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Preliminary Research: Virtual Reality in Residential Aged Care to Reduce Apathy and Improve Mood

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Abstract

This study determines the feasibility of using virtual reality (VR) for residents with and without dementia in the residential aged care (RAC) environment (also referred to as nursing homes or long-term care). A mixed-methods study was conducted with 13 residents of varying cognitive capacity in a residential aged care facility (RACF) operated by a not-for-profit organization in Brisbane, Australia. Residents participated in one facilitated VR session, either as a group or individual session. Residents' mood and apathy were measured by the Observed Emotion Rating Scale (OERS) and the Person-Environment Apathy Rating Scale. Residents also completed a structured interview to provide their feedback after the VR session. In addition, four RACF staff members were interviewed about their experience of using the VR in residents and the ongoing feasibility. The experience of VR administered by a researcher and leisure and lifestyle coordinator as a leisure activity, significantly reduced apathy in residents (Z = -2.818, p = 0.005) through observations of increased facial expression, eye contact, physical engagement, verbal tone, and expression. The study did not find a VR impact on the OERS measures; no significant increase in fear/anxiety was observed. Reminiscence was clearly observed in six of the nine residents with the ability to verbally communicate. VR was found not to be helpful in residents during episodes of acute neuropsychiatric and behavioral symptoms. This study suggested feasibility of using fully immersive VR delivered by mobile phone technologies. It provides preliminary data for a controlled trial presently underway examining the effectiveness of VR as a group activity in RAC to improve mood states, behavioral symptoms, and pro re nata psychotropic medication use. Residents indicated that VR was enjoyable with low levels of physical and emotional discomfort reported or observed.
Preliminary Research:
Virtual Reality in Residential Aged Care
to Reduce Apathy and Improve Mood
Rachel E. Brimelow, BBiomedSci, MMedRes,
1
Bronwyn Dawe, DipComm,
2
and Nadeeka Dissanayaka, BSc (Hons), PhD
1,3,4
Abstract
This study determines the feasibility of using virtual reality (VR) for residents with and without dementia in the
residential aged care (RAC) environment (also referred to as nursing homes or long-term care). A mixed-
methods study was conducted with 13 residents of varying cognitive capacity in a residential aged care facility
(RACF) operated by a not-for-profit organization in Brisbane, Australia. Residents participated in one facili-
tated VR session, either as a group or individual session. Residents’ mood and apathy were measured by the
Observed Emotion Rating Scale (OERS) and the Person–Environment Apathy Rating Scale. Residents also
completed a structured interview to provide their feedback after the VR session. In addition, four RACF staff
members were interviewed about their experience of using the VR in residents and the ongoing feasibility. The
experience of VR administered by a researcher and leisure and lifestyle coordinator as a leisure activity,
significantly reduced apathy in residents (Z=-2.818, p=0.005) through observations of increased facial ex-
pression, eye contact, physical engagement, verbal tone, and expression. The study did not find a VR impact on
the OERS measures; no significant increase in fear/anxiety was observed. Reminiscence was clearly observed in
six of the nine residents with the ability to verbally communicate. VR was found not to be helpful in residents
during episodes of acute neuropsychiatric and behavioral symptoms. This study suggested feasibility of using
fully immersive VR delivered by mobile phone technologies. It provides preliminary data for a controlled trial
presently underway examining the effectiveness of VR as a group activity in RAC to improve mood states,
behavioral symptoms, and pro re nata psychotropic medication use. Residents indicated that VR was enjoyable
with low levels of physical and emotional discomfort reported or observed.
Keywords: virtual reality, technology, aged care, nursing home, dementia
Introduction
Residential aged care (RAC) facilities provide long-
term care for older people in an institutionalized setting.
Transition to RAC is a life-changing event that has significant
implications for residents’ daily routines, social networks,
and autonomy.
1
Leisure activities comprise a number of
discretionary activities and may contribute to greater adap-
tation to life within RAC because of increased relatedness
and self-determined motivation.
2
Engagement in enjoy-
able leisure activities underpin residents’ enjoyment of daily
life,
1
and has been shown to reduce depression
3
and improve
life satisfaction through improved cognitive function, self-
perceived health status, and functional ability.
4
A number of
leisure activities have been shown to benefit residents in
RAC. Psychosocial interventions such as cognitive stimula-
tion, cognitive behavior therapy, reminiscence therapy, sen-
sory stimulation, and tailored activity programs have been
found to be successful in RAC at improving cognition, re-
ducing problematic behaviors, or contributing to improved
mental wellbeing, as have some cultural arts interventions.
5
The addition of tailored leisure activities suitable for both
residents with and without dementia is therefore of special
interest to most person-centered RAC facilities.
1
UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
2
Respite Services and Social Inclusion, Wesley Mission Queensland, Brisbane, Australia.
3
Faculty of Health and Behavioural Sciences, The University of Queensland School of Psychology, St. Lucia, Australia.
4
Department of Neurology, Royal Brisbane and Women’s Hospital, Brisbane, Australia.
CYBERPSYCHOLOGY,BEHAVIOR,AND SOCIAL NETWORKING
Volume 23, Number 3, 2020
ªMary Ann Liebert, Inc.
DOI: 10.1089/cyber.2019.0286
165
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Virtual reality (VR) has recently gained traction as a novel
leisure activity suitable for the RAC environment. In the past
two decades VR has been used in a variety of health care
and aged care settings to enhance the ability to perform ac-
tivities of daily living in patients with dementia, stroke, and
Parkinson’s disease
6,7
(Thangavelu K, et al. Unpublished
work. Designing VR treatment for anxiety in older adults
living with Parkinson’s Disease: integrating literatures to
inform next steps). The use of VR and gaming systems to
enable physical activity has also been tentatively explored in
older adults.
8,9
However, only recently has the use of im-
mersive VR experiences in RAC been identified as a possible
avenue to improve resident quality of life. Previous research
into the use of VR in people with dementia or cognitive
impairment as a sensory experience,
10,11
or to provide at-
tentional
12
or memory-based
13
training, provides further
evidence of possible feasibility in the RAC setting.
The development of a suite of VR videos specially tar-
geted toward aged care has the potential to provide RAC
staff with another tool in their arsenal to engage residents by
providing them with a pleasurable immersive experience.
Previous research has shown that limited activity choices,
impaired physical functioning, resources, and transportation,
are major barriers to residents participating in leisure activ-
ities.
14
The use of VR technology to provide unique three-
dimensional immersive experiences to ‘‘transport’’ users to
other environments voids the need for transportation, phys-
ical mobility, and ongoing costs. VR has previously been
explored in a hospital-based setting and found to elicit pos-
itive responses with minimal discomfort.
15
This study un-
dertakes a similar immersive VR technology in RAC to
measure and describe the effectiveness of fully immersive
VR on engagement and apathy in residents with and without
dementia in an RAC environment. This study also aims to
explore the feasibility of implementing such technologies as
usual care in RAC. This study uses a library of videos con-
sisting of relaxing scenes, such as underwater themes, bea-
ches, farmyard animals, travel destinations, and snowscapes.
Methods
This mixed-methods study conducted between March and
April 2018 (data collection) consisted of quantitative vali-
dated observer tools, a resident feedback survey, and staff
interviews.
Human research ethics approvals were obtained from the
University of Queensland (2018000022) and UnitingCare
Queensland (21317).
Participants
Written consent was obtained from participants that was
determined to have a Psychogeriatric Assessment Scale
(PAS) of 4 or <4 (indicating no or minimal cognitive im-
pairment). For residents with a PAS score of >4, substituted
written consent was obtained from their legal guardians.
Assent before each VR session was obtained from every
resident. Residents were drawn from a 56-bed residential
aged care facility (RACF) and had a range of cognitive and
verbal capabilities. Families and residents were made aware
of the program through advertising and an opt-in approach
was undertaken. The program was open to all residents,
where a signed consent form could be obtained.
Residents were aged between 66 and 93 years with a mean
of 82 8 years. There were nine female and four male par-
ticipants. There were nine participants with dementia and all
participants had some level of cognitive impairment. Four
residents had mild cognitive impairment, two had moderate
impairment, and seven had severe impairment. The mean
time residents had spent in the RACF was 21 months (range:
3–58 months). Residents were excluded if they had symp-
toms or a diagnosis of contagious conditions, serious ill
health, or were in palliative care. Residents were required to
be seated for the VR experience; therefore, residents who
were bed bound and unable to sit up were excluded.
Intervention
A Samsung Galaxy S7 (weight =152 g), preloaded with an
aged care VR library, in tandem with a Samsung Gear VR
headset (weight =345 g) was used to create a fully immersive
VR experience for residents. The phone was inserted into the
headset and applied to the residents face with both a hori-
zontal and vertical Velcro strap to secure the device safely
and distribute the weight. Straps were adjusted to fit each
individual’s face. The 360-degree videos contained within
the library consisted of relaxing scenes, such as underwater
themes, beaches, farmyard animals, travel destinations, and
snowscapes that were specially created for the aged care
industry. These videos lasted between 4 and 5 minutes each,
with the perception changing in response to the viewers head
movements. Scenes also consisted of relaxing background
music and narration about the relevant scene. An image of
the main menu for the application is given in Supplementary
Figure S1. Residents were engaged in one VR session in an
individual or a small group session while at rest. Sessions
were run by the leisure and lifestyle coordinator, to provide a
relaxing and engaging leisure activity, with documentation
completed by the research coordinator. Attempts were also
made to implement VR as a diversion therapy in response to
acute disruptive behaviors, distress, or agitation at the time of
presenting symptoms. This was facilitated by two registered
nurses (RNs) within the facility, and proved unsuccessful
because of practical limitations such as staffing and time
delays, and resident factors such as agitation.
Residents were monitored for any symptoms or signs of
cyber sickness including general discomfort, fatigue, head-
ache, eye strain, difficulty focusing, increased salivation,
sweating, nausea, difficulty concentrating, fullness of head,
blurred vision, dizziness, vertigo, stomach awareness, and
burping.
16
Residents were also monitored for fear and anx-
iety using the observational tools described hereunder and
for physical discomfort of the device. To reduce the risk of
cyber sickness the technology used did not contain sudden
scene changes, all residents were seated throughout the ex-
perience, and residents with deteriorating ill health were
excluded. In cases where the resident was observed to have
symptoms or signs of cyber sickness the device was removed
immediately and the resident was monitored by care staff
over the course of the day. Where residents reported physical
discomfort, the device straps were readjusted. In cases where
the VR elicited a negative emotional response, a different
scene was trialed, with resident assent, to determine whether
it was the particular scenery experience or the VR experience
itself that caused a negative response.
166 BRIMELOW ET AL.
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Procedure
(a) Researcher observed the residents for 10 minutes
before the VR experience and administered baseline
emotion and apathy measures using the Observed
Emotion Rating Scale (OERS) and Person–
Environment Apathy Rating Scale (PEARS), respec-
tively.
(b) Facilitator (Lifestyle Coordinator, RN, or personal
carer) set up the VR program/application based on
resident’s profile/preference (facilitator asked resi-
dent to choose their preferred scenery).
(c) Facilitator informed the resident about the procedure
and what to expect.
(d) Facilitator applied the VR headset for fully im-
mersive VR experience.
(e) Facilitator facilitated engagement by asking ques-
tions. For example:
-What do you see?
-What do you think of the view?
-Have you visited a place similar to this?
(f) Facilitator informed the resident at least 1 minute
before the session ends and explained what the fa-
cilitator will do next. Facilitator also provided
prompts to reduce simulator sickness for example,
closing eyes before removal and slowly opening eyes
to adjust to change in lighting.
(g) Facilitator asked/observed for simulator sickness and
asked the participant about the experience.
(h) The headset was wiped down with alcohol wipes
between residents for hygiene reasons. Residents
presenting with flu-like or gastrointestinal symptoms
were excluded to avoid cross-contamination.
(i) Researcher observed the session and completed the
OERS, PEARS, and qualitative feedback question-
naire with the resident after the session.
Data collected
Data were collected by the research coordinator, in col-
laboration with the leisure and lifestyle coordinator at the
RACF by verbally discussing responses during observation.
This was important as care staff with close relationships to
their residents are able to identify usual behaviors and
emotions expressed by the resident and divergences from
these norms. There was no disagreement to responses be-
tween the two. Observational and qualitative data were re-
corded using the following methods:
(a) PEAR
17
apathy subscale was used to assess resident
apathy before and during the VR session. Apathy was
measured by observing six indicators: facial expres-
sions, eye contact, physical engagement, purposeful
activity, verbal tone, and verbal expression, on a 1–4
scale, with higher scores indicating a greater level of
apathy.
(b) The OERS
18
was used to measure residents’ emo-
tional response. Residents were observed for their
emotional state using the OERS for 10 minutes be-
fore the VR session and for 10 minutes after. The
tool allowed quantification of five observed emo-
tions: pleasure, anger, anxiety/fear, sadness, and
general alertness. Emotions were rated on a scale
representing the frequency of the observed emotions
over a 10-minute period (1 =never; 2 =<16 seconds;
3=16–59 seconds; 4 =1–5 minutes; 5 =>5 minutes;
and 7 =not in view).
(c) Residents were asked a series of structured questions
at the end of their VR session. Residents were asked
to rate on a scale of 1–5 (1 =not at all, 5 =very much)
their enjoyment, their success in navigating the pro-
gram, their discomfort, and whether they would use
the program again. In addition, residents were asked
three open-ended questions: ‘‘What were the best
aspects of the program? What were the worst aspects
of the program? Where would you like to go next
(using the VR)?’’ Resident responses were recorded
verbatim on the resident feedback form.
(d) Residents were observed for signs of simulator sick-
ness. Signs and symptoms of simulator sickness were
defined by the item on the Simulator Sickness
Questionnaire.
19
Data analysis
Data analysis was conducted using SPSSv24. The Wil-
coxon signed rank test was used to analyze pre–post changes
in the OERS and PEAR scores because of the nonparametric
nature of the variables. The sum of the individual subscales
was used to measure total changes in emotion and apathy. An
alpha level of 0.05 was used to determine significance.
Results
Thirteen residents completed observed VR sessions.
Residents with mild to moderate cognitive impairment
completed the tasks as a group in an allocated quiet area of
the dining room. These residents were able to sit, observe
fellow residents using the VR headset, and participate in
group discussions. Residents with severe cognitive im-
pairment were also given the opportunity to participate in a
group setting; however, the majority declined because of
the wait time of using the VR between other participants
and preferred one on one attention with the leisure and
lifestyle coordinator and research assistant. In these cases,
VR was administered individually, either in the resident’s
room or in a quiet area of the dining room based on resident
preference.
Apathy and emotion
The VR experience significantly reduced apathy in resi-
dents (Z=-2.818, p=0.005) (Fig. 1). Total scores reduced
from a mean (standard deviation) of 15.54 (6.11) to 11.38
(3.93). This was because of observations of increased facial
expression (Z=-2.489, p=0.013), eye contact (Z=-2.070,
p=0.038), physical engagement (Z=-2.887, p=0.004),
verbal tone (Z=-2.428, p=0.015), and verbal expression
(Z=-2.714, p=0.007). VR did not significantly impact
measures of the OERS; no significant increase in fear/anxiety
was observed. A trend was observed for increased pleasure
(Z=-1.725, p=0.084) and general alertness (Z=-1.639,
p=0.101).
VIRTUAL REALITY IN AGED CARE 167
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Resident experience
Ten of the 13 residents were able to participate in com-
pleting a survey of their experience, with 9 residents verbally
responsive and 1 resident indicating scale responses with
physical gestures. Scenes preferred by residents included a
farmyard scene comprising goats and chickens, an under-
water scene of the Great Barrier Reef, a beach scene, and a
scene comprising penguins in the snow. Travel scenes of
Bali, Merida and canoeing down a river were used to a lesser
extent. One resident with visual impairment found that the
scene of penguins in the snow was easier to observe because
of the contrasting black and white. Scenes comprising ani-
mals or waterscapes dominated resident’s choices.
All but one resident indicated that they wanted to expe-
rience the VR again. The resident that indicated that she
would not like to use VR in the future stated that she was
‘‘just not that sort of person,’’ and was uninterested in the
activity. Future experiences residents expressed were of in-
terest to them were country areas of Australia, particularly
those that had a link to their past, and the beach; for example,
one resident stated that she ‘‘would love to wander through
the country areas where it’s peaceful.’’ Another resident
indicated that they would love to see their hometown where
they grew up and another wished to visit places where he had
been stationed during their time in the Defense Force.
During the VR experience, reminiscence was also ob-
served in six residents with the ability to verbally commu-
nicate.
Marvellous. It feels like you want to touch it. I’m milking
goats. I used to milk goats, when I was younger (farmyard
scene).
The colour. It seemed so natural to me because I lived down
there. It was lovely to see it (beach scene).
Residents indicated that VR was enjoyable with low levels
of discomfort reported. Two residents with impaired vision
reported that the scenery was blurring. Possible eyestrain and
blurring vision was recorded as symptoms of cyber sickness.
One other resident found that the headset was slightly un-
comfortable and slid down their face because of the weight
of the device. One resident who used the VR during an ex-
perience of acute behavior, and not in an individual or group
session, reported that the VR made her feel ‘‘giddy,’’ which
was temporary upon removal of the device. This was in in-
terpreted by medical staff as an instance of cyber sickness
and was closely monitored. Observances of emotion identi-
fied one resident with severe cognitive impairment as anx-
ious at the onset of the experience. This was mediated by
changing of the scenery from a water scene to a farmyard.
These were the only adverse responses observed in this
sample.
Discussion and Conclusion
This study highlights the feasibility of using fully im-
mersive VR and mobile technologies in RAC, which has
previously not been reported. Minimal side effects were
observed and the results corroborate a recent finding from a
nonimmersive VR study conducted in RAC facilities, re-
porting reductions in resident apathy. A pilot study con-
ducted by Moyle et al.,
11
into the use of a nonimmersive VR
rendered forest scene in RAC facilities, revealed a reduction
in PEAR apathy scores. However, unlike this study, a sig-
nificant increase in anxiety/fear, pleasure, and general
alertness were also observed. Participants in this study were
not observed to suffer increased fear/anxiety, and increases
in resident pleasure and general alertness did not reach sig-
nificance, despite similar sample size to the previous study.
However, the small sample sizes in both studies may have
impacted the statistical significance of results.
This study contained participants with cognitive impair-
ment with 9 of 13 diagnosed with dementia. Half the par-
ticipants had severe cognitive impairment (n=7), reflecting
the typical make up of RAC facilities in Australia.
20,21
This
was important to determine the feasibility of VR in the
typical aged care environment. There was no increase in
adverse reactions in participants with severe cognitive im-
pairment and the VR experience significantly improved ap-
athy (Z=-2.207, p=0.027) in this cohort. The inclusion of
people with cognitive impairment resulted in the use of
FIG. 1. Changes in total mean PEAR apathy scores in response to virtual reality. *Significantly different from pre-
intervention at p<0.05. **Significantly different from pre intervention at p<0.005. PEAR, Person–Environment Apathy
Rating.
168 BRIMELOW ET AL.
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observer rated tools and the necessity for care staff known to
the resident to be included in the procedure. Future research
should focus on how VR can be tailored to participants with
differing levels of cognitive impairment.
Qualitative results from residents revealed that VR was
regarded as an enjoyable experience, one that most residents
wished to do again. The experience provided some residents
an opportunity to converse in a group setting, whereas others
preferred one-on-one experiences. The flexibility of the VR
program allowed for tailoring of the activity. Participants
were able to choose their destinations. This is important, as
personal autonomy in RAC is low, particularly in matters
concerning residents’ social life within the facility
22
;it
however, added a level of heterogeneity to the procedure. It
is possible that group dynamics augment the experience of
VR. Residents both with and without severe cognitive im-
pairment enjoyed the experience, further highlighting the
versatility of VR.
At the completion of this pilot study, VR was im-
plemented by the leisure and lifestyle coordinator in an on-
going manner at the participating site. Feedback from staff
and residents indicated ongoing feasibility of VR technolo-
gies in aged care. A forthcoming controlled trial of group VR
sessions will further explore the use of VR to improve mood
and wellbeing within RAC (clinical trial registry
ACTRN12618000749202).
Acknowledgments
The authors acknowledge the valuable input of Jean Moss,
Mathew James, and Gurgit Bhuller for aiding in project
implementation.
Authors Contributions
Two researchers were employed by the not-for-profit or-
ganization at time of data collection; however, the researcher
responsible for data collection was employed by a separate
department with no provisions on publication.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Supplementary Material
Supplementary Figure S1
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Address correspondence to:
Dr. Nadeeka Dissanayaka
UQ Centre for Clinical Research
The University of Queensland
Building 71/918
Royal Brisbane and Women’s Hospital Campus
Herston
Brisbane, QLD 4029
Australia
E-mail: n.dissanayaka@uq.edu.au
170 BRIMELOW ET AL.
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... However, the reports on the apathy outcomes of VR interventions are scattered across studies. There is inconsistent evidence regarding the effectiveness of VR interventions [24][25][26][27][28][29], making the evaluation of effects difficult. Their study designs, VR contents, and implementation procedures have also differed; in addition, they have not been systematically reviewed in terms of quality. ...
... The characteristics of the included studies are presented in Table 1. Among the 6 included studies, 2 (33%) were randomized controlled trials (parallel-group and crossover design each) [26,27], 1 (17%) was a nonequivalent group controlled trial [29], and the remaining 3 (50%) were quasi-experimental studies with a single-group pre-and posttest design [24,25,28]. Most (5/6, 83%) of the studies were conducted in Australia [24][25][26]28,29], and 1 (17%) was conducted in South Korea [27]. ...
... Among the 6 included studies, 2 (33%) were randomized controlled trials (parallel-group and crossover design each) [26,27], 1 (17%) was a nonequivalent group controlled trial [29], and the remaining 3 (50%) were quasi-experimental studies with a single-group pre-and posttest design [24,25,28]. Most (5/6, 83%) of the studies were conducted in Australia [24][25][26]28,29], and 1 (17%) was conducted in South Korea [27]. Of the 6 studies, almost all (n=5, 83%) were conducted in a residential care setting [24][25][26]28,29], except for 1 (17%) that was conducted at a memory clinic [27]. ...
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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
... According to Brimelow et al. (2020), air pollution increases "human anxiety, anger, and apathy". Air pollution reduces happiness and increases pessimism (Zhang et al. 2017). ...
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This study examined the effect of air pollution on the initial return of IPOs in Pakistan. Cross-sectional data were used to examine 102 listed IPOs on Pakistan Stock Exchange between 1996 and 2019. Ordinary least squares and quantile least squares were employed to examine the influence of air pollution on IPO initial returns. Lastly, stepwise regression was utilised for additional analysis. According to the findings, in the presence of high air pollution, IPO initial returns also increase due to higher uncertainty. The findings demonstrate that air pollution intensifies a company’s information environment and financial uncertainty. Therefore, addressing environmental challenges is critical for both public health and capital formation. This study’s findings will increase companies’ awareness of the economic effect of air pollution, particularly in a country where air pollution is strictly regulated. This study provides businesses with an economic reason to reduce their pollution levels, and it can also help regulators pass environmental laws that are aimed at addressing this issue.
... In particular, speech therapy has been proven effective in primary progressive aphasia [103]and alexia [104]. Virtual reality for patients with dementia has been associated with reduced neuropsychiatric symptoms such as depression and agitation [105], apathy [106], as well as improved quality of life [107]. Teleexercise programs through video conferencing have been proven feasible and acceptable [108], as well as possibly effective in enhancing physical activity in patients with AD and their caregivers [109]. ...
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Background and Objectives: Dementia affects more than 55 million patients worldwide, with a significant societal, economic, and psychological impact. However, many patients with Alzheimer's disease (AD) and other related dementias have limited access to effective and individualized treatment. Care provision for dementia is often unequal, fragmented, and inefficient. The COVID-19 pandemic accelerated telemedicine use, which holds promising potential for addressing this important gap. In this narrative review, we aim to analyze and discuss how telemedicine can improve the quality of healthcare for AD and related dementias in a structured manner, based on the seven dimensions of healthcare quality defined by the World Health Organization (WHO), 2018: effectiveness, safety, people-centeredness, timeliness, equitability, integrated care, and efficiency. Materials and Methods: MEDLINE and Scopus databases were searched for peer-reviewed articles investigating the role of telemedicine in the quality of care for patients with dementia.A narrative synthesis was based on the seven WHO dimensions. Results: Most studies indicate that telemedicine is a valuable tool for AD and related dementias: it can improve effectiveness (better access to specialized care, accurate diagnosis, evidence-based treatment, avoidance of preventable hospitalizations), timeliness (reduction of waiting timesand unnecessary transportation), patient-centeredness (personalized care for needs and values), safety (appropriate treatment, reduction of infection risk),integrated care (interdisciplinary approach through several dementia-related services), efficiency (mainly cost-effectiveness) and equitability (overcoming geographical barriers, cultural diversities). However, digital illiteracy, legal and organizational issues,as well as limited awareness, are significant potential barriers. Conclusions: Telemedicine may significantly improve all aspects of the quality of care for patients with dementia. However, future longitudinal studies with control groups including participants of a wide educational level spectrum will aid in our deeper understanding of the real impact of telemedicine in quality care for this population. Citation: Angelopoulou, E.; Papachristou, N.; Bougea, A.; Stanitsa, E.; Kontaxopoulou, D.; Fragkiadaki, S.; Pavlou, D.; Koros, C.; Değirmenci, Y.; Papatriantafyllou, J.; et al. How Telemedicine Can Improve the Quality of Care for Patients with
... New strategies to successfully target older adults' mental health and well-being needs are therefore urgently required. Novel methods to improve the quality of life of older adults, benefitting from recent technological developments, have been applied in various settings to deliver distance interventions, encourage healthier lifestyles, and conduct non-invasive assessments (Preschl et al., 2011;Kim et al., 2017;Brimelow et al., 2020). Technology developed to meet older adults' needs, or Gerontechnology (Bouma et al., 2009) has been increasingly integrated into daily life routines (Wootton, 2012;Calvo & Peters, 2013;Lattanzio et al., 2014;Bercovitz & Pagnini, 2016) and may have the potential to ameliorate treatment accessibility and quality (Kvedar et al., 2014). ...
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The global population is aging at an unprecedented rate, increasing the necessity for effective interventions targeting the mental health needs of older adults. Technology addressing the aging process of older adults (i.e., gerontechnology) is an avenue for the efficient delivery of programs that enhance adult well-being. Virtual reality (VR) is a type of gerontechnology with the potential to improve mental health and well-being (e.g., by increasing resilience, mindfulness, compassion, connection with nature, and decreasing stress, depression, anxiety); however, evidence in this area is currently lacking and more rigorous research on the acceptability, feasibility, and effectiveness of mental health programming via VR for older adults, such as nature, mindfulness, or compassion-based interventions, is necessary. The present literature review: 1) explores, synthesizes, and critically evaluates the literature on older adult mental health, well-being and gerontechnology, with a focus on virtual reality-based nature, mindfulness, and compassion-based interventions; 2) examines research to date on the relationship between virtual reality technology and nature, mindfulness, and self-compassion; 3) identifies gaps, contradictions, and limitations of existing research; 4) identifies areas for further investigation; and 5) discusses implications for research and clinical practice.
... Previous studies have proven that VR can carry out effective nursing training or intervention in both disaster and community situations (10,11). Besides, both home care and staff stress care based on VR technology have also been prove to be desirable in normal times (12)(13)(14). ...
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Background With the emergence of the metaverse, virtual reality, as a digital technology, must be getting hotter. High quality virtual reality related nursing knowledge scene learning is gradually replacing traditional education and intervention skills. Objective This systematic study aimed to gain insights into the overall application of virtual reality technology in the study of nursing. Methods Citations downloaded from the Web of Science Core Collection database for use in VR in nursing publications published from January 1, 2012, to December 31, 2021, were considered in the research. Information retrieval was analyzed using https://bibliometric.com/app , CiteSpace.5.8. R3, and VOS viewer. Results A total of 408 institutions from 95 areas contributed to relevant publications, of which the United States is the most influential country in this research field. The clustering labels of cited documents were obtained from the citing documents. Virtual simulation, virtual learning, clinical skills, and dementia are the clustering labels of co-cited documents. The burst keywords represented the research frontiers in 2020–2021, which were knowledge and simulation. Conclusion Virtual nursing has had an impact on both nurses and clients. With the emergence of the concept of the metaverse, the research and application of virtual reality technology in nursing will gradually increase.
... Davis and Ohman (56) and Hannans et al. (57) reported VR could help persons with Alzheimer's disease find their way more effectively, help them maintain independence and enhance their cognitive and affective knowledge. Brimelow et al. (58) reported VR could reduce apathy and improve mood in aged care. Although many benefits may get from VR in older people's nursing, difficulties still exist in dementia older people caring, like less empathy in nurses. ...
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Background Virtual simulation has been widely used in nursing education and nursing training. This study aims to characterize the publications in terms of countries, institutions, journals, authors, collaboration relationships, and analyze the trends of virtual simulation in nursing research. Methods Publications regarding virtual simulation in nursing were retrieved from Web of Science core collection. Microsoft Excel 2010, VOSviewer were used to characterize the contributions of the authors, journals, institutions, and countries. The trends, hot-spots and knowledge network were analyzed by Citespace and VOSviewer. Results We identified 677 papers between 1999 and 2021. The number of publications grew slowly until 2019, after that, it got a sharp increase in 2020 and 2021. The USA, Canada and Australia were three key contributors to this field. Centennial College and University of San Paulo, University of Ottawa and Ryerson University were top major institutions with a larger number of publications. Verkuyl M was the most productive and highest cited author. Clinical Simulation in Nursing, Nurse Education Today, Journal of Nursing Education were the three productive journals. The foundational themes of virtual simulation research in nursing are “virtual learning during COVID-19, clinical nursing care, education in nurse practitioners, education technology”. Conclusion Virtual simulation in nursing field has attracted considerable attention during COVID-19 pandemic. The research hotspot is gradually shifting from clinical nursing care to studies of nursing education using different virtual simulation technologies
Article
Background: Novel nonpharmacological therapies are being developed to prevent cognitive decline and reduce behavioral and psychological symptoms in patients with dementia. Virtual reality (VR) reminiscence was reported to improve anxiety, apathy, and cognitive function immediately after intervention in individuals at residential aged care facilities. However, its effect on elderly patients with dementia and how long this effect could last remain unknown. Objective: The aim of this paper is to investigate the effect of immersive VR reminiscence in people with dementia both immediately after and 3-6 months after intervention. Methods: A pilot study was conducted in 2 dementia care units. VR reminiscence therapy sessions were conducted twice per week for a 3-month period. Cognitive function, global status, depressive symptoms, and caregiver burden were assessed before and immediately after VR intervention in 20 participants. Subsequently, 7 participants were reassessed 3-6 months after the VR intervention. Wilcoxon sign-rank test was used for statistical comparisons of the changes. Results: There were no significant changes in cognitive function, global status, and caregiver burden immediately after the VR intervention, but there was a significant reduction in depressive symptoms (P=.008). Moreover, compared with the cognitive function immediately after VR, it kept declining 3-6 months after. Conclusions: Immersive VR reminiscence can improve mood and preserve cognitive function in elderly patients with dementia during the period of the intervention. Studies using a control group and comparing the use of VR with traditional forms of reminiscence should be conducted in the future to confirm and expand on these findings.
Article
Purpose: This study examined the impact of a virtual reality intervention program based on psychological needs on behavioral and psychological symptoms, apathy, and quality of life (QOL) in patients with dementia or mild cognitive impairment living in nursing facilities. Methods: This study is nonequivalent control group pretest-posttest design of quasi-experimental study. The study collected data from November 18, 2020 to July 24, 2021 from patients with dementia or mild cognitive impairment (30 in the experimental group and 30 in the control group) at three nursing facilities in G city using self-reporting and caregiver-informant reporting methods. The analysis employed the chi-square test, Fisher's exact test, paired t-test, independent t-test, Wilcoxon signed rank test, Mann-Whitney U, repeated measures ANOVA, GEE, using SPSS/WIN 27.0. Results: The severity of behavioral and psychological symptoms (Wald χ² = 2.68, p = .102) and the care burden of caregivers (Wald χ² = 1.72, p = .190) were not significant and was no significant time and group interaction effect (Wald χ² = 0.63, p = .426, Wald χ² = 0.52, p =. 471). The difference in apathy and QOL score were statistically significant for the group-time interaction (F = 43.65, p < .001; F = 4.35, p = .041). Conclusion: The virtual reality intervention program of this study shows a positive effect on the apathy reduction and QOL of patients with dementia or mild cognitive impairment residing in nursing facilities.
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This study examines whether using virtual reality (VR) with older adults with mild cognitive impairment (MCI) or mild to moderate dementia with a family member who lives at a distance can improve the quality of life of the older adult and the family member. Twenty-one older adults in a senior living community and a family member (who participated in the VR with the older adult from a distance) engaged in a baseline telephone call, followed by three weekly VR sessions. The VR was associated with improvements in older adults' affect and stress, relationship with their family member, and overall quality of life, compared to baseline. Family members' negative affect, depressive symptoms, and caregiver burden also decreased and their mental health improved after using the VR, compared to baseline. Using the VR, however, did not change their relationship with the older adult. In addition, older adults and family members who experienced the VR sessions as more socially engaging reported better psychological and relational well-being, with older adults also experiencing greater improvements in overall quality of life. Finally, preliminary results suggest that older adults with dementia and their family members might benefit even more from using the VR than older adults with MCI and their family members.
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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.
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Objective: To compare the outcomes and costs of clustered domestic and standard Australian models of residential aged care. Design: Cross-sectional retrospective analysis of linked health service data, January 2015 - February 2016. Setting: 17 aged care facilities in four Australian states providing clustered (four) or standard Australian (13) models of residential aged care. Participants: People with or without cognitive impairment residing in a residential aged care facility (RACF) for at least 12 months, not in palliative care, with a family member willing to participate on their behalf if required. 901 residents were eligible; 541 consented to participation (24% self-consent, 76% proxy consent). Main outcome measures: Quality of life (measured with EQ-5D-5L); medical service use; health and residential care costs. Results: After adjusting for patient- and facility-level factors, individuals residing in clustered models of care had better quality of life (adjusted mean EQ-5D-5L score difference, 0.107; 95% CI, 0.028-0.186; P = 0.008), lower hospitalisation rates (adjusted rate ratio, 0.32; 95% CI, 0.13-0.79; P = 0.010), and lower emergency department presentation rates (adjusted rate ratio, 0.27; 95% CI, 0.14-0.53; P < 0.001) than residents of standard care facilities. Unadjusted facility running costs were similar for the two models, but, after adjusting for resident- and facility-related factors, it was estimated that overall there is a saving of $12 962 (2016 values; 95% CI, $11 092-14 831) per person per year in residential care costs. Conclusions: Clustered domestic models of residential care are associated with better quality of life and fewer hospitalisations for residents, without increasing whole of system costs.
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Background The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care. Methods Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults. ResultsOf all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted β = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care. Conclusions The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.
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Virtual Reality (VR) has emerged as a promising tool in many domains of therapy and rehabilitation, and has recently attracted the attention of researchers and clinicians working with elderly people with MCI, Alzheimer's disease and related disorders. Here we present a study testing the feasibility of using highly realistic image-based rendered VR with patients with MCI and dementia. We designed an attentional task to train selective and sustained attention, and we tested a VR and a paper version of this task in a single-session within-subjects design. Results showed that participants with MCI and dementia reported to be highly satisfied and interested in the task, and they reported high feelings of security, low discomfort, anxiety and fatigue. In addition, participants reported a preference for the VR condition compared to the paper condition, even if the task was more difficult. Interestingly, apathetic participants showed a preference for the VR condition stronger than that of non-apathetic participants. These findings suggest that VR-based training can be considered as an interesting tool to improve adherence to cognitive training in elderly people with cognitive impairment.
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How do older adults living in residential aged care experience leisure activities? What restricts and facilitates participation? These two research questions guided this semi-longitudinal qualitative research, tracking the lived experience of aged care from the perspective of 20 new-aged care residents over 18 months (average age, 80 years) through repeated in-depth semi-structured interviews. Interview data were analyzed using phenomenography, an under-utilized qualitative analysis technique that identifies the variations in how people experience, understand, or conceive of a phenomenon. Phenomenography revealed three qualitatively different ways to understand residents' leisure experience: (1) as a structure for living, (2) creating social connections and (3) maintaining ability. By illustrating the variation and similarities in how these older Australian residents conceptualise and experience leisure in aged care, the findings may help facilitate a more thoughtful understanding that informs theory, policy, and practice.
Article
Purpose of the study: To measure and describe the effectiveness of a Virtual Reality Forest (VRF) on engagement, apathy, and mood states of people with dementia, and explore the experiences of staff, people with dementia and their families. Design and methods: A mixed-methods study conducted between February and May 2016. Ten residents with dementia, 10 family members, and 9 care staff were recruited from 2 residential aged care facilities, operated by one care provider, located in Victoria, Australia. Residents participated in one facilitated VRF session. Residents' mood, apathy, and engagement were measured by the Observed Emotion Rating Scale, Person-Environment Apathy Rating Scale, and Types of Engagement. All participants were interviewed. Results: Overall, the VRF was perceived by residents, family members, and staff to have a positive effect. During the VRF experience, residents experienced more pleasure (p = .008) and a greater level of alertness (p < .001). They also experienced a greater level of fear/anxiety during the forest experience than the comparative normative sample (p = .016). Implications: This initial, small-scale study represents the first to introduce the VRF activity and describe the impact on people with dementia. The VRF was perceived to have a positive effect on people with dementia, although, compared to the normative sample, a greater level of fear/anxiety during the VRF was experienced. This study suggests virtual reality may have the potential to improve quality of life, and the outcomes can be used to inform the development of future Virtual Reality activities for people with dementia.
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Based on the motivational sequence described in Self-Determination Theory, this study explored the relationship between relatedness, motivation, adaptation and leisure in nursing homes. We formulated the hypothesis that the variables of the study would be found in an integrative mediational sequence: Participation in leisure activities → Relatedness → Self-determined motivation → Adaptation to nursing homes. Participants (N = 112, mean age = 84.17) were invited to complete questionnaires assessing these variables. Results of the path analysis found an unsatisfactory fit for this model but revealed another model (Model 2) with a good fit index: Relatedness → Participation in leisure activities → Self-determined motivation → Adaptation to nursing homes → Relatedness. Model 2 fitted better than model 1: the Chi-square values were not significant, Chi² (df = 2) = 5.1, p = .078 and other indices were satisfactory (CFI = .930, RMSEA = .049 and NFI = .918). These results suggest that feeling connected and secure in the relationships with others, and integrated as an individual to the group contribute to enhance leisure practice, self-determined motivation, and finally adaptation to life environment. Consequently, the relatedness promotes leisure activities practice which represents a central adaptive behavior in nursing homes.
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Background: Virtual reality (VR) offers immersive, realistic, three-dimensional experiences that "transport" users to novel environments. Because VR is effective for acute pain and anxiety, it may have benefits for hospitalized patients; however, there are few reports using VR in this setting. Objective: The aim was to evaluate the acceptability and feasibility of VR in a diverse cohort of hospitalized patients. Methods: We assessed the acceptability and feasibility of VR in a cohort of patients admitted to an inpatient hospitalist service over a 4-month period. We excluded patients with motion sickness, stroke, seizure, dementia, nausea, and in isolation. Eligible patients viewed VR experiences (eg, ocean exploration; Cirque du Soleil; tour of Iceland) with Samsung Gear VR goggles. We then conducted semistructured patient interview and performed statistical testing to compare patients willing versus unwilling to use VR. Results: We evaluated 510 patients; 423 were excluded and 57 refused to participate, leaving 30 participants. Patients willing versus unwilling to use VR were younger (mean 49.1, SD 17.4 years vs mean 60.2, SD 17.7 years; P=.01); there were no differences by sex, race, or ethnicity. Among users, most reported a positive experience and indicated that VR could improve pain and anxiety, although many felt the goggles were uncomfortable. Conclusions: Most inpatient users of VR described the experience as pleasant and capable of reducing pain and anxiety. However, few hospitalized patients in this "real-world" series were both eligible and willing to use VR. Consistent with the "digital divide" for emerging technologies, younger patients were more willing to participate. Future research should evaluate the impact of VR on clinical and resource outcomes. Clinicaltrial: Clinicaltrials.gov NCT02456987; https://clinicaltrials.gov/ct2/show/NCT02456987 (Archived by WebCite at http://www.webcitation.org/6iFIMRNh3).
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Objectives: There is limited information on effective balance training techniques including virtual reality (VR)-based balance exercises in residential settings and no studies have been designed to compare the effects of VR-based balance exercises with conventional balance exercises in older adults living in nursing homes in Turkey. The objective of our study was to investigate the effects of VR-based balance exercises on balance and fall risk in comparison to conventional balance exercises in older adults living in nursing homes. Methods: A total sample of 18 subjects (65-82 years of age) with fall history who were randomly assigned to either the VR group (Group 1, n = 7) or the conventional exercise group (Group 2, n = 11) completed the exercise training. Results: In both groups, Berg balance score (BBS), timed up & go duration, and left leg stance and tandem stance duration with eyes closed significantly improved with time (p < 0.05), but changes were similar in both groups (p > 0.05) after training, indicating that neither the exercise method was superior. Conclusion: Similar improvements were found in balance and fall risk with VR-based balance training and conventional balance training in older adults living in the nursing home. Both exercise trainings can be preferable by health care professionals considering fall prevention. Appropriate patient selection is essential.