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: Immersive virtual reality (iVR) has gained considerable attention recently with increasing af-fordability and accessibility of the hardware. iVR applications for older adults present tremen-dous potential for diverse interventions and innovations. The iVR literature, however, provides a limited understanding of guiding design considerations and evaluations pertaining to user expe-rience (UX). To address this gap, we present a state-of-the-art scoping review of literature on iVR applications developed for older adults over 65 years. We performed a search in ACM Digital Library, IEEE Xplore, Scopus, and PubMed (1 January 2010–15 December 2019) and found 36 out of 3874 papers met the inclusion criteria. We identified 10 distinct sets of design considerations that guided target users and physical configuration, hardware use, and software design. Most studies carried episodic UX where only 2 captured anticipated UX and 7 measured longitudinal experiences. We discuss the interplay between our findings and future directions to design effec-tive, safe, and engaging iVR applications for older adults.
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Citation: Ijaz, K.; Tran, T.T.M.;
Kocaballi, A.B.; Calvo, R.A.;
Berkovsky, S.; Ahmadpour, N.
Design Considerations for Immersive
Virtual Reality Applications for Older
Adults: A Scoping Review.
Multimodal Technol. Interact. 2022,6,
60. https://doi.org/10.3390/
mti6070060
Academic Editor: Fotis Liarokapis
Received: 10 June 2022
Accepted: 11 July 2022
Published: 20 July 2022
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4.0/).
Multimodal Technologies
and Interaction
Review
Design Considerations for Immersive Virtual Reality
Applications for Older Adults: A Scoping Review
Kiran Ijaz 1, * , Tram Thi Minh Tran 2, Ahmet Baki Kocaballi 3, Rafael A. Calvo 4, Shlomo Berkovsky 1
and Naseem Ahmadpour 5
1Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University,
North Ryde 2113, Australia; shlomo.berkovsky@mq.edu.au
2Design Lab, School of Architecture, Design and Planning, The University of Sydney, Sydney 2006, Australia;
tram.tran@sydney.edu.au
3School of Computer Science, Faculty of Engineering and IT, University of Technology Sydney,
Sydney 2007, Australia; baki.kocaballi@uts.edu.au
4Dyson School of Design Engineering, Faculty of Engineering, Imperial College London,
London SW7 2BX, UK; r.calvo@imperial.ac.uk
5Affective Interactions Lab, School of Architecture, Design and Planning, The University of Sydney,
Sydney 2006, Australia; naseem.ahmadpour@sydney.edu.au
*Correspondence: kiran.ijaz@mq.edu.au
Abstract:
Immersive virtual reality (iVR) has gained considerable attention recently with increasing
affordability and accessibility of the hardware. iVR applications for older adults present tremendous
potential for diverse interventions and innovations. The iVR literature, however, provides a limited
understanding of guiding design considerations and evaluations pertaining to user experience (UX).
To address this gap, we present a state-of-the-art scoping review of literature on iVR applications
developed for older adults over 65 years. We performed a search in ACM Digital Library, IEEE Xplore,
Scopus, and PubMed (1 January 2010–15 December 2019) and found 36 out of 3874 papers met the
inclusion criteria. We identified 10 distinct sets of design considerations that guided target users and
physical configuration, hardware use, and software design. Most studies carried episodic UX where
only 2 captured anticipated UX and 7 measured longitudinal experiences. We discuss the interplay
between our findings and future directions to design effective, safe, and engaging iVR applications
for older adults.
Keywords: immersive virtual reality; older adults; user experience; design considerations
1. Introduction
The world population is ageing at a faster pace than in previous decades. According
to the world population ageing report [
1
], there are 703 million older adults of age above
65 and this trend is set to increase to 1.5 billion by 2050. This rapid increase demands to
identify the needs of changing population, provide timely services to meet their needs and
support their wellbeing. This must be done with an understanding that older adults are
a diverse group with varied physical and cognitive capabilities and technical literacy. If
designed well, technology can become a great aid to fulfill older adults’ needs and foster
wellbeing goals [2,3].
Emerging technologies such as virtual reality (VR) have seen a growing number
of applications in various domains: entertainment, medicine, training and education,
rehabilitation, architecture, and engineering. In health research, VR terminology has
been interchangeably used to describe a range of displays and environments, e.g., screen
projections. VR systems, however, are broadly categorized as [
4
]: less immersive that show
3D environment on desktop or tablet with limited interactivity; moderately immersive that
project on screen or support interactivity through body-tracking cameras, e.g., Xbox Kinect;
Multimodal Technol. Interact. 2022,6, 60. https://doi.org/10.3390/mti6070060 https://www.mdpi.com/journal/mti
Multimodal Technol. Interact. 2022,6, 60 2 of 26
and highly immersive ones such as CAVE projection system and head-mounted display
(HMD). In this work, we focus on HMD-based highly immersive systems and refer to them
as immersive virtual reality (iVR). Commercially available iVR encompasses a diverse
range varying in cost, types of experiences offered, and possible configuration. One set of
devices are PC-based high-end iVR, such as HTC Vive, Oculus Rift, and Sony PlayStation
VR, which are highly immersive systems with a wide field of view. Other variants like
Samsung Gear and Google Cardboard HMDs are more affordable and operate using mobile
devices. Comparatively, nowadays HMDs offer accessibility, a wide field of view and better
tracking while costing less than their past counterparts [
5
]. This diversity in both end users’
capabilities and available iVR technology not only offers a variety of design choices but
also raises several challenges.
Best practices and guidelines to design iVR applications for older adults are scarce, and
despite the variability of abilities and interests, they are greatly needed. Such guidelines
can help designers take into account the whole spectrum, increasing accessibility to those
who might otherwise be left out. iVR community has recently begun to explore how design
choices in iVR systems impact vulnerable users’ capabilities, including older adult users [
6
].
iVR applications provide a highly immersive user experience with compelling levels of
presence [
7
] due to the wider field of view and efficient tracking capabilities that enable
engaging experiences. However, iVR systems still pose various challenges for older adults
before we reap any potential benefits, despite the advancements made in recent years.
These include technology-related challenges such as cybersickness, discomforts, and heavy
HMDs. Moreover, novelty or unfamiliarity with emerging technology may also undermine
the value it can bring for users who may be technology averse. To leverage potential
benefits, iVR designers need to minimize the challenges and offer experiences that resonate
well with older adults’ needs and desires. However, to achieve the desired outcomes, the
involvement of various stakeholders and users in the design process can be supported by
a better understanding of specific User Experience, system and interaction requirements
of older adults and techniques suitable to involve older adults in User-Centered Design
and the participatory design process. We aim to address this gap through a review of
existing evidence.
Recent review papers have examined the usability and UX of VR for older adults. For
example, Tuena and colleagues conducted a systematic review of usability-specific issues in
VR; however, their scope was specific to clinical applications of all types of VR [
8
]. Kim and
colleagues reviewed the literature on VR UX and challenges for young adults [
9
]. However,
the needs of older and younger adults may not be identical. Others reviewed a wide
spectrum of displays labelled as VR for older adults, lacking focus on HMDs [
10
,
11
], thus
the design recommendations provided were limited in scope. Closer to our work is [
12
].
However, the presented design guidelines were based on a limited number of papers (13)
reviewed from only two databases. We maintain that a wider review of the recent literature
is imminent for a comprehensive set of guidelines. Due to this gap in the literature, we
aim to provide an understanding of existing evidence relevant to the experiences of older
adults to guide future design choices and processes in HMD-based iVR specifically.
Through a scoping review, this research aims to develop a picture of iVR UX design
considerations for older adults and identify trends, gaps, and future directions relevant to
iVR design processes and assessments. Our study is motivated by a gap in useful design
guidelines. As such, we address the following research questions:
1.
What are the design considerations that guide the design and development of immer-
sive VR systems for older adults?
2.
What characterizes the design processes followed to develop iVR systems specific for
older adults?
3.
How to evaluate the user experience of immersive VR for older adults, and what type
of studies and methods are used for evaluation?
4.
What are the reported usability challenges of immersive VR systems for older adults?
Multimodal Technol. Interact. 2022,6, 60 3 of 26
2. Background
In the context of designing for older adults, this section reviews existing literature
pertaining to each research question (RQ). Specifically, older adults’ acceptance of iVR
technology (RQ1), the involvement of older adults in the design process (RQ2), and iVR
user experience design for older adults (RQ3 and RQ4).
2.1. Older Adults’ Acceptance of iVR Technology
Age-related changes are often linked with cognitive decline [
13
], functional limita-
tions [
14
], barriers to physical activity [
15
], and mobility issues [
16
]. Older adults increas-
ingly interact with technology in their homes, at work, and in applications related to
healthcare and quality of life. Functional independence is an important goal for the aged
population to maintain their daily activities [17]. Many technology solutions are explored
to support this goal and aid users to enhance their capabilities as they age [
18
]. Technology-
based interventions, such as video games, chat rooms, 3D virtual environments, robots,
and social networks, were found to be effective in reducing loneliness and social isolation
in older adults [
19
]. Older adults are increasingly aware of various digital platforms, some
of which offer mental health support [
2
]. In addition, it was argued [
20
] the technology
gap among young and older adults would reduce as future ageing populations have better
technology exposure as they grow in the age of the internet.
In recent years, iVR as an emerging technology has been increasingly explored for a
variety of therapeutic and enrichment purposes among the ageing population. In clinical
settings, the technology has been utilized for clinical conditions such as cognitive impair-
ment [
21
], mental disorders [
22
], and movement disorders [
23
]. Regarding the quality of
life, iVR can contribute to the elderly’s emotional, social and physical well-being [
24
27
].
Compared to other types of VR (e.g., computer monitor, large projection screen, CAVE), iVR
offers a fully immersive experience and, to a great extent, supports natural sensorimotor
contingencies for perception [
28
]. Moreover, consumer-grade VR HMDs have become
more affordable and powerful than their predecessors, bringing iVR experiences out of
research labs and into the hands of a broader audience. Standalone VR systems such
as Facebook Oculus Quest also have an uncomplicated setup and a wireless experience.
These advances make HMD-based VR an ideal system to be used in hospitals, care centers,
seniors’ residences, and even at homes.
Older adults, who are well versed in internet usage, are reported to show a willing-
ness to use iVR technology. iVR experiences are positively reviewed by elderly users in
terms of enjoyment and satisfaction [
29
33
] despite the hesitations and negative precon-
ceptions before actual usage, e.g., “virtual reality was a frivolous undertaking that held
little benefit” [
31
]. Nevertheless, iVR as an immature technology also comes with various
usability issues pertaining to hardware and software that must be addressed for optimal
user experience [
29
33
]. Furthermore, older adults with clinical conditions may require
a more sensitive approach in experience design, with careful considerations in the physical
design of systems, shared experiences, multisensory stimulation, personalization, and
active participation [25].
As technologies become more readily available, guiding principles and insights also
emerge. Age-related characteristics and human factors such as vision, hearing, speech,
memory, and physical coordination are most likely to impact UX [
34
37
]. Additionally, [
34
]
highlighted the need for understanding technology literacy and mental models of older
adults to minimize typical usability problems. To a large extent, these guidelines can be
applied to the design of iVR experiences for older adults. However, the fact that they were
formulated based on popular ICT devices, such as smartphones, tablets, and personal
computers, indicates a lack of specificity to the nature of iVR as an emerging technology.
Therefore, for iVR to appeal to elderly users, a comprehensive review of various design
aspects from development to implementation is needed to generate insights on overcoming
the aforementioned challenges.
Multimodal Technol. Interact. 2022,6, 60 4 of 26
2.2. Technology Design with and for Older Adults
Human–Computer Interaction (HCI) research focusing on technology design for older
adults is usually categorized under or together with accessibility studies [
38
], partly because
accessibility issues are more prevalent among older adults. However, addressing these
accessibility issues should not be the only item on the research agenda. Older adults
should not be considered a homogenous group; rather, research must acknowledge them
rightly as complex individuals [
39
], with highly diverse demographics [
38
]. Individual
differences in educational level, income, living arrangement, health status, values, and life
experiences [
34
] contribute to the varying needs and desires of older adults and, therefore,
should be factored into the design process.
Design approaches, such as human-centered design, participatory design, and co-
design enable design with older adults to actively capture their unique experiences as well
as accessibility perspectives, such as cognitive impairment [
40
]. A number of considerations
are noted in the literature in relation to engaging with older adults in participatory processes.
Long discussions may hinder engagement, and particularly in relation to technology,
some find it hard to articulate reflections as well as to picture new technologies [
39
]. If
technologies are not deemed useful, older adult participants may disengage from the
process [
41
]. Older people’s trust in their ability to use a prototype can also be low
due to unfamiliarity with technology; hence, their confidence could easily be shattered
by a usability issue [
42
], or they might not feel comfortable being mixed with younger
participants in the same study session [34].
While the above challenges are by no means exhaustive, they emphasize the complica-
tions associated with involving older adults with varying abilities in the design process. We
postulate that these difficulties may be exacerbated in the context of iVR. For example, the
ergonomic issues of HMD and its fully immersive quality might lead to probable physical
and psychological impacts beyond researchers’ control, raising the need for the engagement
of relevant stakeholders such as family members, carers, and therapists. In this paper, we
critically review existing design processes followed to develop iVR systems for older adults
and synthesize lessons learnt.
2.3. User Experience of iVR for Older Adults
The term User Experience (UX) has been used by researchers and practitioners to refer
to different things [
43
]. In this paper, we adopted the international standard on ergonomics
of human–system interaction, ISO 9241-210, in which user experience is defined as a per-
son’s perceptions and responses that result from the use or anticipated use of a product, system or
service [
44
]. UX is multi-dimensional, concerning user perceptions of both the pragmatic
and hedonic aspects of interactive products [
45
]. Since the cornerstone of VR technology
is its powerfully stimulated experiences, these facets of UX are inherently important to
consider in the process of designing, developing, and evaluating iVR applications [
46
]
proposed and validated a model of user experience in an immersive virtual environment
that consisted of 10 components, namely: presence, engagement, immersion, flow, usability,
skill, emotion, experience consequence, judgement, and technology adoption. Each compo-
nent can be measured using either objective or subjective methods or a combination of the
two. This paper examines which facets or aspects of iVR UX for older adults are typically
evaluated and the measurements used.
Good UX is often linked to positive emotional outcomes while considering the dy-
namic, temporal, and situatedness of the experience [
47
]. The novelty of the iVR technology,
coupled with its seemingly complicated hardware and various side effects, may hinder the
experiences of older adult users. Therefore, to maximize the potential of iVR to improve
the quality of life among older adult users, it is essential to consider iVR UX holistically,
e.g., deliver practice sessions at the beginning, consider how assistance may be provided
during the session, and minimize physiological consequences at the end [
48
]. We argue
that crafting an end-to-end experience will improve the usability of the system and support
Multimodal Technol. Interact. 2022,6, 60 5 of 26
long-term use. For that reason, the analysis also investigates which period of experience
was evaluated in the reviewed studies and key challenges faced by older adults.
3. Method
3.1. Scoping Review Protocol
In this study, we undertook a scoping review in accordance with the guidelines pro-
posed by [
49
]. The database searched included the ACM Digital Library, IEEE Xplore Digital
Library, Elsevier’s Scopus, and PubMed. We selected these databases due to their peer-
review literature focusing on computing, information technology, and biomedical topics.
We tested different combinations of “virtual reality” and “older adults” keywords (as
well as their synonyms) before deciding on the following search string (“virtual reality” OR
“immersive virtual reality” OR “immersive VR”) AND (“older adults” OR “seniors” OR
“elderly”). This query was used consistently throughout the four selected databases. To
search for UX and design in VR, we considered adding “user experience,” “UX,” “design”,
and “frameworks” to the “virtual reality” and “older adults” terms. However, the results
became too narrow since many biomedical or health-focused studies do not explicitly
mention design-related keywords. Therefore, we picked a broader query and invested more
effort in the manual scanning of papers for UX and design aspects. We include the details
of our search strategy in the supplementary material (Supplementary Information S1).
3.2. Selection Criteria
We chose peer-reviewed papers published in English language at conference proceed-
ings or journals based on the following criteria.
Inclusion: Papers were included if they satisfied the following criteria:
Papers presenting systems that were specifically designed for or evaluated with older
adults (65 years old or over), with recent HMDs (introduced after 2010) covering any
range of physical and cognitive capabilities.
Papers that involve mixed user groups of young and older adults with the intention to
capture any specific measures tailored for the older adult user group.
Exclusion: We excluded any study that did not meet the inclusion criteria. Specifically,
we excluded:
Papers in which the systems were designed for or evaluated with a general population
of various age groups.
Papers that report the use of HMD models developed prior to 2010 and mixed real-
ity HMDs.
Papers that use non-HMD VR setups, such as CAVE systems, were excluded because
we were interested to understand characteristics of research in HMD-based setups.
Review papers, perspective, or opinion papers.
Literature on the effectiveness of VR health interventions that focused on primary or
secondary intervention outcomes, sustainability, and intervention adherence, without
examining the impact of VR.
Papers without evaluation and reporting of results, such as demo papers or studies
that focused on just the design phase.
Papers that were published in languages other than English.
3.3. Study Selection
Identification: In two searches conducted in July 2018 and December 2019, we iden-
tified a total of 3874 papers from ACM Digital Library (n = 528), IEEE Xplore (n = 532),
Scopus (n = 2523), and PubMed (n = 291). Duplicates (n = 54) across the databases were
removed in Mendeley Desktop for MacOS.
Screening: Initial screening involved reading the paper titles and abstracts to eliminate
those not meeting the selection criteria. 425 papers were selected.
Multimodal Technol. Interact. 2022,6, 60 6 of 26
Eligibility: The first round of eligibility assessment involved reading full-text papers
to eliminate those not meeting the selection criteria. 65 papers were then selected.
Next, we considered a working definition of ‘design consideration’ as considerations
relevant to the development of VR applications for older adults with specifications relevant
to people, physical configurations, hardware, and software. Our definition state that a de-
sign consideration must be something the authors deliberately implemented with a clearly explained
purpose and rationale behind it with specifications relevant to people, physical configurations, hard-
ware and software. In the second round, 29 papers were eliminated, if offered no evaluation,
not focused on the older adults’ population, and did not provide design information of the
system. For instance, [
50
] was excluded as they offered no design-related information and
mixed user groups. We examined the selected papers more carefully in a second round and
finalized a set of 36 papers) to be included in the review. Supplementary Information S2 in
the supplementary material contains a list of all extracted design considerations in their
original words.
Two reviewers worked on the identification, screening, and the first round of eligibility
assessment (KI and TT), and four reviewers (KI, TT, NA, BK) worked on the second round
to finalize the selection and resolve disagreements. The screening process and the total
number of selected papers in each review stage are shown in a PRISMA flow diagram
(Figure 1).
1
Figure 1. PRISMA flow diagram.
Multimodal Technol. Interact. 2022,6, 60 7 of 26
3.4. Evaluation
For each of the 36 selected papers, we recorded the following details: author, year,
title, paper summary, hardware (type of HMD and other equipment used), commercial
product or bespoke design, narrative of the VR app (e.g., game narrative, tasks, activities),
visual/audio content, physical interactions, postures, embodiment, design considerations,
design process, study method, assessment tools, sample size, age range, gender distribution,
clinical condition (if applicable), study outcome, and reported UX issues.
4. Results
In this section, we present an overview of our analysis corresponding to each re-
search question.
4.1. Overview
4.1.1. Study Objective and Context
We classified the 36 selected papers according to the study objectives and contexts,
as shown in Figure 2. A number of objectives emerged, with wellbeing topics being most
frequent (7), followed by usability-related topics (5) and therapy (5). In terms of context,
22 studies were experimental and conducted in a lab, while others were launched in care or
nursing home facilities (7), community centers (4), homes (1), and participants’ preferred
places (1). One study did not specify its context.
2
Figure 2. Studies classified based on objective and context.
Multimodal Technol. Interact. 2022,6, 60 8 of 26
4.1.2. Study Participants
The majority of the studies (22) were evaluated with older adults. However, there were
11 papers where young adults were recruited for comparison with older adults. In 4 papers,
experts were recruited, which involved therapists [
6
,
22
], care facility staff members [
51
],
and older adult carers [25].
The reported age range of the participants in the selected papers was 18 to 101 years;
however, all papers included older adult participants (=> 65 years). The majority of studies
recruited healthy participants (25), while 8 papers included patients with health problems.
Of note, 3 papers evaluated iVR experiences with both groups; patients diagnosed with psy-
chological conditions and healthy population with no clinical condition reported
[33,52,53].
The female representation in the older adult sample size ranged from 40% [
51
] to 100% [
54
],
as shown in Figure 3a.
3
Figure 3. Studies classified based on sex ratio in sample size (a) and HMD type (b).
4.1.3. HMD Type
Various consumer HMDs were used in the selected papers (Figure 3b), including
Oculus Rift (15), HTC Vive (11), Samsung Gear (4) or Odyssey (1), Google Cardboard (2),
nVisor ST50 (2), Revelation 3D (1), Pico 4k G2 (1), indicating Oculus Rift and HTC Vive
were the two most widely used HMDs.
4.1.4. Application Content
In terms of iVR environment, 27 papers designed bespoke experiences where the re-
maining (9) used off-the-shelf commercially available content. Most popular visual content
was 3D rendered virtual environment (VE), VR games, and 360 videos. However, a few
papers designed photorealistic imagery [
55
] and 3D augmented virtual [
56
] environments
by mapping real-world objects in iVR. 3D VE mostly facilitated task-based narrative, while
iVR games had an element of fun to engage players. 360-degree videos were also used to
simulate relatable scenarios (See Table 1for more details of the visual content, narrative,
and audio offered).
Multimodal Technol. Interact. 2022,6, 60 9 of 26
Table 1.
Summary of 36 reviewed papers (OA: older adults, YA: young adults, en dash "–": Not specified). The papers were arranged alphabetically by the first
author’s surname and divided into three sections: A, B, and C.
Section A
References Objectives Context Hardware Type of
Application Narrative Visual Audio Cohort OA Sample
Size (Female)
OA Age
Range
OA Clinical
Condition
Ahmed et al.
(2018)
Psychological
disorders Lab setting Oculus Rift Bespoke
(1) Wrist and arm exercise for
physical fitness and (2) navigation
practice for memorization
VR game OA 20 (15F) 55–84 Both
Andringa et al.
(2019) Cognitive training Day care
centre HTC Vive Bespoke Play VR balloon pricking game VR game OA 10 (7F) Both
Baker, Kelly
et al. (2019) Wellbeing Lab setting
HTC Vive
and Oculus
Rift
Bespoke Sit around a reflective pond and
talk to each other 3D VE OA 22 (11F) 70–81 Healthy
Baker, Waycott
et al. (2019) Wellbeing Resident
facilities Oculus Rift Commercial
Play games such as Quil (drawing),
Ocean Rift (discovery), ToyBox, and
Power Solitaire
VR game OA, Staff 5 (2F) 74–88 Patient
Banville et al.
(2018)
Neuropsychological
Lab setting Oculus Rift Bespoke Perform several tasks alone based
on daily life 3D VE OA, YA 11 (8F) 63–72 Healthy
Baqai et al.
(2019) Physiotherapy Lab setting Oculus Rift Bespoke Collect fruits hanging from a tree VR game Audio
feedback OA, YA 2 (1F) 58–68 Patient
Benham et al.
(2019) Pain management Senior day
centre HTC Vive Commercial Play popular games (engagement
with pets, interactive music, travel) VR game OA 12 (8F) Mean 70.2 Patient
Brown (2019)
Usability,
Preferences,
Application
Lab setting Samsung
Gear VR Bespoke
Watch a series of 6 videos consisted
of walks and drives around the
town of the participants
360video OA 10 (8F) 63–89 Healthy
Bruun-
Pedersen et al.
(2016)
Physiothrepapy Nursing
home Oculus Rift Bespoke Bike through nature-based trails 3D VE Bird
tweets OA 9 (9F) 69–101 Healthy
Coldham and
Cook (2017) Usability Lab setting HTC Vive Commercial Navigate to any point in Google
Earth and find their way home 3D VE
Background
noise OA 19 > 65 Healthy
Eisapour et al.
(2018a) Physiotherapy
Long-term
care,
retirement
home
Oculus Rift Bespoke Do activities focusing on upper
body motions VR game Audio in-
struction
OA,
Therapists 3 Patient
Eisapour et al.
(2018b) Physiotherapy
Long-term
care,
retirement
home
Oculus Rift Bespoke Do five motions related to neck,
shoulders, and arms VR game Audio in-
struction
OA,
Therapists 6 (5F) Mean 86.8 Patient
Multimodal Technol. Interact. 2022,6, 60 10 of 26
Table 1. Cont.
Section B
References Objectives Context Hardware Type of
Application Narrative Visual Audio Cohort OA Sample
Size, Female
OA Age
Range
OA Clinical
Condition
Hodge et al.,
(2018) Entertainment Community
centre
Google
Cardboard;
Unspecified
HMD
Bespoke Explore and navigate through VR
environments 3D VE Ambient
sound
OA,
Carers 4 53–83 Patient
Howes et al.
(2019) Fall & Balance Day centre Oculus Rift Bespoke
Do four mini-exergames (a) knee
bends; (b) leg abduction; (c)
sideways walking; (d) one leg
stand.
VR game OA 4 > 65 Healthy
Huang (2019) Cognitive training Lab setting Oculus Rift Commercial Play Fruit Ninja game VR game OA 16 Healthy
Huygelier et al.
(2019)
Usability
(Acceptance) Lab setting Oculus Rift Commercial Experience the VR application
Perfect of nDreams 3D VE OA 38 (19F) 60–92 Healthy
Ijaz et al.
(2016) Wellbeing Community
centre Oculus Rift Bespoke
Experience a virtual tour or beat the
previous players by finding more
landmarks in competetive game
VR game Audio
feedback OA, YA 20 60–92 Healthy
Ijaz et al.
(2019) Spatial navigation Lab setting Oculus Rift Bespoke Take a landmark recall test
Immersive
photoreal-
istic
imagery
Audio in-
struction OA 22 50–89 Healthy
Janeh et al.
(2018) Gait Lab setting HTC Vive Bespoke Walk at a normal pace along the
virtual walkway 3D VE OA, YA 21 (12F) 45–83 Healthy
Kim et al.
(2017)
Neuro-
rehabilitation Lab setting Oculus Rift Bespoke
Walk forward in a virtual city on a
pedestrian path for 800m, on a
treadmill
3D VE OA, YA 22 (16F) Mean: 65 Both
Korsgaard
et al. (2019) Wellbeing Lab setting Oculus Rift
CV1 Bespoke
Talk to older friends while eating a
solitary meal in augmented
virtuality.
3D aug-
mented
VE
OA 27 (20F) > 65 Healthy
Kovar (2019) Anxiety Samsung
Gear VR Bespoke
Watch 360video that gradually
simulated similar but easier
traumatic event as he overcame in
the past
360video
Environment
sound OA 4 (2F) 61–77 Patient
Lai et al.
(2019) Entertainment Lab setting HTC Vive
Pro Commercial
Play one of the three different VR
applications, i.e., The Blu, Fruit
Ninja, and Tilt Brush
VR game OA 14 (9F) 54–82 Healthy
Lecavalier
et al. (2018)
Memory
assessment Lab setting Nvisor ST50 Bespoke Memorise a shopping list and then
fetch the items in the store 3D VE Ambient
sound OA, YA 57 (47F) Mean:
67.77 Healthy
Multimodal Technol. Interact. 2022,6, 60 11 of 26
Table 1. Cont.
Section C
References Objectives Context Hardware Type of
Application Narrative Visual Audio Cohort OA Sample
Size, Female
OA Age
Range
OA Clinical
Condition
Liao et al.
(2019) Gait Community
centre HTC Vive Bespoke
Imitate the virtual character and
adjust their movements based on
the simultaneous visual and
auditory feedback
3D VE Audio
feedback OA 18 (11F) >65 Patient
Lin et al.
(2018) Wellbeing
Assisted
living com-
munities
Samsung
Gear VR Commercial Watch videos, Google Street View,
and guided tours 360video OA Pre: 35 (23F),
Post: 31 (21F) 68–99 Healthy
Liu et al.
(2018) Wellbeing Community
centre Pico 4K G2 Commercial Watch video contained China’s
sceneries 360video OA, YA 58 (36F) 60–91 Healthy
Micarelli et al.
(2019) Rehabilitation Home-based
setting
Revelation
3D Bespoke Play the Track Speed Racing 3D
game by tilting the head VR game OA 47 (26F) Mean 76.3 Patient
Mol et al.
(2019) Wellbeing
Participants’
preferred
places
Google
Cardboard Bespoke Dance an old song (Y.M.C.A.)
inside the living room VR game Ambient
sound OA 10 (8F) 60–77 Healthy
Ouellet et al.
(2019)
Memory
assessment Lab setting Nvisor ST50 Bespoke
Participants memorize shopping
list and later have to "buy" these
same items
3D VE Ambient
sound OA, YA 54 (44F)
Mean 68
Mean
67.20
Both
Plechatáet al.
(2019)
Memory
assessment Lab setting HTC Vive Bespoke
Memorize a shopping list and later
find and collect recalled items in
the virtual grocery store
3D VE OA, YA 36 (23F) 60–91 Healthy
Roberts et al.
(2019)
Usability
(Acceptance) Lab setting Samsung
Gear VR Commercial
View two audio-visual VR
simulations ("Jurassic World" and
"Cirque du Soleil")
3D VE OA 41 (31F) 50–99 Both
Sakhare et al.
(2019) Spatial navigation Lab setting HTC Vive
Pro Bespoke Bike 0.5 miles to a fountain
landmark 3D VE Music OA, YA 20 (10F) 52–70 Healthy
Seo et al.
(2019)
Usability
(Experience) Lab setting Samsung
Odyssey Bespoke Evacuate the subway station 3D VE OA, YA 5 (4F) 65–77 Healthy
Süzer and
Olguntürk
(2018)
Spatial navigation Lab setting HTC Vive Bespoke Take route replication task and
picture classification test 3D VR OA 90 (45F) 65–80 Healthy
Yang (2019) Therapy Lab setting HTC Vive Bespoke Help Little Red Riding Hood to
navigate through the game VR game
Audio
feedback,
Music
OA 6 65–70 Healthy
Multimodal Technol. Interact. 2022,6, 60 12 of 26
4.2. Design Considerations
We identified and categorized design considerations in the selected papers in two ways.
In a top-down approach, we structured the design considerations based on our definition
across three layers of interactions between the participants and the iVR systems. The first
layer is Physical and People Configuration, specifying how the participants engaged with the
study environment setup and the researchers involved. The second layer characterizes the
Hardware, comprising iVR HMD, controllers, and other equipment involved. The last layer
is Software, interfacing the features and allowing the user to experience the virtual world.
In a bottom-up approach, we then identified design considerations in the selected papers
and categorized them thematically using the affinity diagramming method [57].
We identified ten categories of design considerations that guided the target users and
physical configuration, hardware use, and design (or selection) of iVR software: onboard-
ing and assistance, safety, embodiment, environment, sound, realism, personalization,
usability, engagement, and consequences. Details of individual design consideration are
visualized in Figure 4and summarized in the following sub-sections. Note that these
categories are not mutually exclusive, and papers may appear under multiple design con-
siderations if they had considered UX as a complex and multi-faceted concept that entails
various considerations.
4
Figure 4. Design considerations grouped by themes and clusters.
Multimodal Technol. Interact. 2022,6, 60 13 of 26
4.2.1. Onboarding and Assistance
In total, 14 papers considered creating opportunities for onboarding to help older
adults become accustomed to novel iVR apps and receive assistance and support when
needed. A number of papers entailed multiple considerations in this area. These included
having researchers present throughout the session to assist with [
24
,
32
,
55
,
58
], introduction
to the equipment [
24
,
30
32
,
59
61
], assistance with the equipment use [
26
,
54
], and providing
application tutorials. The latter was achieved in a number of ways: in-person training [
58
],
through a demo with mini-tasks [
26
,
53
,
54
], a demo of commercial applications, e.g., Oculus
First Contact [51] or Steam VR [31], reading or listening to instructions [6,55,58].
4.2.2. Safety
Safety of older adult users while using iVR was addressed in relation to people
and physical configuration in 12 papers. To ensure safety, 6 papers considered people
configuration such as the presence of a researcher or expert therapists [
22
], 6 papers used
seated physical configuration such as cushioned swivel chair [
22
,
30
,
32
,
58
,
59
,
62
], 2 papers
used platforms that provide stable movement such as stable recumbent exercise tricycle [
26
]
and treadmill with a controlled speed [52]. Other considerations included positioning the
participants’ wheelchairs at the center of the tracking space to ensure that they do not
need to extend their arms too far to reach out [
51
], using a chair with arms to support
stability [30], using an exercise mat to prevent falls [63], and utilizing hand aid [59].
4.2.3. Embodiment
Embodiment, defined as a person’s self-perception of their bodily ownership, was
considered through people and physical configuration and VR software in 5 papers [
53
]
demonstrated how navigation in VR can be paralleled with natural walking (physical
configuration) in order to enhance the user’s experience of presence (i.e., feeling as if they
are there in the virtual world). Other considerations were linked to software design. The
user’s relative height was adjusted (e.g., relative to other objects such as trees) to provide a
correct altitude in the iVR environment and field of view [
25
,
63
]. Two papers used avatars
to represent the user’s body [
56
,
63
], ensuring visibility of various body parts and any
immediate interactions. One study used the tunneling technique during locomotion to
reduce motion sickness on sharp turns while the user was on a virtual bicycle [64].
4.2.4. Visuals
The visual design of iVR spans across several software elements like landscape, build-
ings, virtual objects, and avatars/characters This aspect was addressed in 13 papers, with
considerations extending across multiple areas. Two papers considered providing mean-
ingful and relatable activities [
6
,
53
] to enhance engagement. Designing familiar scenes
in iVR was considered in 7 papers, which included the following environments: farm or
rural [
6
,
22
], nature [
32
,
54
,
65
], living room with classic furniture [
66
]. Considerations for
simple, vibrant, and contrasting colors were demonstrated in 2 papers to assist the visual
functioning that declines with age [
58
,
67
]. To avoid cognitive load and distraction, 3 papers
limited the number of virtual objects in the environment [6,22,55].
Object design was addressed in 2 papers, with one providing proportional geome-
try [
66
] and the other a sense of spatial stability using dimensions as the real assessment
room [
68
]. Additionally, two papers provided assistance with orientation and locomotion
in VR using navigation aids, such as a compass and map [
26
,
55
]. Other considerations
that were mentioned in just one paper each were: avoiding moving objects and rotating
actions that may cause motion sickness while maintaining high-quality rendering and
frame rate [
25
], mindful positioning of objects in the field of view to match user’s physical
capabilities [
6
], and using 360-degree head movements to allow natural visual affordances
to enhance immersion [68].
Multimodal Technol. Interact. 2022,6, 60 14 of 26
4.2.5. Audio
Sound and audio experience were considered in 13 papers. Spatial audio was used in
2 papers to give a directional cue in the 3D environment [
24
,
66
], although some participants
were unsuccessful in detecting the direction of the voice. Ambient sounds were used in
4 papers in forms of natural sound of waves, wind, and birds to complement the envi-
ronment [
25
], background noise for realistic effect [
53
,
68
], and music for enjoyment [
64
].
Audio feedback was used in 4 papers to indicate scores and successful actions [
63
], naviga-
tion cues [
26
], situational awareness [
65
], as well as to provide feedback on participants’
movement [
21
]. Audio instructions were used in 3 papers to transition users into the VR
scenes [6] and deliver task instructions [22,55].
4.2.6. Realism
Maximizing realism of virtual experiences was only considered in 2 papers. One
demonstrated realism through authentic tasks and scenarios [
31
]. Another embedded
human-like avatars that speak and act like a human [
24
] to achieve a sense of realism.
While not explicitly categorized as realism, some studies demonstrated visual elements
and ambient sounds that may be described as contributing to a sense of realism. However,
those papers are listed in Sections 4.2.4 and 4.2.5 and are not repeated under this section.
4.2.7. Personalization
Personalized hardware and software were considered in 8 papers to fulfill older adults’
capability needs. This included personalizing the narratives in 4 papers to have familiar
elements and places known to users and reduce their cognitive load [
25
,
26
,
65
,
66
]. Allowing
users to select iVR apps that meet their preferences (e.g., power solitaire, painting game
Quill) was considered in 2 papers [
51
,
62
]. Lastly, one study used customizable hardware to
accommodate additional tasks while allowing the use of equipment that is known to users
to provide less demanding interaction modes (e.g., using a joystick instead of a conventional
VR controller, which offers smoother movement) [55].
4.2.8. Usability
Usability considerations spanned across the hardware and software levels in 6 pa-
pers [
22
] limited the use of controllers and button presses during iVR interaction to aid user
learning and reduce cognitive load. In relation to software design, [
6
] used a simple and
intuitive iVR user interface [
55
] used large fonts and objects with clear signage to guide
users while repeating instructions and task reminders on the iVR interface [
59
] considered
the use of colors and enhancing clarity and ease of reading the text in the iVR [
6
] used
haptic feedback, such as controller vibration, to trigger user tasks or actions [
53
] used
a two-step response process (e.g., select and validate) to confirm user selection and avoid
any errors or unintentional button presses [30] simplified menu navigation.
4.2.9. Engagement
A few design considerations aimed to capture user attention and provide a sense of
value in iVR experience through relatable or gamified tasks. Engagement-related design
considerations were identified in 5 papers. Using game rewards was considered in 2 pa-
pers [
64
,
65
], pointing to the importance of maintaining a simple design to foster a sense of
accomplishment [
65
]. Gamification in the form of different game levels or leaderboards to
engage users in competition [
26
,
69
] was used in 2 papers. One paper considered a realistic
activity-based design with clear actions, tools, and aims [58].
4.2.10. Minimize Side Effects
We identified 8 papers that considered minimizing the iVR side effects, predominantly
in relation to hardware and software. Reducing users’ anxiety was considered in one paper
by providing extra familiarization time with iVR devices [
60
]. Another paper considered
clear instructions on tasks to put users at ease, specifically while transitioning from one
Multimodal Technol. Interact. 2022,6, 60 15 of 26
scene to another [
6
]. Additionally, one paper considered maintaining communication with
users to ensure they are not feeling sick while maintaining low-latency tracking and using
a high frame rate [
54
]. Another paper considered giving users full control of their motion in
the environment to reduce symptoms of motion sickness [
32
]. Minimizing stress was con-
sidered in another 2 papers through eliminating task completion time limits
[55,58].
Finally,
2 papers considered avoiding over-exertion through reducing the interaction time [
26
] and
allowing users to take regular breaks [65].
4.3. Design Process
We identified 12 papers that reported, in detail, the process of designing iVR ex-
periences for older adults. A human-centered design approach was employed in 7 pa-
pers [
6
,
22
,
25
,
56
,
59
,
60
,
65
], whereby user needs and requirements were identified and user
feedback was collected throughout the process (e.g., interviews) [
27
] followed a similar
process for selecting commercial applications, specifically focusing on users’ social re-
lationships, daily activities, physical and cognitive abilities, as well as emotional needs.
Moreover, participatory action research with iterative cycles of planning, action, and reflec-
tion was considered in one paper [
24
]. Apart from users, other stakeholders were involved
in a number of studies, including kinesiologists [
6
,
22
], therapists [
6
,
22
], clinicians [
59
],
developers [
59
], psychologists [
55
], and carers [
25
]. Finally, design requirements were
generated from existing literature in 4 papers [25,58,65,66].
4.4. Evaluation
Out of the 36 papers, 35 used UX research methods which can be classified into
quantitative, qualitative, and mixed methods, as summarized in Table 2. One study did not
report a typical UX evaluation [
21
] and instead focused on measuring executive functions
and dual-task gait performance.
Table 2. Research methods used.
UX Research Methods Number of Articles (%) References Type of Methods
None 1 (2.8%) Liao et al. (2019)
Qualitative 9 (25%)
Baker, Kelly et al. (2019),
Benham et al. (2019), Brown (2019),
Coldham and Cook (2017), Eisapour et al. (2018a),
Hodge et al. (2018), Korsgaard et al. (2019),
Seo et al. (2019), Yang (2019)
Focus groups,
interviews,
observations, audio,
and video
recordings.
Quantitative 15 (41.7%)
Ahmed et al. (2018), Banville et al. (2018),
Eisapour et al. (2018b), Huang (2019),
Huygelier et al. (2019), Janeh et al. (2018),
Kim et al. (2017), Kovar (2019), Lai et al. (2019),
Lecavalier et al. (2018), Micarelli et al. (2019),
Ouellet et al. (2019), Plechatáet al. (2019),
Sakhare et al. (2019), Süzer and Olguntürk (2018)
Physiological data,
task performance
data, standardised
and custom
questionnaires.
Mixed methods 11 (30.5%)
Andringa et al. (2019),
Baker, Waycott et al. (2019), Baqai et al. (2019),
Bruun-Pedersen et al. (2016), Howes et al. (2019),
Ijaz et al. (2016), Ijaz et al. (2019), Lin et al. (2018),
Liu et al. (2019), Mol et al. (2019),
Roberts et al. (2019)
The evaluated aspects of UX varied across the studies, as shown in Table 3. Overall,
UX [
70
] was addressed in 13 papers, mainly using qualitative techniques such as inter-
views. Standardized questionnaires were frequently used to measure cybersickness (8), e.g.,
Simulator Sickness Questionnaire [
71
], and presence (12), e.g., Slater-Usoh-Steed Presence
Questionnaire [
72
]. Other types of standardized questionnaires included the Intrinsic Moti-
Multimodal Technol. Interact. 2022,6, 60 16 of 26
vation Inventory [
73
] to assess user acceptance [
32
] and the International Test Commission
Sense of Presence Inventory [74] to develop an assessment of enjoyment and immersion.
Table 3. Evaluated UX aspects.
UX Aspects Number of Articles (%) References
Generic 13 (36.1%)
Andringa et al. (2019), Baker, Kelly et al. (2019),
Baker, Waycott et al. (2019), Brown (2019),
Bruun-Pedersen et al. (2016), Eisapour et al. (2018a),
Hodge et al. (2018), Howes et al. (2019), Ijaz et al. (2016),
Ijaz et al. (2019), Korsgaard et al. (2019), Mol et al. (2019),
Yang (2019)
Presence/Immersion 12 (33.3%)
Banville et al. (2018), Bruun-Pedersen et al. (2016),
Eisapour et al. (2018a), Huang (2019), Huygelier et al. (2019),
Janeh et al. (2018), Kim et al. (2017), Lecavalier et al. (2018),
Liu et al. (2019), Roberts et al. (2019), Sakhare et al. (2019),
Süzer and Olguntürk (2018)
Performance 10 (27.8%)
Ahmed et al. (2018), Andringa et al. (2019), Banville et al. (2018),
Baqai et al. (2019), Ijaz et al. (2019), Lecavalier et al. (2018),
Ouellet et al. (2019), Plechatáet al. (2019), Sakhare et al. (2019),
Süzer and Olguntürk (2018)
Others * 9 (25.0%)
Andringa et al. (2019), Baqai et al. (2019), Brown (2019),
Eisapour et al. (2018b), Ijaz et al. (2016), Howes et al. (2019),
Roberts et al. (2019), Sakhare et al. (2019), Seo et al. (2019)
Cybersickness/Discomfort/
Challenges 8 (22.2%)
Banville et al. (2018), Huygelier et al. (2019), Janeh et al. (2018),
Kim et al. (2017), Lecavalier et al. (2018), Micarelli et al. (2019),
Sakhare et al. (2019), Seo et al. (2019)
Experience 7 (19.4%)
Baker, Kelly et al. (2019), Baker, Waycott et al. (2019),
Baqai et al. (2019), Benham et al. (2019),
Bruun-Pedersen et al. (2016), Coldham and Cook (2017),
Mol et al. (2019)
Motivation 7 (19.4%)
Andringa et al. (2019), Baker, Kelly et al. (2019),
Bruun-Pedersen et al. (2016), Huygelier et al. (2019),
Ijaz et al. (2016), Ijaz et al. (2019), Lecavalier et al. (2018)
Usability/Applicability/
Acceptability/Perceived
Usefulness/Desirability
7 (19.4%)
Baker, Waycott et al. (2019), Bruun-Pedersen et al. (2016),
Howes et al. (2019), Huygelier et al. (2019), Lin et al. (2018),
Plechatáet al. (2019), Roberts et al. (2019)
Affect/Emotion/Feeling 6 (16.7%) Lai et al. (2019), Lin et al. (2018), Liu et al. (2019),
Mol et al. (2019), Roberts et al. (2019), Seo et al. (2019)
Attitude/Perception 6 (16.7%) Brown (2019), Huygelier et al. (2019), Lai et al. (2019),
Lin et al. (2018), Liu et al. (2019), Mol et al. (2019)
Anxiety/Stress 5 (13.9%) Andringa et al. (2019), Ijaz et al. (2019), Kim et al. (2017),
Kovar (2019), Sakhare et al. (2019)
Enjoyment 4 (11.1%) Andringa et al. (2019), Eisapour et al. (2018b),
Huygelier et al. (2019), Ijaz et al. (2016)
Satisfaction/
Likely to recommend 3 (8.3%) Eisapour et al. (2018b), Ijaz et al. (2019), Lin et al. (2018)
* Other aspects include: Safety, Competence, Connectedness, Preferences, Comfort, Engagement, Exertion, Task
understanding, Familarity.
Episodic UX, which involves assessing user experience post-interaction, was evaluated
in almost all the papers (34), except for a study by [
62
]. Meanwhile, 13 papers involved real-
time UX evaluations using physiological data [
27
,
55
,
60
,
63
], experience sampling during the
interaction [
26
,
54
], observation notes or video recordings [
2
,
6
,
29
,
51
,
56
,
59
,
66
]. Anticipated
UX was evaluated in 2 papers [
32
,
75
] to capture user expectations prior to interaction.
Multimodal Technol. Interact. 2022,6, 60 17 of 26
Only 7 papers involved longitudinal evaluation of UX; two papers gathered participants’
feedback at the end of the intervention period using an open-ended questionnaire [
62
]
and interviews [
75
], another had daily and weekly evaluation of physical activity [
22
].
Meanwhile, UX data were collected after each session over a number of sessions in other
papers [51,58,60,61].
4.5. Reported Usability Challenges
User challenges reported in the selected papers were linked to HMD, controllers, visual
content, audio, and physical motion. As shown in Figure 5, the largest number of issues
was reported in relation to hardware (75), followed by visual content (16). A UX trade-
off can be identified between compact devices and high-quality rendering; for example,
most standalone VR HMDs are light and non-tethered (supporting good UX) but lack
processing power (diminishing UX). However, the gap between these all-in-one headsets
and those with wired connections is gradually narrowing as the new generation of devices
are commercialized.
5
Figure 5. Challenges reported for older adults in iVR.
Multimodal Technol. Interact. 2022,6, 60 18 of 26
In relation to HMD, 15 papers reported simulator sickness (e.g., dizziness, nausea,
headaches), 11 reported fatigue and discomfort, and 8 reported complaints about the HMD
weight. Older adult users voiced challenges in remembering how to operate controllers
in 3 papers. Visual content was perceived as unrealistic in 5 papers. The novelty of iVR
introduced further challenges for older adults in 4 papers. Audio and sound direction was
reported as a challenge in 2 papers [
24
,
33
]. Age-related changes, such as limited physical
movement, caused frustration and made some visual content inaccessible in 5 papers.
Other challenges included claustrophobia, stress, fear of short circuits, alignment with the
real world, feeling like a passive observer, dislike of low lighting visuals, hearing issues
due to both low or loud audio, and risk of fall.
4.6. Summary
To summarize: (1) software design considerations currently dominate the literature;
(2) however, physical configuration received less attention; (4) human-centered design
and engagement with stakeholders are considered best practices in iVR design; (5) UX
evaluation is dominated by momentary and episodic assessments and there may be an
opportunity to further investigate anticipated and longitudinal UX evaluation; (6) here may
also be an opportunity to further examine the impact of older adults’ stress, enjoyment,
psychological needs, preferences and comfort with iVR UX; (7) clear opportunities exist in
resolving the reported usability challenges, such as motion sickness, lack of comfort due to
HMD design and weight, learnability of hardware interaction (e.g., controller), balancing
the novelty impact (e.g., by enhancing realism), and improving accessibility both in terms
of sensory experience (e.g., audio) and physical interactions.
5. Discussion
In this review, we identified 10 categories of iVR design considerations for older
adult users and investigated existing trends in design processes, UX evaluation, as well
as usability challenges, which can inform the design of future iVR applications. In this
section, we reflect on our findings and discuss the limitations of our study. The first section
discusses design considerations to address RQ1, followed by a section on the design process
to address RQ2, the evaluation to address RQ3, and finally, a section on usability challenges
to address RQ4.
5.1. Design Considerations
The following categories of iVR design concerns were derived from empirical research
published in 36 papers to explore RQ1: Onboarding and Assistance, Safety, Embodiment,
Visuals, Audio, Realism, Personalization, Usability, Engagement, and Minimizing Side Ef-
fects. Because study aims, the complexity of iVR systems, and sample characteristics varied
across research, we viewed the synthesized design considerations as comprehensive but
preliminary, prompting future work to determine their effectiveness and generalizability
to a larger audience. Additionally, our detailed analysis uncovered key challenges and
tensions identified in multiple studies but not addressed that merit further discussion.
5.1.1. Tension between “Familiar” vs. “New” experiences
Of the design considerations identified, onboarding and assistance were mentioned
most frequently. Older adult users were found to experience anxiety when interacting with
less familiar technologies [
60
,
76
]. Supporting familiarization with novel iVR configuration,
hardware, and software at the beginning of the interaction is therefore essential to older
adults’ UX.
Cultivating familiar narratives in software and experiences with configuration and
hardware during the interaction was found to provide better UX to older adults due to
alignment with their mental models. Existing literature does not provide much guidance
as to what makes software familiar [
77
] suggested that virtual environments can appear
more familiar, despite the novelty of the experience, if they trigger previously known
Multimodal Technol. Interact. 2022,6, 60 19 of 26
scenes. Similarly, [
25
] suggested blending the aspects of old and familiar experiences
in new settings, particularly for users with cognitive decline [
30
] suggested that making
familiar environments accessible to older adults (e.g., through a virtual tour) is enjoyable for
those who may not be able to visit or easily navigate the old places. Familiar environments
and contexts have emotional values that older adult users find enjoyable [
10
]. Importantly,
users over 60 years of age are found susceptible to cybersickness effects when exposed
to unfamiliar content in iVR [
78
]. Therefore, initial onboarding appears to be useful for
non-tech savvy users to gain familiarity and reach a comfortable interaction. Using the
new iVR medium and yet providing familiar experiences demands careful and balanced
design strategies for older adults; however, future research should uncover expectations of
adults who grow old in the age of the internet, are more familiar with iVR, and are open to
experiencing novel interactions.
While familiarity may facilitate interaction, [
30
] noted that familiar content in iVR
may have emotional consequences and aggravate the disconnect, loneliness, and anxiety
in older adults. For example, [
23
] found that viewing one’s own images in immersive
360-degree videos resulted in various reactions in users with Parkinson’s disease due to
the depiction of their frailty, with some users finding it distressing and losing motivation
for physiotherapy activities. The authors also suggested that preparation and onboarding
could mitigate this impact.
Choices made in relation to iVR configuration, software, and hardware have ethical conse-
quences; however, more evidence and guidelines are needed to inform future developments.
5.1.2. Transition between Virtual to Real World
A considerable number of design considerations identified in the 36 selected papers
focus on supporting users in discrete phases, especially prior to (onboarding) and during
the interaction with iVR. However, we did not find much information about user transitions
from the real to the virtual world, the internal transition(s) within iVR, or the final transition
from the virtual to the real world, which is important as immersed iVR users experience
a reduced sense of real world during their interaction [
79
]. This may be considered an
opportunity for future research as this transition was not mentioned in any of the studies
reviewed. To maintain UX continuity, a smooth transition from one virtual scene to another
is deemed important [
80
] Transition to the real world involves both mental and physical
awareness of exiting the iVR boundary [
30
] reported that older adults face balance issues
when removing iVR HMD. Providing a smooth exit transition is, therefore, vital to prevent
spatial disorientation [
81
] suggested designing virtual worlds with a sense of realism that
offers a smooth transition to and from the virtual world. In a qualitative study, [
82
] explored
UX across space, control, sociality, time, and sensory adaption as users transitioned out
of iVR, which may guide future research in this area. We suggest future research should
consider holistic studies that address transitions across the iVR experience.
5.1.3. Active vs. Passive User Participation in Immersive Experiences
Our review suggests that iVR designed for older adults considers users as either
passive observers (e.g., watching a 360-degree video) or active players (e.g., interactive
games). Older adults seem to prefer fully immersive virtual environments that appear
realistic over video-based VR content [
83
]. Active iVR participation offers interactive
experiences and provides a higher sense of agency and presence [
84
], which can lead to
more engaging experiences. In terms of realistic environments, [
85
] showed that active
exploration of the environment and object structure can enhance recognizability, compared
to passive observation. In the health domain, active iVR engagement is found to be
particularly effective and sufficiently distracting in managing pain [
86
,
87
] while providing
opportunities for personal growth [88].
Our review uncovers a broad range of applications designed for older adults, including
360-degree videos, 3D interactive environments, and gameplay. The choice of iVR content
and hardware for older adults should provide personalization opportunities to meet their
Multimodal Technol. Interact. 2022,6, 60 20 of 26
physical and cognitive abilities [
26
] suggested keeping a relaxed interaction pace during an
active exergame play to avoid over-exertion of older adult users. Similarly, [
65
] designed
a temporary meditation room and kept game time limited to allow rest time. Therefore,
design considerations often vary for these experiences depending on the type and range of
interaction intended, as well as safety concerns.
5.2. Design Process
In addition to design considerations found, we regard the design process followed
as critical for experiences catering to older audience needs. Thus, we investigated the
characteristics of the design process followed in the included papers. While it is evident
that the inclusion of older adults into the design process results in highly relevant insights,
the number of papers reporting the use of a human-centered design or participatory ap-
proaches to create bespoke iVR experiences was relatively small. Some notable challenges
found in our review include recruitment difficulties (especially with people with demen-
tia) [
25
,
51
], limited time spent with the participants [
25
], and the inability or unwillingness
of the participants to travel to a research center [
59
]. Nonetheless, building an extended
engagement with a few participants still helped to inform the development of a tailored
environment [
25
]. Conversations that take place in care or community centers also ben-
efit from a familiar and friendly atmosphere. For example, [
25
] integrated workshops
and interviews into an existing schedule, i.e., afternoon tea sessions, at the community
centers. In these engagements, HMD-VR systems and existing VR programs were often
introduced early to gauge older adults’ opinions and experiences [
6
,
59
], helping to resolve
the difficulties envisioning new technology—an issue that was previously raised by [
39
,
89
].
Apart from end-users, involving other stakeholders in the design process adds unique
and pertinent viewpoints that contribute to the overall quality of iVR programs. For
instance, [
6
] consulted with kinesiologists and exercise therapists to select motions and
virtual environments for a VR exergame [
55
] refined a cognitive assessment tool using
inputs and feedback from clinical neuropsychologists who are subject-matter experts. The
companion of caregivers, as in the study by [
25
], allowed researchers to understand the
social context around the person with dementia. Besides, it was the shared experiences
with family members that enabled easy conversations with the patients and reduced their
hesitation in using a novel system. Staff members of residential aged care facilities who
have good knowledge about the resident’s capacities could support shortlisting potential
participants and provide feedback for the VR system based on their experience organizing
lifestyle activities [
51
]. In the study by [
59
], care center managers provided insight into the
services and service users. Previous research suggested that staff participation in the design
process is critical not just for developing useful and accessible iVR experiences but also for
addressing their concerns about the suitability of iVR for older adults, hence increasing
their readiness to employ the technology.
5.3. Evaluation
Our review highlighted the lack of longitudinal studies, specifically in relation to
evaluating iVR design for older adults [
90
] discussed the concept of temporality in UX and
considered three UX phases: orientation, incorporation, and identification. Over time, as
familiarity increases, so does functional dependency and emotional attachment. Increased
familiarity with the technology may reduce frustration, while the novelty of the experience
wears off slowly. This can be extended to the iVR UX, where understanding the changes in
UX through longitudinal studies with older adults might generate valuable design insights.
Furthermore, the effectiveness of iVR in many areas is linked to its potential to blur the
boundaries of real vs. virtual world. The latest tracking technologies and improvements in
iVR graphics offer highly immersive UX, but may pose several physical and psychological
risks [
91
] listed six possible issues when using iVR as a research tool: limited experimental
environments, informed consent related to long-lasting psychological effects, possible
risks in clinical applications, malicious use of research outcomes, online exposure, and
Multimodal Technol. Interact. 2022,6, 60 21 of 26
limited code of conduct available for iVR research itself. As such, they noted that it is hard
to fully realize all the associated risks unless longitudinal studies are conducted, which,
consequently, raises concerns around maleficence. We note this is an important direction
for future research.
It is also worth noting that only 8 of the 36 reviewed studies assessed motion sickness,
whereas 12 assessed presence. Both aspects deserve more attention, given that older adults,
even in a controlled environment, are prone to psychological and physical harm that may
undermine the benefits of iVR. Motion sickness and related complaints, reported in the
reviewed papers, have been previously discussed in the literature [
92
94
]. With the latest
advancements in iVR, motion sickness has been improved; however, a number of studies
suggested minimizing time pressure [
55
] while maintaining communication with the user
to check their condition [
54
]. Similarly, presence in iVR can potentially pose several safety
challenges, such as falling or attempting actions not possible in the real world (e.g., trying to
sit on a virtual chair). Furthermore, there is still no guideline as to the optimal iVR exposure
time, particularly for older adults, mainly due to the lack of longitudinal studies [
95
]
outlined that older adults felt 6 min was a suitable duration, while some who were more
engaged with iVR used it for up to 20 min.
5.4. Usability Challenges
Identified usability challenges of current iVR designs for older adults posed in RQ4
need to be overcome for safe and useful future experiences. A major theme identified in
our review is the numerous issues related to iVR hardware systems, including the headset
and hand controllers. Nevertheless, we postulate that rising consumer demand and more
investment in VR hardware will quickly bring about a paradigm shift in form factors for
iVR devices. Current HMDs that lack aesthetics and physical comfort are yet to evolve
into more socially acceptable and user-friendly wearables. The recently-debuted all-in-one
VR platforms represent a huge leap forward compared to the exorbitantly expensive and
cumbersome tethered systems that were popular many years ago [96].
While almost half of our reviewed papers reported the use of Oculus Rift, the model
is now discontinued as a result of the new standalone VR headsets [
97
]. These changes
indicate a trend toward resolving technical challenges; however, the evolving UX is yet to
be fully examined to account for this transformation. With regards to usability, we suggest
that the role of caregivers and residential aged care staff should be considered to ensure
safe and effective deployments of iVR programs. One example is that a wheelchair should
be positioned at the center of the tracking space to minimize user overreaching [
51
]. In
another case, older adults needed help moving the wheelchair to access particular virtual
objects [
98
]. Since it is apparent that facilitator competency is critical, [
11
] advised that
training be offered to both aged care personnel and family members.
5.5. Limitations
Our review study is limited in several ways. The selected papers were identified based
on the keywords employed in our search strategy and other combinations may potentially
yield a wider range of papers. The search terms “virtual reality” OR “immersive virtual
reality” were used to find more relevant results, though “immersive VR” could be a good
alternative. To maintain a focus on HCI literature, we searched the ACM Digital Library,
IEEE Xplore Digital Library, Elsevier’s Scopus, and PubMed databases; however, other
databases may address additional UX design considerations or evaluation methods. The
selected papers include diverse iVR setups using a range of HMDs, affording different
aesthetics and tracking quality. In addition, some of the iVR apps offered off-the-shelf
commercial content, while others were designed specifically for older adults. Additionally,
some of the studies recruited young participants in addition to older adults. Studies
concerning designed and bespoke iVR apps did not necessarily examine the effectiveness
of their design, while those which used commercial apps undermined the impact of custom
design on the study outcomes. Study designs also varied in terms of contexts, aims, and
Multimodal Technol. Interact. 2022,6, 60 22 of 26
outcomes. Therefore, some level of contextualization is needed in generalizing our findings.
The diversity in hardware, software, and configuration may have affected some of the
reported results, reducing our ability to compare the design decisions made.
6. Conclusions
In this paper, we reviewed 36 papers published between 2010 and 2019, whereby iVR
applications were developed for older adult users in the context of clinical, entertainment,
and wellbeing. Our research was motivated by the gap in useful design guidelines, aim-
ing to develop effective and enjoyable UX in safe iVR applications for older adults. We
identified 10 categories of design considerations that were explicitly applied in the studies.
Design considerations were extended beyond software development to consider people
and physical configuration as well as hardware use. Taken together, these support discrete
phases like onboarding or visual iVR experience. The review also highlighted a general
lack of guidelines to best support older adults’ safe iVR experiences and smooth transi-
tion to/from the real world. Limited evidence suggests the use of participatory design
approaches and inclusion of various stakeholders; however, recruitment challenges in
several studies were reported. Most attention was given to overall UX evaluation in current
literature, where several usability challenges were reported, but the need for longitudinal
UX remains. Moreover, further research is needed on the effectiveness of the 10 design
considerations categories we identified, their effectiveness in a given context and links to
UX evaluations. Overall, this study emphasizes the need to develop guidelines that inform
the design and choice of UX evaluation methods in iVR for older adults.
The unprecedented growth rate of the world’s elderly population, together with the
emergence of the metaverse age, underscore the importance of iVR research for older
individuals. We call for future research to engage closely with older adults as active
participants in the design process to better capture their needs and strategically extend the
10 proposed design considerations. These should encompass ethical considerations across
the boundaries of the user’s physical and psychological needs, iVR hardware and software,
and UX.
Supplementary Materials:
The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/mti6070060/s1.
Author Contributions:
Conceptualization, K.I. and N.A.; methodology, K.I.; formal analysis, K.I.,
T.T.M.T., N.A. and A.B.K.; investigation, K.I. and T.T.M.T.; resources, K.I. and S.B.; data curation,
T.T.M.T. and K.I.; writing—original draft preparation, K.I. and T.T.M.T.; writing—review and editing
T.T.M.T., K.I., A.B.K., R.A.C., S.B. and N.A.; visualization, T.T.M.T.; supervision, N.A.; project admin-
istration, R.A.C.; funding acquisition, S.B. All authors have read and agreed to the published version
of the manuscript.
Funding:
This work was supported by the National Health and Medical Research Council (NHMRC)
under grant APP1134919 for Centre of Research Excellence in Digital Health. The NHMRC Centre
of Research Excellence in Digital Health had no role in the study design; in the collection, analysis,
and interpretation of data; in the writing of the report; or in the decision to submit the article
for publication.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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... In their study of technology teams who adapt ethical sensitivity, Boyd and Shilton state; "significant new empirical research is needed to define the factors most important to particularization within tech workplaces, alongside the stimuli and cues that are most effective for recognition of ethical issues, and how these two components interact to result in ethical judgements, policy, and design decisions" [6, P. 18]. This sentiment is shared by others [20,30,37,41,49] and extends the Human-Computer Interaction (HCI) practice from being predominantly concerned with developing effective and functional systems (and by extension UX) to reflecting on socio-technical implications of the designed systems [35,51,64,66]. In other words, the field is mobilised to introspect the design process and the practice itself [43] indicating an evolving demand to actively anticipate and engage with the consequences of design [76] and ethical pedagogy in HCI education [22]. ...
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