to be mediated
by frontal brain regions, frontal areas have multiple connec-
tions with cortical and subcortical regions, as well as to the
amygdala, cerebellum, and basal ganglia (for a review, see Tekin
and Cummings, 2002). Specifically, functional magnetic reso-
nance imaging (fMRI) studies have shown that BOLD signals
increase in the basal ganglia during the performance of EF tasks
which require cognitive flexibility, shifting of mental sets, and
updating of working representations (Cools et al., 2004; Leber
et al., 2008; Hikosaka and Isoda, 2010). Further evidence that
the basal ganglia is part of the circuitry crucial for executive
functioning comes from studies with patients with basal ganglia
Frontiers in Behavioral Neuroscience December 2014 | Volume 8 | Article 405 |1
Cipresso et al. VMET: a virtual reality tool
lesions, specifically patients who suffer from Parkinson’s Disease
(PD; Cools et al., 1984, 2001; McKinlay et al., 2010). Indeed,
in addition to the typical motor signs, a number of different
cognitive deficits have received relevant clinical attention in PD
(Levy et al., 2002; Vingerhoets et al., 2003; Foltynie et al., 2004;
Muslimovi´c et al., 2005; Williams-Gray et al., 2009). The char-
acteristics of cognitive impairment in PD may be extremely
variable in regard to the timing of the onset and the rate of
progression (Aarsland et al., 2005, 2007; Buter et al., 2008;
Hely et al., 2008), and in terms of what cognitive functions are
impaired (Verleden et al., 2007; Kehagia et al., 2010). Even if
the neuropsychological profile of patients who suffer from PD
is heterogeneous, including memory deficits (Whittington et al.,
2006; Ramanan and Kumar, 2013) and visuo-spatial impair-
ments (Montse et al., 2001; Kemps et al., 2005), it is marked
specifically by executive deficits (Cools et al., 2001; McKinlay
et al., 2010). Moreover, the impairment of EFs appears to be
the core feature of a neuropsychological profile in PD-related
dementia (Girotti et al., 1988; Jacobs et al., 1995; Padovani et al.,
2006; Pagonabarraga and Kulisevsky, 2012; Kudlicka et al., 2013).
Similar executive deficits also can be found in nondemented
PD patients (for reviews, see Kudlicka et al., 2011; Ceravolo
et al., 2012), but they are more severe in patients who suffer
from dementia. Following this direction, several recent studies
have pointed out the predictive value of early EF deficits in
the transitional stage of mild cognitive impairment (MCI) of
the disease (Levy et al., 2002; Woods and Tröster, 2003). The
concept of MCI, originally introduced to identify the earliest
cognitive changes due to Alzheimer’s Disease (AD; Petersen
et al., 2001; Petersen, 2004), has also been applied to PD to
improve the detection of patients at risk for developing dementia
(Aarsland et al., 2011). Litvan et al. (2012) proposed the diag-
nostic guidelines to facilitate the diagnosis of “mild cognitive
impairment in Parkinson’s Disease” (PD-MCI). These criteria
are generally based on the established principles of MCI given
by Petersen, namely, subjective cognitive decline and objective
evidence of impairment assessed by neuropsychological eval-
uation that does not interfere with functional independence
(Petersen, 2004). Similar to AD, the risk of developing demen-
tia increases appreciably with the presence of PD-MCI (Janvin
et al., 2006). As underlined by Biundo et al. (2013), a great
challenge today is to characterize the neuropsychological profile
of PD-MCI and to evaluate the screening power of traditional
neuropsychological tests. In their work, 104 PD patients were
given an extensive neuropsychological evaluation. Results showed
that specific neuropsychological tests measuring attentional/set-
shifting, verbal memory, and visual-spatial functions are the best
predictors of PD-MCI. In this perspective, EF dysfunction is
a possible marker of potentially more severe cognitive impair-
ment and may indicate a likely decline into dementia. Similarly,
Goldberg proposed that EF deficits are also key markers for
later dementia in AD (Goldberg, 2009). Petrova et al. compared
the performances of 23 patients suffering from amnestic PD-
MCI utilizing 25 cognitively healthy controls to investigate which
subcomponent of EFs are impaired in PD-MCI patients (Petrova
et al., 2010). The diagnosis of MCI was made according to
modified criteria proposed by Petersen et al. (2001). They found
that amnestic PD-MCI patients showed impairment in several
aspects of attention/EFs, including the ability to inhibit irrelevant
responses and in cognitive flexibility, as measured by the Stroop
test (Stroop, 1935) and Modified Wisconsin Card Sorting Test
(Nelson, 1976), in formulating and following a complex plan,
as revealed by Trail Making Test (Greenlief et al., 1985), and in
sustaining a cognitive load during a language test, as highlighted
by the phonemic and semantic verbal fluency test (Lezak, 1995).
These findings underline the need for a complex evaluation
of EFs in MCI-PD patients, especially in the possible relation-
ship between these early executive impairments and behavioral
Previous studies indicate a need for rigorous ecologically valid
assessments that reliably capture subtle impairments that may
be markers for later dementia. In fact, there are some critical
issues in the traditional neuropsychological evaluation of EFs
(Chan et al., 2008). A more ecological and prompt assessment
of EFs is essential to evaluate the specific cognitive profile of
different individuals (Goldstein, 1996; Chaytor and Schmitter-
Edgecombe, 2003; Burgess et al., 2006). Indeed, the traditional
evaluation does not reflect the complexity of EFs in everyday
situations. A more detailed assessment may evaluate if indi-
viduals are able to formulate, store, and check all the goals
and subgoals in order to effectively respond to environmen-
tal and/or internal demands. In this direction, there are some
instruments developed to measure executive deficits in situa-
tions similar to daily ones, such as the Behavioral Assessment
of Dysexecutive Syndrome (BADS; Wilson et al., 1996) and the
Multiple Errands Test (MET; Shallice and Burgess, 1991). The
BADS (Wilson et al., 1996) consists of six subtests and a Dysex-
ecutive Questionnaire (DEX). The DEX is designed to assess
everyday cognitive, emotional, and behavioral changes, and it
is completed by the patient (self-rating: DEX-S) and a person
who knows the patient (independent rater: DEX-I). Although
the BADS has good validity (Wilson et al., 1998), and the
DEX was recently found to be, with some limitations, a useful
instrument for capturing changes in to day to day functioning
(Barker et al., 2011), it does not measure performance during
real-life tasks. An interesting example of a functional instrument
is the MET (Shallice and Burgess, 1991), in which participants
are invited to complete different tasks following specific rules
to adhere to within a specified time frame. Even the simplified
versions of the MET, however, adapted especially to be per-
formed in a hospital setting or a nearby shopping mall (Alder-
man et al., 2003), can be particularly demanding for a patient
because these versions require good motor skills; for a clinician
these versions are time consuming and demand high economic
To address the issue of ecological validity and clinical util-
ity, virtual reality (VR) appears to be an appropriate instru-
ment for the evaluation of EFs because it provides the chance
to deliver different tasks within ecologically valid, controlled,
and secure environments (for a review, see Bohil et al., 2011).
Based on this, the virtual version of the Multiple Errands
Test (VMET) has been recently developed and tested in dif-
ferent clinical populations (Albani et al., 2011; Raspelli et al.,
2012; Cipresso et al., 2013a). The VMET is a VR-based
Frontiers in Behavioral Neuroscience December 2014 | Volume 8 | Article 405 |2
Cipresso et al. VMET: a virtual reality tool
tool aimed at evaluating different aspects of EFs by enabling
active exploration of a virtual supermarket, where partici-
pants are requested to buy various products presented on
shelves and to abide by different rules. Thanks to the poten-
tial of the VR, with the VMET the real functional status of
patients can be easily evaluated, as manifested in executive
dysfunctions, which had not been fully acknowledged in lab-
oratory tests. Specifically, the VMET measures a patient’s abil-
ity to formulate, store, and check all the goals and subgoals
to effectively respond to environmental demands in ecologi-
cal situations and to complete the specified task. The VMET
has demonstrated good inter-rate reliability, showing an intr-
aclass correlation coefficient (ICC) of 0.88 (Cipresso et al.,
2013b) and good usability (Pedroli et al., 2013). This test
has demonstrated that it can be used with patients who are
not familiar with computerized tests. On the basis of these
methodolical strengths, we argue that the VMET may signif-
icantly improve the traditional assessment of EFs in PD-MCI
The main objective of this study is to compare the perfor-
mances of PD-MCI with PD with normal cognition and cogni-
tively healthy controls using traditional assessments of EFs and
the VMET. In order to understand which subcomponents of EFs
are early impaired, this experimental study aimed to specifically
investigate the instruments that best discriminate among these
three groups.
A total of 45 participants allocated to three groups were included
in the study: 15 PD patients with normal cognition (PD-NC),
15 PD patients suffering from MCI, and 15 cognitively healthy
individuals (CG, control group). The PD-NC group was com-
posed of six women (40%) and nine men (60%), while the
PD-MCI and the CG included seven women (46.7%) and eight
men (53.3%) and nine women (60%) and six men (40%),
respectively. CG and PD patients were recruited from the San
Giuseppe Hospital’s Istituto Auxologico Italiano in Verbania,
Italy. Individuals did not receive money for their participa-
tion in the study. Detailed demographic and clinical charac-
teristics of the three groups are reported in Table 1. Individu-
als gave their written consent for the procedures, which were
approved by the Ethical Committee of the Istituto Auxologico
Table 1 | Demographic characteristics of the three groups of the
study: PD patients with normal cognition (PD-NC), PD patients
suffering from mild cognitive impairment (PD-MCI), and healthy
individuals (CG, control group).
Variables Group
PD–NC (n= 15) PD–MCI (n= 15) CG (n=15)
Age 69 (8.1) 68.1 (9.4) 61.7 (5.2)
Years of Education 7.93 (3.7) 7.2 (3.3) 12.2 (3.1)
PD patients were classified into the two cognitive groups (PD-NC
and PD-MCI), following the guidelines of the Task Force for the
diagnosis of PD-MCI (Litvan et al., 2012). The proposed PD-MCI
criteria utilized a two-level schema depending on the compre-
hensiveness of the neuropsychological testing. The Level I and II
categories represent PD-MCI, but they differ in regard to the type
of neuropsychological assessment and, consequently, the level of
diagnostic certainty. Specifically, for the diagnosis of PD-MCI
by Level II criteria, the Task Force recommends comprehensive
neuropsychological testing that highlights either two impaired
tests in one cognitive domain or one impaired test in two different
cognitive domains. For the division of PD patients into PD-
ND and PD-MCI (Level II), a comprehensive neuropsychological
battery with at least two neuropsychological tests per cognitive
domain was employed. First, to evaluate the cognitive functioning
of the participants in the study, the Mini Mental State Examina-
tion (MMSE; Folstein et al., 1975) was administered. The MMSE
is a brief questionnaire widely used to obtain a picture of an
individual’s present cognitive performance in different cognitive
domains (short- and long-term memory, orientation, attention,
verbal fluency, and constructional apraxia). A score of <24 is
generally the accepted cutoff, indicating the presence of cognitive
impairment. The MMSE has been validated in the Italian sample
with 1019 elderly subjects (aged 65–89 years) (Magni et al.,
To evaluate the visuo-spatial function, the Behavioral Inat-
tention Test (BIT; Wilson et al., 1987) was used. The BIT is
traditionally used to screen for neglect behaviors, and it con-
sists of six conventional pencil and paper subtests and nine
behavioral subtests reflecting aspects of daily life. In the present
study, the Italian validation of the BIT’s conventional subtests was
administered (Wilson et al., 2010): line crossing, letter cancella-
tion, star cancellation, figure and shape copying, line bisection,
and representational drawing. The maximum total score is 146
To assess language comprehension abilities, the Token test was
administered within the brief neuropsychological examination
(Mondini et al., 2003). This is a simple test which requires 20
tokens that vary in shape, color, and size. The Italian validated test
has 32 commands, each of which requires the attention and/or the
manipulation of one or more of the tokens (e.g., “Put the small red
square under the white large circle.”).
The Italian validated Digit Span was used to evaluate short-
term memory abilities (Orsini et al., 1987). In this easy-to-
administer test, the researcher reads a series of digits aloud to
the participant, who is requested to repeat back the same series
of digits in the same sequence (i.e., 9–1–7 for 9–1–7). To assess
long-term memory abilities, the Short Story test (Novelli et al.,
1986a) was administered. The researcher read aloud the Short
Story, required participants to provide a first immediate recall,
then read aloud the story again, requesting another immediate
recall. After a delay of around 15 min, participants were asked
for a delayed retrieval. The final score is the average of the
number of correctly recalled morphological units over three recall
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Cipresso et al. VMET: a virtual reality tool
Table 2 | Mean scores of neuropsychological global assessment tasks
reported by the three groups of the study.
Variables Group
PD–NC (n= 15) PD–MCI (n= 15) CG (n=15)
MMSE 27 (1.8) 25.1 (3.2) 29.7 (1.0)
BIT 140 (9.6) 130 (13.3) 144 (1.3)
Token test 33.1 (2.1) 30.1 (2.1) 33.9 (1.0)
Digit span 5.5 (1.2) 5.1 (1.2) 6.2 (0.9)
Corsi block test—span 4.61 (0.8) 3.4 (1.3) 5.5 (0.9)
Short Story 14 (2.8) 10.3 (3.0) 14.8 (4.3)
In order to specifically evaluate the spatial memory abilities
of the study’s participants, the following standard neuropsy-
chological test was administered: the Corsi Block Test (Corsi,
Unpublished Thesis; Spinnler and Tognoni, 1987). This task is
used to measure short-term spatial memory (Corsi Span) and
long-term spatial memory (Corsi Supraspan). The participants
are invited to tap a sequence of wooden blocks in the same order
as the researcher, with increasing span length on each trial.
Neuropsychological data for the three groups are reported in
Table 2.
All scores obtained from these neuropsychological tests have
been corrected for age, education level, and gender, according to
Italian normative data.
In order to fully evaluate the executive functioning of the study
participants, a comprehensive standard neuropsychological bat-
tery focused on the different aspects of EF was administered.
The Clock Drawing Test (Freedman et al., 1994; Caffarra
et al., 2011) has been traditionally used to assess a wide range of
cognitive abilities including EFs, specifically understanding verbal
instructions and abstract thinking and planning abilities. It is
brief, easy to administer, and has excellent patient acceptability.
Participants were required to draw numbers in a circle on a paper
to resemble a clock and then draw the hands of the clock to read
“10 after 11”.
To evaluate multi-tasking and cognitive flexibility, two types of
verbal fluency tests were employed. Phonological verbal fluency
(Novelli et al., 1986b; Lezak, 1995) is a traditional neuropsycho-
logical measure of language production in which a number of
words are given with an initial letter (e.g., F). Semantic verbal
fluency (Novelli et al., 1986b; Lezak, 1995) is a more complex
traditional neuropsychological measure of language production
in which the number of words in a specific category produced in
60 s (e.g., animals) is evaluated. Both tests require participants
to use executive processes to solve them because an efficient and
creative organization of the verbal retrieved material, as well as
the inhibition of responses when appropriate, is crucial.
To specifically detect early deficits in problem-solving and
planning, the Tower of London test (Shallice, 1982; Fancello et al.,
2006) was administered. The researcher explained the rules of
the task (e.g., don’t make more moves than necessary), and then
used one tower with three rods of descending heights and a set
of beads to display the desired goal: Participants are invited to
rearrange the set of beads on the tower to match the examiner’s
The VMET consists of a Blender-based application that enables
the active exploration of a virtual supermarket, where partici-
pants are requested to select and buy various products presented
on shelves. From a technical point of view, the VMET was
created with the software NeuroVR1(Riva et al., 2011), a free
virtual-reality platform for creating virtual environments use-
ful for neuropsychological assessment and neurorehabilitation.
NeuroVR is software that allows nonexpert users to adapt the
content of several virtual environments to the specific needs
of the clinical and research setting. Thanks to the NeuroVR
Player, it is possible to visualize virtual environments: The user
enters the virtual supermarket, and he/she is presented with
virtual objects of the various items to be purchased. Each virtual
object has been inserted through the NeuroVR Editor, which
offers a rich database of 2D and 3D objects; these can be eas-
ily placed into the predesigned virtual scenario by using an
icon-based interface. Using a joystick, the participant is able to
freely navigate the various aisles (using the up-down joystick
arrows) and to collect products (by pressing a button placed on
the right side of the joystick), after having selected them with
the viewfinder. After an initial training phase with a smaller
supermarket, the user enters the virtual supermarket and is pre-
sented with virtual objects of the various items to be purchased
(Figure 1).
The virtual supermarket contains products grouped into the
main grocery categories, including beverages, fruits and veg-
etables, breakfast foods, hygiene products, frozen foods, garden
products, and pet products. Signs at the top of each section
indicate the product categories as an aid for navigation.
Participants are also given a shopping list, a map of the
supermarket, some information about the supermarket (opening
and closing times, products on sale, etc.), a pen, a wrist watch, and
the instruction sheet. The instructions are fully illustrated for the
participants, and the rules are explained with precise reference to
the instruction sheet. The VMET test is composed of four main
tasks. The first involves purchasing six items (e.g., one product on
sale). The second involves asking the examiner information about
one item to be purchased. The third involves writing the shopping
list 5 min after beginning the test. The fourth involves responding
to some questions at the end of the virtual session by using
useful materials (e.g., the closing time of the virtual supermarket).
To complete the task, participants have to follow several rules:
(1) they have to execute all the proposed tasks; (2) they can
execute all the tasks in any order; (3) they cannot go to a place
unless it is a part of a task; (4) they cannot pass through the same
passage more than once; (5) they cannot buy more than two items
per category (look at the chart); (6) they have to take as little time
as possible to complete the exercise; (7) they cannot talk to the
researcher unless this is a part of the task; and (8) they have to go
to their “shopping cart” after 5 min from the beginning of the task
and make a list of all their products. The time is stopped when the
Frontiers in Behavioral Neuroscience December 2014 | Volume 8 | Article 405 |4
Cipresso et al. VMET: a virtual reality tool
FIGURE 1 | Screenshot of the virtual multiple errands test (VMET).
participant says, “I finished. During the task, the examiner takes
notes on the participant’s behaviors in the virtual environment.
As suggested by Shallice and Burgess (1991), the following errors
were recorded (please also see the VMET validation procedure in
Raspelli et al., 2012): task failures, inefficiencies, strategies, rule
breaks, and interpretation failures. A task failure occurs when a
subtask is not completed satisfactorily; for example, the first task
required participants to purchase six items, so it was composed of
six subtasks. For errors in executing the tasks, the scoring range
was from 11 (the participants had correctly done the 11 subtasks)
to 33 (the participants had totally omitted the 11 subtasks). The
scoring scale for each task failure was from 1 to 3 (1 = the
participant performed the task 100% correctly as indicated by the
test; 2 = the participant performed aspects of the task, but not
completed 100% accurately; 3 = the participant totally omitted
the task). An inefficiency occurs when a more effective strategy
could have been applied to accomplish the task. An example of
the eight inefficiencies is not grouping similar tasks when it is
possible. The scoring range was from 8 (many inefficiencies) to 32
(no inefficiencies). More precisely, the scoring scale for each inef-
ficiency was from 1 to 4 (1 = always; 2 = more than once; 3 = once;
4 = never). To measure the participant’s ability to use effective
strategies that facilitate carrying out the tasks, it is possible to
evaluate 13 possible strategies. An example of a good strategy is
doing accurate planning before starting a specific subtask. For
each strategy, the scoring scale for each strategy was from 1 to
4 (1 = always; 2 = more than once; 3 = once; 4 = never). The total
score range was from 13 (good strategies) to 52 (no strategies). A
rule break occurs when one of the eight rules listed in the instruc-
tion sheet has been violated (e.g., talking with the examiner when
not necessary). The scoring scale for each rule break was from 1
to 4 (1 = always; 2 = more than once; 3 = once; 4 = never). For
rule breaks, the scoring range was from 8 (a large number of rule
breaks) to 32 (no rule breaks). Finally, an interpretation failure
occurs when the requirements of a particular task are misunder-
stood; for example, when a participant thinks that the subtasks all
have to be done in the order presented in the information sheet.
The scoring range was from 3 (a large number of interpretation
failures) to 6 (no interpretation failures). The scoring scale for
each interpretation failure was from 1 to 2 (1 = yes; 2 = no).
After participants gave written informed consent to participate,
they underwent a neuropsychological global assessment; this was
done in order to obtain an accurate overview of their cognitive
function and to split the PD sample according to the guidelines
of the Task Force for the diagnosis of PD-MCI (Litvan et al.,
2012). Then, all participants were required to complete the
neuropsychological functions evaluation. At the beginning of the
experimental session, participants were asked to sit at a desk in
front of a computer monitor to complete the VMET. The VMET
was rendered using a portable computer (Intel Core 2 Duo with
graphics board OpenGL compatible and 256 MB video memory;
operative System was Microsoft Windows XP). Participants also
had a gamepad (Logitech Rumble F510), which allowed them
to explore and interact with the environment. Then they were
asked to complete the VMET procedure after a training session.
A training period of about 15 min was first provided in a smaller
version of the virtual supermarket environment in order to
familiarize participants with the navigation and shopping tasks.
Data were entered into Microsoft Excel and analyzed using SPSS
version 18 (Statistical Package for the Social Sciences–SPSS for
Frontiers in Behavioral Neuroscience December 2014 | Volume 8 | Article 405 |5
Cipresso et al. VMET: a virtual reality tool
Windows, Chicago, IL, USA). To investigate differences in EFs
and VMET scores between groups (CG vs. PD-NC vs. PD-MCI),
a series of analysis of variance were calculated. Post hoc tests (with
Bonferroni’s adjustment) were carried out to compare significant
differences. The level of significance was set at α= 0.05.
In order to investigate differences in neuropsychological evalua-
tion of EFs, a series of analysis of variance were computed with
groups (CG vs. PD-NC vs. PD-MCI) as between variable. Five
participants (three of the PD-MCI and two of the PD-NC group)
were not included in the Clock Drawing Test analyses for errors
in the score recording. Moreover, one patient from the PD-MCI
group was excluded from the analyses of the phonological and
semantic verbal fluency tests.
Regarding the Clock Drawing Test, results showed significant
differences between groups [F(2,37)= 9.82, p<0.001, ηp2= 0.347].
In particular, post hoc comparisons indicated that PD-MCI
patients performed significantly poorer (M= 7.62, SD = 2.25)
when compared with the CG (M= 9.83, SD = 0.224, p<0.001)
and with the PD-NC group (M= 9.3, SD = 0.804, p<0.01).
In regard to the Phonological verbal fluency test, findings
showed significant differences between groups [F(2,41)= 34.7,
p<0.001, ηp2= 0.629]. Post hoc comparisons demonstrated that
the CG performed significantly better (M= 50.1, SD = 8.55) when
compared with the PD-MCI (M= 22.7, SD = 10.1, p<0.001) and
PD-NC group (M= 32.9, SD = 8.55, p<0.001). Moreover, mean
scores of the PD-NC group were significantly higher (p<0.05)
when compared with those of the PD-MCI group.
In regard to the Semantic verbal fluency test, the one-
way ANOVA showed significant differences between groups
[F(2,41)= 21.8, p<0.001, ηp2= 0.516]. In particular, post hoc
comparisons revealed that the CG (M= 53.4, SD = 7.8) performed
significantly better when compared with the PD-NC (M= 43.5,
SD = 9.2, p<0.01) and the PD-MCI group (M= 33.2, SD = 8.01,
p<0.001). More interestingly, findings showed that the PD-MCI
group was significantly worse (p<0.01) than the PD-NC group.
Finally, analysis conducted on the Tower of London test
revealed significant differences between groups [F(2,42)= 16.5,
p<0.001, ηp2= 0.441]. Post hoc comparisons showed that
the PD-MCI group performed significantly poorer (M= 15.5,
SD = 5.01) than the CG (M= 26.4, SD = 4.64, p<0.001) and
the PD-NC group (M= 23, SD = 5.01, p<0.001).
Table 3 summarized the main results.
In order to investigate differences in VMET scores, a series of
analysis of variance were computed with groups (CG vs. PD-NC
vs. PD-MCI) as between variable. First of all, in regard to the time
needed for each participant to complete the task, analysis showed
significant differences between groups [F(2,42)= 3.83, p<0.05,
ηp2= 0.154]. In particular, post hoc analyses indicated that the
PD-MCI group took significantly less time (M= 1223, SD = 579,
p<0.05) compared with CG (M= 727, SD = 308).
Concerning the task failure, results showed significant differ-
ences between groups [F(2,42)= 20.2, p<0.001, ηp2= 0.491].
In particular, post hoc comparisons indicated that the CG
performed significantly better (M= 14.3, SD = 2.32) when
compared with the PD-NC group (M= 22.3, SD = 4.25,
p<0.001) and the PD-MCI group (M= 22.8, SD = 5.22,
Regarding inefficiencies, findings revealed significant differ-
ences between groups [F(2,42)= 3.58, p<0.05, ηp2= 0.146].
Post hoc comparisons indicated that the PD-MCI group per-
formed significantly worse (M= 18.6, SD = 4.03, p<0.05) with
respect to the CG (M= 24.2, SD = 8.18).
Results also showed significant differences between groups in
the strategies [F(2,42)= 9.82, p<0.001, ηp2= 0.319]. In particular,
post hoc comparisons indicated that the CG used significantly
more effective strategies (M= 32.2, SD = 5.3) when compared
with the PD-NC group (M= 40.5, SD = 8.69, p<0.01) and the
PD-MCI group (M= 43.6, SD = 7.42, p<0.001).
Finally, no significant differences between groups were found
in the rule breaks and in the interpretation failure. Results are
summarized in Table 4.
Because cognitive impairment is a common complication of
PD and is associated with significant disability for patients
and a burden for caregivers, it is crucial to fully investigate the
distinguishing features of the neuropsychological profile in this
clinical population (Aarsland et al., 1999, 2000; Schrag et al.,
2000). As the PD progresses, a relevant proportion of patients will
develop dementia (Aarsland et al., 2003; Bosboom et al., 2004;
Hely et al., 2008). Specifically, Aarsland et al. (2005) found that
more than 30% of PD patients have dementia. So the focus now
is to identify patients with a potentially higher risk of dementia,
with the possibility to implement an early and individualized
cognitive rehabilitation treatment to improve their quality of life.
Table 3 | One-way ANOVA results of mean scores obtained by participants divided into the three groups at the EF tasks.
EF test Group Post hoc comparisons
pPD-NC vs. CG PD-NC vs. PD-MCI CG vs. PD-MCI
Clock drawing test 9.3 (0.8) 7.6 (2.2) 9.8(0.2)9.8 *** 0.347 N.S. ** ***
Phonological verbal fluency 32.9 (8.5) 22.7 (10.1) 50.1(8.5)34.7 *** 0.629 *** * ***
Semantic verbal fluency 43.5 (9.2) 33.2 (8.0) 53.4(7.8)21.8 *** 0.516 ** ** ***
Tower of London test 23 (5.0) 15.5 (5.0) 26.4(4.6)16.5 *** 0.441 N.S. *** ***
Values are shown as mean (SD).
p values: *** <0.001, ** <0.01, * <0.05, N.S. = Nonsignificant.
Frontiers in Behavioral Neuroscience December 2014 | Volume 8 | Article 405 |6
Cipresso et al. VMET: a virtual reality tool
Table 4 | One-way ANOVA results of mean scores obtained by participants divided into the three groups at the VMET.
VMET scores Group Post hoc comparisons
pPD-NC vs. CG PD-NC vs. PD-MCI CG vs. PD-MCI
Time (seconds) 1110 (600) 1223 (579) 727 (308) 3.8 * 0.347 N.S. N.S. *
Task failure 22.3 (4.2)22.8 (5.2)14.3 (2.3) 20.2 *** 0.491 *** N.S. ***
Inefficiencies 22.3 (4.3)18.6 (4.0)24.2 (8.1) 3.6 * 0.146 N.S. N.S. *
Strategies 40.5 (8.7)43.6 (7.4)32.2 (5.3) 9.8 *** 0.319 ** N.S. ***
Rule breaks 23.2 (7.0)21.9 (5.1)23.6 (7.0) 0.324 N.S 0.015 N.S. N.S. N.S
Interpretation failures 5 (0.8) 5.07 (1.0)4.47 (0.8) 1.9 N.S 0.086 N.S. N.S. N.S.
Values are shown as mean (SD).
p values: *** <0.001, ** <0.01, * <0.05, N.S. = Nonsignificant.
Particularly, an increasing number of studies have suggested that
the executive deficits in PD are predictive of the conversion to
dementia (Levy et al., 2002; Woods and Tröster, 2003).
On these premises, the main objective of this study was to
investigate the potentiality of the VMET, to integrate the tradi-
tional neuropsychological evaluation of EFs in PD with a more
ecologically valid evaluation. This study offers initial evidence that
a more ecologically valid evaluation of EFs is more likely to lead
to detection of subtle executive deficits in PD patients. VMET
specifically seems to capture the early executive dysfunctions of
PD-NC patients, while they did not differ in the traditional
assessment of EFs when compared to CG.
First, although some recent reviews suggested that executive
deficits are present in the early stage of PD (Kudlicka et al.,
2011; Ceravolo et al., 2012), our results showed that PD-NC
patients were not impaired in the traditional neuropsychological
evaluation of EFs when compared with the CG. In fact, in their
review, Kudlicka et al. (2011) underlined that studies on EFs
in PD are marked by a general lack of clarity in regard to the
measure selection and their clinical interpretation. Obviously, it is
crucial to acknowledge the possibility that different results across
studies might reflect the different tests used, and the underlying
functions that the tests are thought to capture. So it is crucial
to fully understand which subcomponents of EFs are impaired
early in this population. In this direction, Kudlicka et al. (2013)
used a data-driven approach to investigate which areas of EF
are particularly deficient in 34 patients with PD. Results showed
that the impairment was more profound in tests requiring time-
efficient attentional control; for example, the Trail Making Test
(Tombaugh, 2004).
Our findings showed only a significant difference in the
semantic verbal and phonetic verbal fluencies between PD-NC
and cognitively healthy participants. As previously explained, ver-
bal fluency tests measure several EF components, including set-
switching, strategy generation, and rule attainment, along with
other non-EF components such as semantic memory and verbal
lexicon. Our results are consistent with a recent meta-analysis that
reports verbal fluency deficits in PD (Henry and Crawford, 2004).
Specifically, Henry and Crawford (2004) found that PD patients
were significantly more impaired in semantic fluency, concluding
that this deficit may be associated not only with a problem in
executive functioning, but also properly with an initial disorder in
the semantic memory (namely, concept-based knowledge). Also,
in an interesting study with 88 PD patients and 65 healthy partic-
ipants, Koerts et al. (2013) pointed out that verbal fluency deficits
can be interpreted in light of the progression of the disease and
the dysfunctions in other cognitive domains. The performance in
the verbal fluency tests is explained by the psychomotor speed in
the mild stage of PD, while the cognitive flexibility accounts for
deficits in those tests in the moderate phases of the disease.
Concerning the VMET, as previously indicated, our main
findings revealed significant differences in some VMET scores
between the PD-NC and the cognitively healthy participants.
Specifically, within all VMET scores, it is interesting to note a sig-
nificant difference in task failure and strategies between these two
groups. PD-ND patients, compared with cognitively healthy con-
trols, made a greater number of errors in completing the subtasks
of VMET. Furthermore, compared with the CG, PD-ND patients
showed poorer ability in using effective strategies that facilitate the
carrying out of the tasks; for example, accurate planning before
starting a specific subtask or using the map for navigating the
virtual supermarket. These executive deficits may reflect a specific
deficit in cognitive flexibility; namely, the ability with which a per-
son’s conceptualization changes selectively to effectively respond
to external/internal stimulation. This may also explain why there
is no significant difference between PD-ND and PD-MCI in these
VMET scores. Indeed, to discriminate between PD-MCI and PD-
ND, it is important to follow the recent guidelines of the Task
Force (Litvan et al., 2012). So our findings confirm that the
traditional assessment of EFs appears to be more useful to detect
differences in the EFs between these two cognitive groups.
In conclusion, our results showed that the VMET appears
sensitive to evaluate the functional status of PD with normal
cognition, as manifested in terms of executive deficits, which had
not been fully acknowledged by traditional neuropsychological
evaluations. The VMET allows the possibility to evaluate some
subcomponents of EFs in ecological settings, giving a more accu-
rate estimate of the patients’ deficits that are difficult to detect
with traditional tests.
As previously explained, one of the most crucial criticisms
of the neuropsychological tests is the lack of ecological validity
(Goldstein, 1996; Chaytor and Schmitter-Edgecombe, 2003;
Chan et al., 2008). Even though patients with supposed
executive deficits may perform as well as controls on traditional
neuropsychological tests, they may experience difficulties in real
world situations. VR may be used to offer a new human-computer
Frontiers in Behavioral Neuroscience December 2014 | Volume 8 | Article 405 |7
Cipresso et al. VMET: a virtual reality tool
interaction paradigm in which patients are active participants
within an ecological virtual world (Riva, 2009). In virtual tasks
such as the VMET, it is possible to simulate life-like challenges,
which require a more complex series of goals to achieve and the
cognitive flexibility to elaborate different strategies to accomplish
them and to inhibit inappropriate actions.
Our results may also represent a theoretical contribution in
the attempt to isolate the specific subcomponents of EF. Most
of the traditional neuropsychological tests, therefore, measure
one specific EF component, but they don’t reflect a true picture
of a functional patient’s status. According to different theories,
however, EF is best conceptualized as a system of interconnected
processes guided necessarily by a central supervisor system to
facilitate goal-oriented behavior (Luria, 1966; Norman and
Shallice, 1986; Miller and Cohen, 2001; Miller et al., 2002). Our
findings contribute to emphasize the idea that a breakdown in
the executive control mechanisms is reflected in deficits in many
multitasking behaviors, such as effective planning and strategy
allocation and monitoring.
The findings of this study are interesting and valuable, but
there are some limitations. First, the small sample size of 45
participants may limit the generalizability of the results. The
sample, however, was carefully evaluated with a comprehensive
neuropsychological assessment according to the criteria
established by Litvan et al. (2012). Second, considering the
use of computerized tests for PD patients with motor deficits, it
would be important to also assess the individual’s perception of
VMET usability (for example, difficulties during the experience
in using the joystick, selecting products from aisles, and learning
to move in the supermarket). As explained above, a recent study
showed good usability of this virtual instrument (Pedroli et al.,
2013). The performance on the VMET, however, must be read
with consideration of the motor deficit. A final limitation of our
study is the difference between the PD and CGs in terms of years
of educations. All scores obtained from neuropsychological tests
were corrected for education level according to Italian normative
data, but the results from VMET must be viewed according to this
potential limit. A future challenge is to explore the relative impact
of age, gender, education on VMET scores: for example, in an
interesting work of Boone (1999) it was found that the impact
of educational level and gender was limited to some Wisconsin
Card Sorting Test score. Obviously, further studies are needed
to evaluate the potentiality of the VMET, especially in terms of
its temporal stability, namely, test–retest reliability and criterion
validity for PD. This study, however, provides initial evidence that
a more ecological evaluation of EFs may provide the possibility
to also detect subtle executive deficits in PD-ND patients.
All participants’ data were memorized in encrypted and
password-protected files, following the criteria to protect personal
health information (El Emam et al., 2011) and using PsychoPass
method (Cipresso et al., 2012) to generate and share passwords
information among colleagues.
Conceived and designed the experiments: Pietro Cipresso, Gio-
vanni Albani, Silvia Serino, Alessandro Mauro, Giuseppe Riva.
Performed the experiments: Elisa Pedroli. Analyzed the data:
Pietro Cipresso, Silvia Serino, Federica Pallavicini. Wrote the first
version of the paper: Silvia Serino. Revised and contributed to the
last version of the paper: Pietro Cipresso, Giovanni Albani, Silvia
Serino, Elisa Pedroli, Federica Pallavicini, Alessandro Mauro,
Giuseppe Riva.
This study was supported by the Italian funded project “VRe-
hab. Virtual Reality in the Assessment and TeleRehabilitation
of Parkinson’s Disease and Post-Stroke Disabilities”—RF-2009-
The authors are grateful to the anonymous Reviewers for their
advice and suggestions, many of which were used in the final
version, making the paper better than the early version.
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Conflict of Interest Statement: The authors declarethat the research was conducted
in the absence of any commercial or financial relationships that could be construed
as a potential conflict of interest.
Received: 17 May 2014; accepted: 07 November 2014; published online: 05 December
Citation: Cipresso P, Albani G, Serino S, Pedroli E, Pallavicini F, Mauro A and Riva
G (2014) Virtual multiple errands test (VMET): a virtual reality-based tool to detect
early executive functions deficit in Parkinson’s disease. Front. Behav. Neurosci. 8:405.
doi: 10.3389/fnbeh.2014.00405
This article was submitted to the journal Frontiers in Behavioral Neuroscience.
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... Cognitive dysfunction represents one of the major clinical NMS of PD 17 , and executive dysfunction is the best-defined cognitive impairment in early-stage non-demented PD 20 , particularly affecting attention, planning, deduction, inhibition, capacity to elaborate a strategy, set-shifting (flexibility) and working memory 21 . As a result, patients have trouble in many goal-directed everyday activities, with negative implications for daily functioning (i.e., preparing meals, managing money, shopping, and work) 12,22,23 and quality of life [23][24][25] . Interestingly, an increasing number of longitudinal studies suggested that early executive dysfunction is predictive of PD conversion in "PD with dementia" 26,27 . ...
... Interestingly, an increasing number of longitudinal studies suggested that early executive dysfunction is predictive of PD conversion in "PD with dementia" 26,27 . However, some studies showed that traditional standard assessment appeared not sensitive to the early detection of executive deficits 22 . Therefore, EXIT 360° could permit early detection of executive deficits and, consequently, identify patients at risk of developing dementia, providing early neurorehabilitative interventions 22,28 . ...
... However, some studies showed that traditional standard assessment appeared not sensitive to the early detection of executive deficits 22 . Therefore, EXIT 360° could permit early detection of executive deficits and, consequently, identify patients at risk of developing dementia, providing early neurorehabilitative interventions 22,28 . ...
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EXecutive-functions Innovative Tool 360° (EXIT 360°) is an original 360° instrument for an ecologically valid and multicomponent evaluation of executive functioning. This work aimed to test the diagnostic efficacy of EXIT 360° in distinguishing executive functioning between healthy controls (HC) and patients with Parkinson’s Disease (PwPD), a neurodegenerative disease in which executive dysfunction is the best-defined cognitive impairment in the early stage. 36 PwPD and 44 HC underwent a one-session evaluation that involved (1) neuropsychological evaluation of executive functionality using traditional paper-and-pencil tests, (2) EXIT 360° session and (3) usability assessment. Our findings revealed that PwPD made significantly more errors in completing EXIT 360° and took longer to conclude the test. A significant correlation appeared between neuropsychological tests and EXIT 360° scores, supporting a good convergent validity. Classification analysis indicated the potential of the EXIT 360° for distinguishing between PwPD and HC in terms of executive functioning. Moreover, indices from EXIT 360° showed higher diagnostic accuracy in predicting PD group membership compared to traditional neuropsychological tests. Interestingly, EXIT 360° performance was not affected by technological usability issues. Overall, this study offers evidence that EXIT 360° can be considered an ecological tool highly sensitive to detect subtle executive deficits in PwPD since the initial phases of the disease.
... Por otro lado, los resultados evidencian dos grandes tendencias sobre el desarrollo de herramientas basadas en la RV, una centrada en el campo de la Neuropsicología y otra en el área de la Psicología Clínica. Dentro del área neuropsicológica, cobra importancia el estudio de la equivalencia psicométrica entre las pruebas neuropsicológicas tradicionales y las pruebas basadas en la RV (Allain et al., 2014;Cipresso et al., 2014;Kourtesis et al. 2021). Esto con el fin de desarrollar y validar instrumentos virtuales que permitan obtener una medida válida y confiable de distintos procesos cognitivos. ...
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Introducción: La Realidad Virtual (RV) se sitúa como una de las herramientas más prometedoras para la evaluación psicológica. No obstante, su utilización en la práctica todavía presenta resultados poco concluyentes. Objetivos: Analizar la literatura científica existente sobre la aplicación de la RV en el campo de la evaluación psicológica, publicada entre los años 2011 y 2021. Se propone describir las tendencias actuales del uso de RV en este campo y los posibles beneficios que brindan estas tecnologías. Metodología: La muestra estuvo compuesta por 44 artículos científicos. Resultados:Se evidencia un constante interés en la temática a lo largo de los últimos años, el cual alcanza su pico en 2018; además, se identificó a España como uno de los países que lideran este campo de investigación. Se observan tendencias al desarrollo y diseño de herramientas de RV en las áreas de Neuropsicología y Psicología Clínica. Conclusión: El papel de la RV en la evaluación psicológica está cada vez más consolidado, debido a que permite generar experiencias inmersivas y controladas, adecuadas al estudio de distintos procesos psicológicos. Finalmente, se proponen algunas líneas de investigaciones futuras que permitan expandir los conocimientos y progresos expuestos en la revisión.
... Second, a virtual kitchen task differentiated between impairments related to early Parkinson`s disease and early manifest Huntington's disease (Júlio et al., 2020). Third, a virtual supermarket task successfully discriminated between HC and Parkinson patients with and without MCI (Cipresso et al., 2014). Fourth, a short VR functional capacity assessment of patients with Parkinson's disease found those with MCI to have higher error rates and higher completion times than those without MCI (Turner, Atkins, & Keefe, 2021). ...
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Background Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders. Objective To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders. Data source Systematic literature searches via PubMed (last literature update: 9th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders. Eligibility criteria To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology. Study evaluation For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria. Results Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder. Conclusion While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application. Review registration PROSPERO register CRD42020188436. Funding The review was funded by budgets from the University of Bonn. No third party funding was involved.
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Background and objective: EPELI (Executive Performance of Everyday LIving) is a Virtual Reality (VR) task that was developed to study goal-directed behavior in everyday life contexts in children. In this study, we had 72 typically developing 9- to 13-year-old children to play EPELI with an immersive version implemented with a head-mounted display (HMD) and a non-immersive version employing a flat screen display (FSD) in a counterbalanced order to see if the two versions yield similar results. The children’s everyday executive functions were assessed with the parent-rated Behavior Rating Inventory for Executive Functions (BRIEF) questionnaire. To assess the applicability of EPELI for online testing, half of the flat screen display version gameplays were conducted remotely and the rest in the laboratory. Results: All EPELI performance measures were correlated across the versions. The children’s performance was mostly similar in the two versions, but small effects reflecting higher performance in FSD-EPELI were found in the measures of Total score, Task efficacy, and Time-based prospective memory score. The children engaged in more active time monitoring in FSD-EPELI. While the children evaluated the feeling of presence and usability of both versions favorably, most children preferred HMD-EPELI, and evaluated its environment to be more involving and realistic. Both versions showed only negligible problems with the interface quality. No differences in task performance or subjective evaluations were found between the home-based and laboratory-based assessments of FSD-EPELI. In both EPELI versions, the efficacy measures were correlated with BRIEF on the first assessment, but not on the second. This raises questions about the stability of the associations reported between executive function tasks and questionnaires. Conclusions: Both the HMD and FSD versions of EPELI are viable tools for the naturalistic assessment of goal-directed behavior in children. While the HMD version provides a more immersive user experience and naturalistic movement tracking, the FSD version can maximize scalability, reachability, and cost efficacy, as it can be used with common hardware and remotely. Taken together, the findings highlight similarities between the HMD and FSD versions of a cognitively complex VR task, but also underline the specific advantages of these common presentation modes.
Virtual Reality (VR) affords clinicians the ability to deliver safe, controlled, task-specific customised interventions that are enjoyable, motivating and engaging. Elements of training in VR comply with principles of learning implicated in new skill acquisition and re-learning skills post-neurological disorders. However, heterogeneity in the description of VR systems and the description and control of ‘active’ ingredients of interventions (like dosage, type of feedback, task specificity, etc.) have led to inconsistency in the synthesis and interpretation of evidence related to the effectiveness of VR-based interventions, particularly in post-stroke and Parkinson’s Disease (PD) rehabilitation. This chapter attempts to describe VR interventions with respect to their compliance with principles of neurorehabilitation, with the goal of optimising interventions for effective training and facilitation of maximum functional recovery. This chapter also advocates using a uniform framework to describe VR systems to promote homogeneity in literature in order to help in the synthesis of evidence. An overview of the evidence revealed that VR systems are effective in mediating deficits in upper extremity, posture and gait function seen in people post-stroke and PD. Generally, interventions were more effective when they were delivered as an adjunct to conventional therapy and were customised for rehabilitation purposes, in addition to complying with principles of learning and neurorehabilitation. Although recent studies imply that their VR intervention is compliant with principles of learning, only a few explicitly describe how these principles are incorporated as ‘active ingredients’ of the intervention. Finally, VR interventions targeting community ambulation and cognitive rehabilitation are yet limited and therefore warrant attention.KeywordsCerebrovascular accidentsCognitionParkinson’s diseaseRehabilitationSensorimotor systemsVirtual reality
Neuropsychological testing aims to measure individu-als' cognitive abilities (e.g. memory, attention), analysing their performance on specific behavioural tasks. Most neuropsychological tests are administered in the so-called 'paper-and-pencil' modality or via computerised protocols. The adequacy of these procedures has been recently questioned , with more specific concerns about their ecological validity, i.e. the relation between test scores observed in the laboratory setting and the actual everyday cognitive functioning. In developing more ecological tasks, researchers started to implement virtual reality (VR) technology as an administration technique focused on exposing individuals to simulated but realistic stimuli and environments, maintaining at the same time a controlled laboratory setting and collecting advanced measures of cognitive functioning. This systematic review aims to present how VR procedures for neuropsy-chological testing have been implemented in the last years. We initially explain the rationale for supporting VR as an advanced assessment tool, but we also discuss the challenges and risks that can limit the widespread implementation of this technology. Then, we systematised the large body of studies adopting VR for neuropsychological testing, describing the VR tools' distribution amongst different cognitive functions through a PRISMA-guided systematic review. The systematic review highlighted that only very few instruments are ready for clinical use, reporting psychometric proprieties (e.g. validity) and providing normative data. Most of the tools still need to be standardised on large cohorts of participants, having published only limited data on small samples up to now. Finally, we discussed the possible future directions of the VR neuropsychological test development linked to technological advances. K E Y W O R D S cognitive assessment, neuropsychology, PRISMA, test, virtual reality, VR
Background Cognitive disorders, such as Alzheimer's disease, are a global health problem. Digital healthcare technology is an innovative management tool for delaying the progression of dementia and mild cognitive impairment. Thanks to digital technology, the possibility of safe and effective care for patients at home and in the community is increasing, even in situations that threaten the continuity of care, such as the COVID-19 pandemic. However, it is difficult to select appropriate technology and alternatives due to the lack of comprehensive reviews on the types and characteristics of digital technology for cognitive impairment, including their effects and limitations. Objective This study aims to identify the types of digital healthcare technology for dementia and mild cognitive impairment and comprehensively examine how its outcome measures were constructed in line with each technology's purpose. Methods According to the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews guidelines, a literature search was conducted in August 2021 using Medline (Ovid), EMBASE, and Cochrane library. The search terms were constructed based on Population-Concept-Context mnemonic: ‘dementia’, ‘cognitive impairment’, and ‘cognitive decline’; digital healthcare technology, such as big data, artificial intelligence, virtual reality, robots, applications, and so on; and the outcomes of digital technology, such as accuracy of diagnosis and physical, mental, and social health. After grasping overall research trends, the literature was classified and analysed in terms of the type of service users and technology. Results In total, 135 articles were selected. Since 2015, an increase in literature has been observed, and various digital healthcare technologies were identified. For people with mild cognitive impairment, technology for predicting and diagnosing the onset of dementia was studied, and for people with dementia, intervention technology to prevent the deterioration of health and induce significant improvement was considered. Regarding caregivers, many studies were conducted on monitoring and daily living assistive technologies that reduce the burden of care. However, problems such as data collection, storage, safety, and the digital divide persisted at different intensities for each technology type. Conclusions This study revealed that appropriate technology options and considerations may differ depending on the characteristics of users. It also emphasises the role of humans in designing and managing technology to apply digital healthcare technology more effectively.
Conference Paper
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Sexting (sending and receiving sexual messages) could entail risk for adolescent users. Hence, it is important that parents are able to address their children's sexuality and mediate to them the implications of sexting. The goal of the current study was to identify parental factors that lead to dysfunctional communication about sexting among 427 parents of Israeli adolescents (ages 10±18) and to determine whether parents' perceived severity of sexting function as mediating factors. Parents completed a set of online questionnaires. Findings indicated that of the parenting styles examined, the authoritarian and permissive styles were positively associated with dysfunctional parent-child communication. The authoritative style was inversely related to dysfunctional communication and was mediated by positive attitudes regarding sex education. Additionally, authoritative parents were capable of assessing the severity and susceptibility of their children's sexting activities. It appears that the quality of the discussion initiated by authoritative parents enabled them to be aware of adolescent behaviors and phenomena and modulate their communication regarding the implied risks accordingly. Moreover, ethnic differences emerged between Arab and Jewish parents with regard to the quality of parent-child communication about sexting. Specifically, Arab parents tended more toward dysfunctional communication about sexting than did Jewish parents. Findings suggest that perceiving the implications of sexting as too risky diminishes parents' ability to conduct a high-quality discussion. In conclusion, parents need to mediate and conduct constructive discussions with their children regarding this topic.
. Losing a significant other to suicide increases the risks of depression and suicide. Fear of stigma, fatigue and lack of services may hinder the help-seeking behavior of suicide mourners, or “survivors”. The study aimed at exploring characteristics and needs of recent survivors seeking for help online and the pros and cons of the use of live-chats as a first-aid tool in bereavement support. A data-driven thematic analysis with the software ATLAS.ti was carried out on 20 live-chat conversations from the major Italian association providing free-of-charge online support. Socio-demographics details were retrieved from the transcripts. Three categories were explored: users’ features, users ‘requests and online interactions. The users were mainly women (18 of 20), partners, siblings, or parents of the deceased (11 of 20), aged between 24 and 56 years, who had lost their significant other between one day and 12 months before. Users expressed needs to receive practical information on how and where to find support and requests to be emotionally reassured. Features such as anonymity and accessibility were fondly appreciated. Live-chat services represent a safe space where survivors can obtain useful information and start processing their loss. Because of its anonymity and accessibility, a live-chat service may represent a valid first line of support and a tool for prevention of suicidal ideation. The strengths of the study reside in its ecology: differently from a simulated user study, this analysis stems from a real context of emergency.
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Annual Review of CyberTherapy and Telemedicine (ARCTT – ISSN: 1554-8716) is one of the official journals of the International Association of CyberPsychology, Training, and Rehabilitation (iACToR). The journal is published annually (once per year) by the Interactive Media Institute (IMI) - a 501c3 non profit organization, dedicated to incorporating interdisciplinary researchers from around the world to create, test, and develop clinical protocols for the medical and psychological community - in cooperation with Università Cattolica del Sacro Cuore, hosting and maintaining this web site. ARCTT is an Open Access journal that does not charge readers or their institutions for access.
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The frontal lobes are often referred to as the seat of cognition and higher-order processing that play a role in virtually all domains of neuropsychological functioning; however, the examination of this mysterious cortical area is often plagued with dubiety. The frontal lobes have fascinated and perplexed scientists who study human behavior for decades, yet still remain largely understood (Filley, 2010). They play a role in virtually all neurological and psychiatric disorders (Levine & Craik, 2012) as well as in theories of development in children and adults. The frontal lobes regulate higher-order “executive” cognitive functions needed to successfully perform complex tasks in the environment. They include a number of psychological processes, including the selection and perception of pertinent information; maintenance, retrieval, and manipulation of information in working memory; self-directed behavior, planning, and organization; behavioral regulation and control in response to a changing environment; and appropriate decision-making on the basis of positive and negative outcomes. Dysfunction in the frontal lobes can result in a variety of deficits including distractibility and perseveration, social irresponsibility, lack of initiation, impulsivity, and disinhibition (Chudasama & Robbins, 2006).
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Many of the symptoms that are particularly difficult to treat are associated with damage to the frontal lobes. There are a very large number of symptoms which are collectively referred to as 'dysexecutive symptoms'. This chapter describes some of the latest findings about the functional anatomy of the frontal lobes, the main clusters of frontal lobe symptoms, how they relate together, and their relative importance. It explains the main theories of how the frontal lobe executive system works and how they relate to the symptoms seen day to day. It also offers some predictions about therapeutic methods that might be worth pursuing based on these theories. Many of the symptoms that are particularly difficult to treat are associated with damage to the frontal lobes. There are a very large number of symptoms which are collectively referred to as 'dysexecutive symptoms'. These are not only problematic in themselves, but can also affect a patient's ability to benefit from therapy aimed at ameliorating other forms of deficit (e.g. physical therapy), and are often associated with a generally poor response to treatment (Alderman 1991). Considerable treatment advances have been made in this area in the last few years. However, in order to develop new methods we need to understand the causes of the particular symptoms. This chapter has four aims: (1) To describe some of the latest findings about the functional anatomy of the frontal lobes; (2) to describe the main clusters of frontal lobe symptoms, how they relate together, and their relative importance; (3) to explain the main theories of how the frontal lobe executive system works and how they relate to the symptoms you can expect to see day to day, and (4) to give some 'blue-sky' predictions about which therapeutic methods might be worth pursuing based on these theories.
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Much effort has been made to understand the role of attention in perception; much less effort has been placed on the role attention plays in the control of action. Our goal in this chapter is to account for the role of attention in action, both when performance is automatic and when it is under deliberate conscious control. We propose a theoretical framework structured around the notion of a set of active schemas, organized according to the particular action sequences of which they are a part, awaiting the appropriate set of conditions so that they can become selected to control action. The analysis is therefore centered around actions, primarily external actions, but the same principles apply to internal actions—actions that involve only the cognitive processing mechanisms. One major emphasis in the study of attentional processes is the distinction between controlled and automatic processing of perceptual inputs (e.g., Shiffrin & Schneider, 1977). Our work here can be seen as complementary to the distinction between controlled and automatic processes: we examine action rather than perception; we emphasize the situations in which deliberate, conscious control of activity is desired rather than those that are automatic.
L’esame neuropsicologico dell’adulto con lesioni cerebrali o patologie neurodegenerative è oggi considerato indispensabile a fini diagnostici, prognostici, peritali e riabilitativi: è una conditio sine qua non per una completa valutazione psicologica dell’individuo. L’ENB-2 si colloca fra il materiale che non può non essere presente fra gli strumenti psicometrici più aggiornati e affidabili dell’indagine neuropsicologica. Rispetto alla precedente versione, l’ENB-2 presenta rilevanti cambiamenti riguardo ai dati normativi e alla correzione dei punteggi. Il campione è stato ampliato e presenta ora 702 individui adulti di età, sesso e scolarità diversi. Particolare attenzione è stata rivolta alle fasce di età più avanzata rappresentate da un gruppo di soggetti fra i 70 e gli 80 anni e da un gruppo con età superiore agli 80 anni. È ora possibile calcolare, per ogni individuo, un punteggio globale di funzionamento cognitivo, un indice che in ambito clinico fornisce in modo immediato il livello generale di funzionamento. È possibile ora somministrare la batteria ENB-2 anche a distanza di un solo mese allo stesso individuo. L’introduzione di questo nuovo calcolo del punteggio test-retest ha indubbiamente dei vantaggi nella pratica clinica, oltre che nella ricerca di base. Tutto il materiale, i protocolli di valutazione, gli strumenti testistici e le tabelle per la correzione dei punteggi vengono forniti attraverso risorse elettroniche disponibili online sul sito internet della casa editrice.
Objective: To determine the emotional and social distress of caring for a patient with Parkinson's disease and to explore the impact of motor and mental symptoms in subjects with Parkinson's disease on their caregivers' situation. Design: Cross-sectional, population-based study using self-report questionnaires to measure caregiver distress and rating scales to assess patient symptomatology. Setting: Neurology and old age psychiatry services in Stavanger, Norway. Subjects: Caregivers of 94 home-dwelling patients with Parkinson's disease. Two control groups (patients with diabetes mellitus and healthy elderly). Outcome measures: Measures of social and emotional distress in caregivers, including the Relative Stress Scale, Beck Depression Inventory and the General Health Questionnaire. Results: Caregivers, in particular spouses, had more severe depression and a higher proportion reporting tiredness, sadness and less satisfaction with life compared with healthy elderly subjects. Using linear regression analysis, patient predictors of caregiver distress were depression, functional and cognitive impairment, agitation, aberrant motor behaviour and delusions. Conclusions: Caring for a spouse with Parkinson's disease is associated with emotional and social distress, underlining the importance of also assessing the needs of carers. Mental symptoms of parkinsonian patients were the most consistent and powerful predictors of caregiver distress, suggesting that identification and treatment of mental symptoms may reduce distress in caregivers of subjects with Parkinson's disease.
This chapter shows that key higher-level cognitive functions known as the executive functions are strongly associated with the human prefrontal cortex (HPFC). It argues that an important way to understand the functions of the HPFC is to adapt the representational model that has been the predominant approach to understanding the neuropsychological aspects of, for example, language processing and object recognition. The representational approach developed is based on the structured event complex framework. This framework claims that there are multiple subcomponents of higher-level knowledge that are stored throughout the HPFC as distinctive domains of memory. The chapter also argues that there are topographical distinctions in where these different aspects of knowledge are stored in the HPFC.