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Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic

Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study... Background: Advancements in supporting personalized health care and well-being using virtual reality (VR) have created opportunities to use immersive games to support a healthy lifestyle for persons living with dementia and mild cognitive impairment (MCI). Collaboratively designing exercise video games (exergames) as a multistakeholder team is fundamental to creating games that are attractive, effective, and accessible. Objective: This research extensively explores the use of human-centered design methods that involve persons living with dementia in long-term care facilitates, exercise professionals, content developers, game designers, and researchers in the creation of VR exergames targeting physical activity promotion for persons living with dementia/MCI. Methods: Conceptualization, collaborative design, and playtesting activities were carried out to design VR exergames to engage persons living with dementia in exercises to promote upper limb flexibility, strength, and aerobic endurance. We involved a total of 7 persons living with dementia/MCI, 5 exercise professionals, 5 community-dwelling older adults, a VR company for content creation, and a multidisciplinary research team with game designers, engineers, and kinesiology experts. Results: An immersive VR exergame called Seas the Day was jointly designed and developed and it is freely available to be played in state-of-the-art VR headsets (Oculus Quest 1, 2). A model for the triadic interaction (health care institution, industry partner, academia) is also presented to illustrate how different stakeholders contribute to the design of VR exergames that consider/complement complex needs, preferences, and motivators of an underrepresented group of end users. Conclusions: This study provides evidence that a collaborative multistakeholder design results in more tailored and context-aware VR games for persons living with dementia. The insights and lessons learned from this research can be used by others to co-design games, including remote engagement techniques that were used during the COVID-19 pandemic. (JMIR Serious Games 2022;10(1):e29987) doi: 10.2196/29987 KEYWORDS virtual reality; exergames; persons living with dementia; physical activity; head mounted displays; participatory design; co-development; gaming; older adults; elderly; design; dementia; VR; user-centered; physical activity; exercise; COVID-19 https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al meaningful to them in a way that respects and reflects their Introduction needs, abilities, and perceptions of personhood. As persons living with dementia have wide and dynamic preferences and Background abilities that are difficult (sometimes impossible) to simulate Technology has a key role to play in supporting people of all or speculate about, it is crucial to have their voice as a central abilities’ fundamental rights to inclusion and participation. The part of the design process of technologies intended for them. essential purpose of technology is enabling people to do things While actively involving persons living with dementia in they could not otherwise do. However, applications need to be technology development has already started and multiple articles specifically adapted to the needs and abilities of end users for have documented valuable insights [2,3,13], the adoption rate them to be accessible and meaningful [1]. Top–down approaches is quite low and appropriate/effective methods for supporting where designers independently create technologies can lead to their involvement are still being explored. well-intended but poorly suited solutions, especially for older This paper presents the participatory cocreation of Seas the Day, adults (defined here as aged 60+) with cognitive, physical, or an exergame (ie, a game that is intended to promote exercise) sensory impairments, such as people living with mild cognitive designed to include persons living with dementia/MCI as core impairment (MCI) or dementia [2-4]. To meet the needs of such end users. Seas the Day uses immersive head-mounted virtual end user groups, a multistakeholder team has been shown to reality (VR) to encourage players to engage in exercises that better understand the experiences, challenges, and adoption of can be beneficial for their health and well-being. The research technology from different perspectives (eg, end users, health described in this paper was guided by the question: “How can care professionals, service providers, researchers from multiple human-centered participatory design methods be used to involve disciplines, industry designers/developers, and engineers) to multiple stakeholder groups in the collaborative creation of VR form a holistic view [1]. Combining this diversity of knowledge exergames to promote physical and mental well-being among enables creation of novel solutions that can be effective, usable, persons living with dementia/MCI?”. We present our work as and adoptable by the end users [5]. Human-centered design a case study of a collaborative co-design wherein we discuss (HCD) is an approach where solutions are created by focusing main considerations, roles, and lessons learned through our on understanding the context, needs, behavior, and preferences process of co-designing VR exergames for persons living with of the people whom the solution will serve. In HCD, the end dementia/MCI; this includes strategies that were adopted to users’ needs, system requirements, and technology specifications steer the design process while being involved in the COVID-19 are defined using data from observations, interviews, and pandemic, a situation that brings many challenges due to the participatory design activities. Participatory design is one of limited access to the target stakeholder groups. We describe the techniques used in HCD in which end users and other how we tackled previously reported issues in designing games stakeholders are actively involved as partners throughout the targeting older adults with cognitive impairment, in particular: design process [4,6]. (1) creating solutions that are designed with and for persons Adopting participatory and collaborative design approaches in living with dementia/MCI by identifying where exceptional HCD has been shown to result in the development of effective needs (eg, cognitive, physical, sensory impairment, and solutions and improve the effectiveness of serious games in technology literacy) of this population exist and complementing promoting healthy lifestyles among the end users [7]. However, them [14]; (2) integrating players’ needs and preferences early many requirements of these approaches are reported as barriers in the design process [15]; and (3) balancing both attractiveness that can be difficult to overcome [8]. For instance, increased and effectiveness to create enjoyable and useful immersive time and effort are required to come to a common and shared experiences [8]. This research highlights specific considerations understanding of the problem and possible solutions [9]. As a regarding designing exergames for head-mounted displayed-VR result, technology development still predominantly relies on (HMD-VR) technology and specifies how using HMD-VR conventional and less participatory approaches that often come impacted the design choices we made throughout the iterative at the cost of a greater chance of misalignment of the technology and participatory process. with the intended user population [5]. This is particularly the Supporting Aging in Persons Living With Dementia case when designing solutions for people with complex needs or impairments. For instance, understanding the desires, needs, Using Physical Activity: The Opportunity of and abilities of older adults with cognitive impairment can be Exergames extremely complex, dynamic, and unpredictable considering Dementia is an umbrella term for a number of progressive the physical and cognitive challenges faced by this population diseases and disorders, such as Alzheimer disease, Lewy Bodies, [10]. While there is a general agreement on the importance of and Parkinson disease. Symptoms of dementia involve having a multistakeholder co-design approach to design, implicit deterioration in cognitive function including impairment in complexities such as different viewpoints (eg, people from memory, reasoning skills, and the ability to perform everyday different sectors or schools of thought), conflicts of interest (eg, activities as well as changes in behavior and mood [16,17]. MCI intellectual property of the designed solutions), and access to is a high-risk state for dementia where individuals experience end users that are willing to participate in the design process a decline in cognitive abilities, which is not yet sufficient to limit widespread adoption [11]. hinder functional independence. There is ample evidence on numerous physical and psychological health benefits of regular As put forward by Dixon and Lazar [12], technology for persons physical activity participation for older adults [18]. For persons living with dementia should support activities that are https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al living with dementia or those with MCI in particular, physical in response to the COVID-19 pandemic, older adults are facing activity has been recognized as a practical and side effect–free restrictions of physical activity behaviors that can lead to short- therapeutic strategy for both mitigating and managing the and long-term adverse health consequences [42,43]. For those symptoms of MCI and dementia. Regular participation in living in long-term care (LTC) homes or apartment buildings physical activity can improve functional performance, mobility, where going outdoors requires moving through shared spaces, activities of daily living (ADLs) among persons living with risks for physical inactivity and its various adverse health dementia and those with MCI, and may have a positive impact outcomes are even higher. Reduced social connection and on their global cognition and balance [19-21]. increased feelings of loneliness may also decrease older adults’ motivation for physical activity during the COVID-19 pandemic While some guidelines recommend that persons living with [44-46]. dementia/MCI exercise at least twice a week [22], other guidelines recommend they participate at the same level of To mitigate the negative impacts of COVID-19 on the health activity as healthy older adults—150 minutes of moderate and well-being of older adults (with and without cognitive intensity or 75 minutes of vigorous aerobic physical activity impairment), various remote and technological solutions have and strength training twice a week [21]. However, despite strong been suggested, such as [47-50]. Concurrently, literature evidence supporting physical and mental benefits of physical indicates the growing feasibility of using exergaming strategies activity for persons living with dementia/MCI, physical activity to enhance physical activity among older adults during the participation and adherence are particularly restricted in this COVID-19 pandemic [51-54]. For example, VR exergaming population due to the motor and cognitive changes associated has been introduced as a coping strategy to facilitate older with the condition. Various individual, social, and environmental adults’ at-home physical activity and enhance favorable health barriers such as lack of motivation, low levels of self-efficacy, outcomes among this population [55,56]. This can be due to the apathy, poor access to exercise opportunities, lack of fact that virtual environments are customizable and can be dementia-appropriate exercise programs or safe and accessible tailored to the participants’ functional and cognitive abilities, community infrastructure, transportation challenges, and societal including those with MCI/dementia. For individuals reluctant stigma have been reported as contributors to sedentary behavior to participate in exercise, the immersive and interactive among persons living with dementia/MCI [23-26]. environment of VR can provide an engaging, entertaining, and motivational means of exercising and target desired physical Given the increasing number of dementia cases worldwide activity outcomes through the gameplay [57]. (expected to double by 2050) [27] and considering the significant health benefits of regular physical activity, it is While there is promising potential for VR exergames to support imperative to develop innovative and effective strategies to older adults, research on preferences of VR exergames among facilitate physical activity participation and maintenance among older adults with various cognitive abilities is limited. both healthy older adults and those living with cognitive Additionally, the availability of custom-made content and impairment. Serious or applied games, such as exergames, are easy-to-use VR hardware often limit the technology uptake by one plausible strategy to promote physical activity among older older adults [58]. Moreover, public health measures to contain adults by motivating participation through the enjoyment of the spread of COVID-19 have made it more challenging to carry play [28]. VR exergaming is a novel strategy that can encourage out participatory and collaborative cocreation activities with physical activity participation and offer exercise routines that vulnerable end users such older adults and persons living with require minimal guidance and supervision from the therapists dementia/MCI during the pandemic. Therefore, despite the [29,30]. The multisensory and immersive environment of VR growing need and technological advances in VR systems (eg, exergames (especially those employing HMD-VR) have been standalone headsets), the use of VR exergames to promote previously employed as a therapeutic tool to promote the health exercise among older adults is still very limited. and wellness of older adults and to support rehabilitation [31,32]. What We Know About Serious Games and Cocreation Studies that explored VR exergames for older adults have shown for Persons Living With Dementia positive results and demonstrated that exercising using In order to provide a comprehensive understanding of what has exergaming systems can benefit motor learning and neural been done in the field of serious games for persons living with plasticity [33-37]. VR exergaming has been found to be a dementia/MCI, we present below a comprehensive review of feasible strategy to complement conventional exercise the literature, specifically literature covering VR technologies. interventions [32,38]. The rise of consumer-level HMDs and accessibility of the Exergaming During the COVID-19 Pandemic content have fostered the creation of literature related to both Older adults are among the most vulnerable and profoundly nonimmersive and immersive VR systems adopted for dementia impacted during the COVID-19 outbreak and its physical and care. Examples are reflected in the following publications: (1) mental health impacts [39]. Staying physically active during a review of nonimmersive games and simulations including the COVID-19 pandemic is particularly important for older tools for ADL to “brain” games (eg, games for cognitive training adults because physical activity is a protective factor against or assessment) [59]; (2) a review on the cost-effectiveness of viral infections that can increase the immune response as well exergaming interventions and their impact on physical, as the positive benefits toward supporting overall physical and cognitive, emotional, and social functioning of persons living mental well-being [40,41]. However, with the contact with dementia/MCI, which revealed that only 3 studies met the restrictions, isolation measures, and exercise facilities closure inclusion criteria (eg, randomized controlled trials, participants https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al diagnosed with dementia, exergames); (3) a minireview of 10 for those who do not enjoy or have trouble participating in studies on interactive interventions to promote well-being of group-based exercises. They wanted interventions that were not persons living with dementia/MCI revealed that virtual only interactive and engaging, but also inclusive and informed experiences were enjoyable for the participants and improved by the participant’s therapeutic goals. They were also interested their mood and apathy [60]; and (4) the effectiveness of VR in exploring what kinds of objective data could be automatically (full-immersive and semi-immersive) for persons living with collected through gameplay to track changes/progress in physical dementia/MCI was reviewed in a recent meta-analysis of 11 and cognitive function over time. studies concluding that immersive VR is a cost-effective, The multistage collaborative design process that ensued occurred comprehensive, flexible, and potentially useful tool for over the span of 15 months and was driven by multidisciplinary patient-centered care [61]. researchers, exercise therapists, VR game developers, persons The future of VR technologies to foster interactive and living with dementia/MCI in LTC facilities, and therapeutic experiences for persons living with dementia/MCI community-dwelling older adults. The process is divided into presents several challenges that have been repeatedly mentioned 2 main stages: (1) ideation and planning and iterative design in most of the reviews. These challenges can be grouped as and (2) development process. A special emphasis has been put follows: (1) the need to establish practical guidelines for VR in describing the techniques, activities conducted, and people design and implementation for people with cognitive involved during each stage. impairments [61]; (2) the need for less anecdotal, more Preliminary Work on VR and Exergames for Persons consistent, and more therapeutically and scientifically valid Living With Dementia/MCI interventions (eg, randomized controlled trials) to systematically The design process described in this paper is heavily inspired document the effectiveness of VR interventions in persons living by previous research conducted before COVID-19 by our with dementia/MCI [62]; (3) the opportunity to include research team where a set of VR exergames were prototyped noninvasive measurements (eg, gameplay metrics, physiological and tested. Initially created as a proof of concept, a set of signals) and system intelligence (eg, machine learning [63]) to activities in a virtual farm setting was created to engage persons better examine changes, propose novel ways for tracking the living with dementia/MCI in the use of HMD-VR [65,66]. VR intervention progress, and better quantify its impact [60]; Important insights from that study were as follows: (1) end users and (4) the need to improve the rationale behind specific game had positive perceptions of the exergame experience using elements (eg, mechanics, technology) and their impact on the HMDs and were able to engage in the exercise program, (2) outcome measures (eg, cognitive, physical) in order to better involving health care professionals and persons living with define the goals of the interactive interventions [64]. For dementia/MIC in the design process was incredibly beneficial instance, there is a need to better define the role of the level of to creating usable VR environments for persons living with immersion offered by the technology (eg, HMDs, 2D screens) dementia/MCI, and (3) qualitative and quantitative measures in game user experience variables such as engagement or demonstrated comparative results between exercising with the replayability. VR exergaming program and conventional human-guided exercises. Results from this pilot study were crucial to define Methods the next steps and to identify opportunities of using HMD-VR Cocreation of the Seas the Day Exergame technology in promoting physical activity among persons living with dementia/MCI [67]. Furthermore, an analysis of the main This section describes how we carried out our co-design of the strengths, weaknesses, opportunities, and threats (SWOT) was Seas the Day VR exergame, including presenting the ideation conducted to better shape the next steps of the project (Table stages, involvement of stakeholders, and a table summarizing 1). This approach is conventionally used among companies for the iterative and collaborative design and development process, strategy building, marketing, and project planning. A focus of which was partially carried out during the COVID-19 pandemic. the SWOT analysis was to consider how rapidly evolving VR Our process of cocreating Seas the Day was sparked by technology could be used to create a solution that could be conversations with exercise therapists in LTC facilities. They adopted by persons living with dementia/MCI in dementia care expressed a desire for additional ways to engage persons living and by elder care institutions. with dementia/MCI in exercise routines that are fun, particularly https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al a b Table 1. SWOT analysis of VR exergames previously developed and piloted [67]. Strengths Weaknesses Opportunities Threats Demonstrated feasibility of Hard to replicate due to hard- Use less cumbersome VR sys- Difficulty in technology uptake • • • • ware and software limitations tem (eg, standalone rather than due to system’s complexity and using HMD-VR in persons Discomfort of sweating while desktop) cost living with dementia using HMDs Include engaging game me- Content and platform sustain- • • Successfully scaffolded a hu- More suitable for stretching chanics and integrate gamified ability man-centered design process than conditioning exercises activities Design and development time with persons living with demen- Limited visual aesthetics Simplify and improve data longer than time for student • • tia Interactivity errors that can logging MASc degree Included 3 activities placed in lead to frustration Facilitate system calibration Potential motion sickness for • • different scenarios (diversity) Can get monotonous if used Explore metrics to track physi- some people • • Simplified interaction (guided too frequently cal and cognitive performance Users with hearing or visual through voice instructions) Data logging system can be Include full-body interaction impairments might not be able • • Included a calibration process difficult to interpret to engage fully in content for range of motion SWOT: strengths, weaknesses, opportunities, and threats. VR: virtual reality. HMD-VR: head-mounted displayed-virtual reality. communities to identify potential candidates. One of the Ideation and Planning researchers met with company representatives, presented the project vision, and discussed ways to establish collaboration. Overview This stage consisted of a set of activities carried out by the A healthy, robust, and valued partnership is grounded in multidisciplinary research team to identify, define, and plan for perceived benefits that are equal to or greater than the research approaches and goals, game design concepts, and investment for each partner. The nature of the stakeholder with prototyping methodologies required to create VR exergames their specific interests, key people, required investment (eg, using HCD methodologies. The process is described in 2 main time, activities), and benefits are summarized in Figure 1. The stages as follows: main investment for the LTC facility is represented as the time spent by the exercise professionals to partake in the participatory Defining Research Approach and Partnering With design process, playtesting sessions, and performance evaluation Industry of persons living with dementia/MCI participating in the design The initial research team was formed by academic researchers, process. Additional resources, rooms in the home to meet about including professors and graduate students (master’s, PhD, and the project, availability of the exercise professionals and other postdoctoral) with interests/expertise in engineering, human personnel, and use of display devices (eg, projectors or TV factors, and assistive technologies (n=3); kinesiology and screens) for facilitating discussions were part of the LTC applied health sciences with a focus on exercise programming stakeholder investment (in-kind contribution). As a benefit, the and delivery for older adults with and without cognitive LTC facility will get a discount on the final product for 5 years impairments (n=4); and a game designer with experience in and will have a tailored solution that implements needs and health care applications (n=1) as well as exercise professionals ideas from their staff and residents, thus facilitating technology from a local LTC home (n=5). Among the exercise uptake. A shared intellectual property agreement was also professionals, kinesiologists and recreational therapists with negotiated that defined up-front how innovation from the project more than 10 years of experience were engaged and were would be shared in a way that was deemed to be equitable to champions during the design process. The strategy to engage the researchers, industry partner, and LTC facility. exercise therapists consisted of inviting interested professionals To facilitate technology deployment, the industry partner of the LTC homes to be part of the research team, involving provided 2 state-of-the-art, standalone VR equipment (eg, them in the decision-making processes, and inviting them to Oculus Quest) for both the research team and the LTC facilities. take part in the strategic planning of the participatory design As part of their in-kind investment, the company allocated a process. specialized development team to create the virtual environments The next step was to find an industry partner interested in as well as to conduct research on new gameplay metrics. The conducting participatory game design who had related company also spearheaded the development of the business experience/expertise and know-how in developing custom-made model of the envisioned system to provide a sustainable and VR content and commercialization in health care. This step was financially feasible proposal to the team. The benefit for the particularly challenging as human-centered and participatory industry partner is having the exclusivity of commercializing design research with older adults has mostly been conducted in the product as well as gaining experience and insights on academic settings [11]; this is mainly due to differences in the working closely with both potential clients and a time frames between academia and industry as well as relative multidisciplinary research team. By engaging with academia, novelty of the technology. Our strategy to find our industry the industry partner is eligible to receive government grants to partner consisted of researching local company directories and https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al support research and tax breaks; our team has taken advantage design of evidence-based games). The involvement of an of both. industry partner also increased the chances of creating immersive exergames that are widely accessible (eg, through Finally, the research team had the mission of carefully planning purchase, freemium) for both health care and academic settings and managing every step of the process; this included creating compared with when no perspective or active stakeholder is activities to appropriately engage all of the stakeholders by involved in commercialization during the design process. designating academic subteams with graduate students, research assistants, and principal investigators aligned to the different The output of this planning process is a detailed and structured research outputs. Having an industry partner facilitated the Work Plan that is shaped and agreed upon by all stakeholders designing and development of usable and scalable games and and that serves as the guide for the design that allows for the allowed the researchers to stay more focused on the scientific creation of the activities, timelines, and milestones for the team. aspects of the activities (eg, game user research, evaluation, Figure 1. Components of the triadic interaction between the research team, industry partners, and LTC homes. LTC: long-term care; MCI: mild cognitive impairment; PLWD: person living with dementia/MCI; R&D: research and development; VR: virtual reality. limitations [21,22] and risks of using HMD-VR technology Defining the Game Design Concepts and Requirements with older adults [68]), we consulted with team members who for VR Exergaming in Persons Living With have expertise in exercise therapy on multiple occasions via Dementia/MCI dedicated ideation meetings. This resulted in our decision to focus our design on exergames targeting upper limb movements Purpose that have been shown to improve endurance, flexibility, and After assembling the multidisciplinary team, a series of design balance. This decision is supported by the results of a systematic activities (described below) were conducted to explore the review on the effects of exercise on persons living with different perspectives of the team and to create cohesion, dementia/MCI in care homes, which reported that exercise empathy, and mutual understanding. Because some of the team intervention that combined aerobic, strengthening, and stretching members were not familiar with the symptoms and abilities activities had the greatest benefit [69]. We intentionally designed associated with MCI and dementia, we used existing user and developed seated exergames to increase player’s safety and personas to describe some of the characteristics as well as the reduce risk of falls [15,70] while simultaneously incorporating most representative needs and motivations to facilitate the guidelines that consider both physical and cognitive capabilities exchange of information among the team members [15,59]. for exergames in persons living with dementia/MCI [71]. Three researchers who were new to MCI/dementia shadowed A list of desired movements and targeted joints along with their 3 exercise sessions in LTC to gain some first-hand experience correlation with physical fitness was defined (Table 2), which with exercise programming and delivery for persons living with considers (1) exercise routines carried out in the LTC facilities dementia/MCI in this setting. with persons living with dementia/MCI, (2) recommendations Physical Activity and Therapeutic Requirements for exercise prescription in older adults [72], and (3) physical To narrow down the scope of physical activities to ones that challenges specific to persons living with dementia/MCI (eg, are appropriate for this population (including considering on average a decrease in mobility, balance, and strength) [21,69]. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al a b Table 2. List of movements to be included in the VR exergames for persons living with dementia/MCI . Targeted joint/limb Desired movement(s) Application for persons living with dementia/MCI Cervical Neck flexion and extension (bending the head forward and backward) • • ROM Neck rotation (turning the head to the left and right) Flexibility/Mobility ADL Shoulder Shoulder flexion (frontal arm raise) ROM • • Shoulder abduction and adduction (side arm reach) Flexibility/mobility • • Shoulder rotation (360° circumduction) Endurance • • Overhead arm stretch ADL • • Elbow/Wrist Elbow flexion and extension (biceps curls) ROM • • Elbow supination and pronation (outward and inward rotation of the Flexibility/mobility • • forearm) Endurance Wrist flexion and extension (tilting toward the palm and tilting toward ADL • • the back of the hand) Trunk Trunk flexion and extension (bending forward and backward) ROM • • Lateral flexion (side bending) Flexibility/mobility • • Trunk rotation Weight shifting and postural balance (seated) • • Core strength ADL VR: virtual reality. MCI: mild cognitive impairment. ROM: range of motion. ADLs: activities of daily living. One-Page Level Design Concept Ideation and Brainstorming Activities To facilitate the communication across the research team and Three main activities were conducted to conceptualize the VR stakeholders, a 1-page game level design (Figure 2A) [74] was exergames: (1) literature review of exergame design used where exercise components (eg, stages, intensity) were frameworks, (2) inclusion of simplified game design elements outlined and 4 different game levels were initially proposed. to improve communication among stakeholders, and (3) The farm theme was chosen as suggested by the results of our brainstorming sessions. pilot study and because of its broad acceptability among persons Exergaming and Design Frameworks living with dementia/MCI and exercise therapists [66]. The game is named Exerfarm Valley and its concept consists of 4 A literature review was conducted to explore existing design different levels that recreate a productive farm: fishing, frameworks used to create engaging and effective exergaming harvesting, horse caring, and beekeeping; these activities were experiences [73]. One of the design frameworks specialized in chosen from a list of activities generated through discussions exergaming for healthy lifestyle promotion, called the dual flow with the exercise therapists and researchers and in consideration model [8], was used to guide the design process. In the dual with their mapping to the movements defined in Table 2. flow model, the design is guided by balancing both effectiveness Exerfarm Valley was envisioned by the game designers, and attractiveness in exergames to maximize the level of integrating the input from different stakeholders and considering engagement while keeping the beneficial aspect of the games. other similar exergaming approaches found in the literature The implementation of the dual flow model framework was [15,70]. The initial design was presented and discussed with achieved by mapping the 3 main components of an exercise the research team for further refinement. Each game level has training session (ie, warm-up, conditioning, and cool-down) 3 different stages including specific activities that reflect with individual activities suggested by persons living with warm-up, conditioning, and cool-down movements. In the dementia/MCI and their therapists [65]. These activities were iterative design and development stage, details of each game integrated in each stage of the exercise session (ie, warming up, level were discussed and integrated to facilitate a more concrete conditioning, cool-down) using a different game mechanic for and streamlined development process. For instance, Figure 2B each one considering the recommended exercise intensity and shows the design of the rowing/fishing level (called Seas the duration. Day) after discussing it with the development team. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Figure 2. One-page level design of the Exerfarm Valley concept. (A) Four-level design sketch representing the activities and main game levels envisioned (including Seas the Day). (B) Seas the Day level design discussed with the development team of the virtual reality company specifying the spatial characteristic of the elements in the virtual environment. participants to the different perspectives of the team and (2) Envisioning and Brainstorming collect ideas on the activities and narratives of the envisioned To further explore the initial design, 2 brainstorming sessions games. The scenario was defined as instructions that were given were conducted to create paper prototypes and discuss possible as follows: game mechanics and scenarios of the VR exergames. • Target population: persons living with dementia/MCI in The first brainstorming session (Figure 3A) was carried out LTC settings (persons living with dementia/MCI personas with (1) 2 VR specialists (from our industry partner), (2) 3 health were used [75]); care professionals (1 per each institution: university, LTC • Game purpose: engage players in seated upper limb partner, industry), (3) 2 external researchers with experience in exercises wearing a standalone VR headset; and designing digital technologies for persons living with • Interaction structure: 15 minutes of exergaming using the dementia/MCI, and (4) 2 graduate students with experience in VR headset eliciting physical activity responses according user experience design. The goal of the session was to create to the warm-up, conditioning, and cool-down stages multidisciplinary subgroups to (1) introduce and expose (exertion cards were used to filter the ideas [76]). Figure 3. Brainstorming sessions. (A) Introductory session carried out involving multiple stakeholders of the project. (B) Exploratory sessions carried out with exercise therapists to introduce the head-mounted displayed-virtual reality technology and collect ideas about game mechanics. The final result encompassed a set of ideas of virtual activities company to start off with the prototyping process; having the for various game levels (eg, fishing, rowing, animal care). These industry partner as an active stakeholder in the brainstorming ideas were used to create a game design document (ie, document session was invaluable to building a shared understanding of detailing the envisioned game specifying game elements such the opportunities and challenges as well as creating a backdrop as mechanics and aesthetics) to be used as an input for the VR with which they could frame ideas. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al The second brainstorming session (Figure 3B) was conducted approximately every 2 weeks during a 6-month period. Versions in 2 LTC facilities with 11 exercise professionals: (1) 2 physical of the games were installed on the VR equipment and then therapists, (2) 3 kinesiologists, (3) 3 recreational therapists, and playtested by the research team, end users, or therapists to (4) 3 kinesiology students. The session aimed at exploring ideas collect feedback and prepare a playtesting report suggesting on exercise movements, activities, and game mechanics. The required changes and potential improvements for the new game concept was introduced by defining the farm theme and prototype. Playtesting sessions were carried out both in-person the 3 intended stages (warm-up, conditioning, cool-down) with (before the COVID-19 pandemic) and virtually via audiovisual their respective timing and intensities. The goal of the session conference platforms (during the COVID-19 pandemic). While was twofold: (1) to gather therapists’ feedback on the use of the the exergame was initially designed with and for persons living HMD-VR technology in promoting physical activity in persons with dementia, because of the limitations of accessing persons living with dementia/MCI and (2) to collect ideas on specific living with dementia/MCI in LTC due to the pandemic, we activities, feedback modalities, and instructions in each stage. conducted a remote, 1-week pilot with community-dwelling We used a large paper layout dividing the 3 stages and older adult volunteers who agreed to receive the headsets at specifying the exercise intensities and asked the therapists to their home and play our exergame 3 times. The development write down or sketch the specific activities they would like to was initially focused on the creation of experimental game see on each stage, providing as many details as possible. Three mechanics associated with the movements and therapeutic researchers analyzed the qualitative results using an affinity requirements previously discussed. Other game design elements diagram approach after moving the concepts to sticky notes and such as aesthetics and story were gradually added to our clustering the ideas to build affinity maps [77]. These generated exergame, based on feedback from the end users and other themes centered around (1) the feasibility and requirements of stakeholders during the playtesting sessions. In total, 3 using standalone HMD-VR devices in the LTC (eg, network playtesting sessions were conducted with 7 persons living with connectivity, privacy, and adaptation of existing spaces or dementia/MCI (6 females; mean age 81.3 years) from 2 LTC elements) and (2) specific game mechanics that can be used by homes, a total of 9 exercise providers (both from LTC and persons living with dementia/MCI in the envisioned Fishing community, including the ones in the research team) with (Figure 2A) game level (eg, exploring while rowing, fishing experience in dementia care (7 females; mean age 38.1 years), with rod, hand-biking, scuba diving, and beach activities such and the researchers to evaluate different aspects of the exergame. as stretching or playing sports). Table 3 summarizes the objectives, participants, and insights of each playtesting session. After completing the first playtesting Iterative Design, Development, and Playtesting session with persons living with dementia/MCI, the COVID-19 An iterative, agile, and cyclical human-centered development pandemic and public health restrictions forced us to halt process was carried out to merge research concepts, design in-person research, resulting in access restrictions to persons requirements, and technical feasibility to shape the requirements living with dementia/MCI and exercise providers at LTC homes. of the prototype. Each iteration consisted of short Similarly, other preplanned participatory design activities to prototyping–testing–evaluation cycles, coordinating the research continue cocreating and playtesting different game design team, exercise therapists, end users, and the development team concepts with exercise professionals and persons living with from our VR partner. Playable prototypes were developed dementia/MCI had to be paused. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Table 3. Playtesting sessions. Playtesting name Objectives Participants Methods Main insights Rowing and de- Game mechanics: 7 persons liv- Face-to-face playtest- • • All players learned easily how to row in VR using sired visual ele- Rowing forward ing with demen- ing: the prototype ments (number of Rowing backward tia 20 minutes interac- Rowing backward/forward and turning left/right • • sessions: 2) Rowing turning 5 exercise thera- • • tion were intuitive for most participants (left, right) pists (from Individual, a When asked about desired visual elements, end LTC facilities) semistructured Game aesthetics: users preferred animals (eg, fishes and birds), na- Overseen by exer- ture and landscape (eg, sunset, mountains), and Desired visual ele- cise therapists ments other boats and more people. Debrief with the One player could not complete the test because the therapists at the Game technology: headset was uncomfortable. end of the session. Motion sickness • Therapists mentioned the importance of adding and comfort cues or elements to guide the navigation. COVID-19 outbreak Rowing improve- Game mechanics: 4 community exer- Remote playtesting: Add configurable menu to define (1) session dura- ments and game cise providers with tion, (2) player’s position calibration to facilitate Rowing and navi- 1-hour discussion • • level design experience in demen- rowing. gation around the Online (through (number of ses- tia care (who were Add configurable menu to define (1) session dura- level designed Zoom) sions: 1) not working in LTC) tion, (2) player’s position calibration to facilitate (Figure 3B) Semistructured fo- rowing. Modify world physics to have more natural cus group Game aesthetics: tree shaking and water waving effects. Oars aspect and Adding cues to guide participants (eg, signs, audio positioning clips). Game objects and water effects Game technology: Capture player’s re- sponses and behaviors Conditioning and Game mechanics: Research team Remote playtesting: Add strategies to avoid getting stuck while rowing. cool-down (without LTC exer- Better define the virtual world limits by adding Rowing and fish- 1-hour discussion • • stages, rowing cise therapists) buoys regarding the dolphin: (1) sounds should be ing cohesion online (through and fishing inte- added to facilitate prompting, (2) dolphin’s behav- Dolphin as exer- Zoom) gration (number ior should help in meeting exercise intensities in cise intensity of sessions: 3) conditioning. modulator Variables such as attention paid to the animals in Game technology: the scenario as well as the response of players to haptic stimulus can be used to quantify reaction Player’s responses time. and behaviors Game aesthetic, Consider movement limitations when fishing to story avoid persons living with dementia from getting Narrative to aid frustrated. engagement LTC: long-term care. VR: virtual reality. activities that encourage exercise movements that have been Results shown to be beneficial to persons living with dementia/MCI [21,69]. Seas the Day places the players in a tropical Seas the Day: Final Game and System Overview environment surrounded by animals, hills, and water. Three (Description) activities lasting a total of 15 minutes were created (Figure 4 Seas the Day is an immersive HMD-VR experience that and Textbox 1) to align with the design requirements and needs transports seated players to a virtual seaside with different identified in conceptualization and playtesting sessions. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Figure 4. Seas the day screenshots showing the game levels of Tai Chi (warm up, left), rowing (conditioning, middle), and fishing (cool-down, right). Textbox 1. Activities to align with design requirements and needs identified in conceptualization and playtesting sessions. Tai Chi (warm-up, 3 minutes) A set on a beach with a sunset in the horizon and birds seen and heard in the virtual scene. Players start the experience with a short Tai Chi routine that encourages upper limb movements that are connected with the virtual scene (Figure 4A). To guide players in performing the correct movements, a leaf-shifting metaphor is used wherein players are instructed to hold a floating leaf with 2 hands and guide it through trajectory paths drawn up in front of the players. Examples of the incorporated Tai Chi movements for range of motion are “wings of a bird” (moving arms to the side followed by a folding-like movement of the arms toward the chest), “open the door” (raising arms straight up and bring down with elbows bent) and “flower shifting with the breeze” (hands moving side to side). Rowing (conditioning, 9 minutes) The activity invites players to explore the tropical environment while rowing in a boat using 2 wooden oars attached to their virtual hands. This stage has been created as a conditioning phase as the rowing game mechanic involves exercising the muscle groups described in Table 2 aiming to improve strength and aerobic fitness (Figure 4B). As shown in Figure 4C, this game level has different spaces to explore such as a marsh, small archipelagos, and a valley and rocky spots among others. Hanging bridges, waterfalls, and thatched cottages are some of the objects that players will see while rowing. Five different animals have been included based on the suggestions collected in the playtesting sessions: fish, dolphins, dogs, cows, rabbits, and birds. To guide players, 2 aids have been included: (1) a virtual dolphin that swims specific paths and encourages players to follow along and to explore the virtual environment while keeping an adequate pace, and (2) voice-over narrations recorded by an experienced exercise therapist aiming to guide players on the movements and activities to perform. Following the dolphin is optional and, if players do not wish to do so, they will still be able to explore the environment at their own pace and preference. In this way, players are encouraged to keep exploring the environment by rowing the boat while multiple stimuli appear at different times and places to make the conditioning exercise more enjoyable. Figure 4B shows a screenshot of the rowing activity with the virtual boat, virtual hands, the environment, and the dolphin. Fishing (cooldown, 3 minutes) The activity comes after rowing, where players are transported to a fishing scene where they are encouraged to fish using a rod attached to their virtual hands. Neck rotations, elbow flexion, and elbow extensions are the main movements included in this game mechanic (Figure 4C). Fish are placed in the visual periphery (180°) and jump intermittently. The players are asked to use one of their hands to throw the fishing line to a targeted spot. Once in the water, the bait is ready for the fish to take; when one does so, the controller will start vibrating and players have to “pull” the rod out to hook the fish. Once hooked, players have to carry out a series of 6-10 repetitions of the desired movement (elbow flexion–extension) to get the fish and put it inside a bucket in the boat. By bringing the fishing rod close to the other hand, the players will be able to switch the hand used to hold the rod and repeat the fishing process. Figure 4C shows a screenshot of the moment where the player catches a fish and brings it to the boat. The game rewards the fishing efforts by displaying the fish in front of the player and moving it to the bucket. Main Characteristics Key features of Seas the Day are presented in Textbox 2. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Textbox 2. Key features of Seas the Day. Three exercise stages with 3 game mechanics Seas the Day has been specifically designed to align with exercise recommendations for persons living with dementia/mild cognitive impairment (MCI) by creating an experience that is accessible and autonomously adjusts the exercise intensity for appropriate warm-up, conditioning, and cooldown stages of the exercise training. This is achieved by proposing different game mechanics (ie, Tai Chi, rowing, fishing) for each subgame that are suitable for persons living with dementia/MCI using data from playtesting sessions along with exercise professionals’ recommendations. Game mechanics were designed to be intuitive, realistic, and adapted to the older population (ie, no buttons required, no teleportation) without frustrating those with limited mobility, as suggested by guidelines for exergames for persons living with dementia/MCI [71]. The main goal was for the game mechanics to achieve a balance between the serious intent of the game while keeping the fun and joy of playing in an immersive environment [74]. Narrative guiding players through the activities From the playtesting sessions and previous research [67], we noticed that guiding players in performing targeted activities was a key component to create an effective gameplay experience and to elicit the desired physical responses. Thus, a game narrative approach was integrated into Seas the Day by using voice clips recorded by an exercise therapist within the research team with expertise guiding persons living with dementia through exercise therapy. Narrative has been found to be an experience booster in both exergaming and virtual reality (VR) experiences that enhances engagement [78], positively impacts perception of physical activity [79], and reduces motion sickness [80]. For instance, the following script was used as a voice over to encourage players to initiate and guide rowing: “There is nothing better than a trip in a rowboat! You’re holding the oars for the boat in your hands. Can you see the dolphin? I think she wants to play...let’s try to follow her!” Automatic data logging Seas the Day includes a data logging system that automatically captures movement and game variables during the gameplay. After each session, the system creates a data file containing the time series reflecting the changes of the game variables for the session and stores it in the headset internal memory. Examples of game events being recorded are (1) Tai Chi (time that players were following the path, time to complete each exercise); (2) Rowing (boat speed, distance traveled, number of strokes [total, right, and left oar], boat collisions, dolphin status [eg, away, following], birds approaching the boat, and time for the player to respond to it); and (3) Fishing (number of fish caught, pulling the rod up [repetitions], fish taking the bait, and time for the player to respond). As capturing physical and cognitive performance of players was a feature frequently discussed among exercise therapists and the research team, Seas the Day includes experimental variables in all the game levels that aim to capture (1) head and upper limb range of motion of players using kinematic variables (eg, position and acceleration from headset and controllers) and (2) reaction time using game events associated with cognitive function (eg, birds approaching/landing on the boat, pull out the controller after vibration when fishing). Configurable options to customize the exercise session To facilitate the customization of the experience, a configuration menu was integrated where therapists can modify components of the exercise session: (1) duration of 10, 15, or 20 minutes was given for each session; the distribution of time for each exercise stage is automatically configured and (2) calibration of the position in the boat for rowing with adjustable height of the avatar’s position to ensure that rowing can be performed smoothly. Novel standalone VR systems (as the Oculus Quest 2) also have improved the calibration by including inside-out tracking technology (the cameras are in the headset and therefore, the calibration of the player position is automatic). Seas the Day is freely available to be played using the Oculus Quest 1 and 2 headsets and can be found at Reality Well platform [4] and at the Oculus digital store [81]. The game complements a suite of VR content (360 videos, 3D tours, and interactive games) created by our VR industry partner and is (to the authors’ knowledge) the first effort toward creating content through a participatory design process (involving various stakeholders such as the company, research team, persons living with dementia/MCI, and exercise therapists) and making the game available to anyone who wishes to use it. The study protocol, including safety and hygiene procedures Pilot of At-Home System Deployment With for using HMD-VR devices safely at home and within the Community-Dwelling Older Adult Volunteers COVID-19 context, was approved by the University Ethics Because of subsequent access restrictions to our target Board (Multimedia Appendix 2). We then shipped the equipment population (persons living with dementia/MCI) due to the to our community-dwelling older adult test group members; COVID-19 pandemic, we decided to carry out a final pilot shipping was done via a prepaid courier service. Five playtesting and co-design session with community-dwelling community-dwelling older adults were added as test group older adults. The goal of this pilot was to gather feedback members, and the remote activities in Textbox 3 were carried regarding the exergame and overall user experience as well as out. to co-develop a workable protocol for remote deployment in Upon completion of the pilot playtesting and remote assessment the community of the system, using the exergame, and remote sessions, our older adult team members indicated several physical and cognitive assessments to quantify potential important aspects related to their experiences and opportunities outcomes of playing our VR exergame (Multimedia Appendix for improvement, which are summarized in the 4 categories in 1). The resulting protocol will be used in our future feasibility Textbox 4. study, which aims to remotely deploy the exergame with 20 community-dwelling older adults. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Textbox 3. Remote activities for the community-dwelling older adults. Week 1: Introduction to virtual reality and conducting assessments An Oculus Quest 2 virtual reality (VR) headset with the Seas the Day exergame was shipped to the participants along with a custom-designed, printed manual to facilitate the technology uptake at home. Remote sessions with a research assistant were also conducted on how to use the system and play the games. A battery of assessments were conducted during Week 1 to estimate cognitive and physical abilities: (1) Cognitive function (Montreal Cognitive Assessment, Verbal Fluency Test, Oral Trail Making Test, Flanker Test, 4 perceptual tasks [response time, simultaneity judgment, sound-induced flash illusion, temporal order judgment]); (2) Mental well-being (Geriatric Depression Scale and Physical Activity Affect Scale); and (3) Physical activity (Physical Activity Scale in Elderly, Exercise Self-efficacy). Week 2: Playing Seas the Day Older adult test group members were asked to play the exergames 3 times during Week 2 at their convenience with a maximum of 1 time per day. They were asked to play the game for 15-20 minutes while seated, and when finished playing, rate their level of perceived physical exertion and enjoyment. We also asked them to make notes regarding their observations and thoughts about the VR exergaming experience. Week 3: Debrief with the research team Two activities were conducted during this week: (1) a 30-minute long semistructured interview with each older adult, and (2) a 90-minute long focus group with all 5 older adults, members of the research team, and a member from our industry partner. The purpose of conducting interviews and the focus group session was to better understand experiences and to collaboratively figure out how to improve the protocol. Textbox 4. Aspects related to experiences of older adult team members and opportunities for improvement. Study process and remote support The older adults in the test group enjoyed the social aspect of high levels of interaction with the researchers but felt communication through email was overwhelming. They stated the Week 1 process and assessments needed to be simplified to avoid confusion, such as not finding the correct links or having difficulties to complete the tasks. Test group members also wanted to know more about the purpose of assessments, their test scores, and final results of the future study. They suggested having more introductory sessions with the virtual reality (VR) equipment to facilitate the use of the system (eg, calibration, content selection, exiting the game) and improve rapport with the research team. Overall, the experience of receiving and shipping back the headset and printed material was satisfactory. Exergaming experience and playability Overall, playing the exergame was perceived as a positive experience and the virtual environment produced a pleasant and engaging exercise experience for the test group. They reported that the most challenging part of the game was when they were asked to row while following a virtual dolphin. The rowing mechanics were perceived to be unrealistic for people with previous rowing experience, although it was easy to follow for other users. The members of the test group found the game easy to play, and the voice and sound effects were considered to be relaxing. Playing the game was perceived as a light-intensity physical activity for all 5 test group members; some suggested making the gameplay more challenging and others wished there were more diverse activities to do. Finally, some participants indicated interest in knowing more about the exergaming design and development process and how our study results may impact future development of the games. VR technology experience The experience of using the VR hardware for at-home exercise was generally positive but still challenging for most participants. While the instructions in the custom-made VR manual were found to be sufficient (although somewhat lengthy), issues related to calibration, buttons, and locating the controllers in the physical environment after wearing the headset were mentioned during the interviews and focus group sessions. Some participants also reported the need to ask for family members technology support while playing (eg, for troubleshooting or calibration). Launching and exiting the game were also challenges among test group members who were interacting with a VR system for the first time. None of 5 community-dwelling older adults in the test group reported motion sickness or feeling disorientated after the sessions. However, during the introductory session, 1 of the older adults in the test group had difficulties to launch the game and, while troubleshooting with the research team, she spent more than 30 minutes using the VR and reported feeling nauseous. Remote assessment The test group found performing the online assessments challenging. The computer-based tasks were perceived as being monotonous and repetitive, which resulted in test group members feeling bored or overwhelmed by the amount of time spent in the assessments. A more integrated accompaniment of researchers was suggested to better support participants when completing the online tasks. There was a disparity in technology that was used and some test group members reported having difficulties in completing the tasks when using certain devices (eg, touch computers with small keyboards). circumstances (including adhering to COVID-19 restrictions), Discussion a key contribution of our work is to demonstrate a working model that blends the interests, investments, key stakeholders, Principal Findings and benefits of an interaction among the academics and private Our research assembled a collaboration of disparate institutions that develop dementia-centered solutions with the professionals and people with lived experience to form a potential of being adopted in LTCs as well as generates a cohesive, productive, and focused multidisciplinary team to sustainable business model for the private sector. The second create engaging and tailored exergames that can promote key contribution of this research is establishing and describing physical activity for older adults, including persons living with a process, including the purpose, inputs, methods, and outputs dementia/MCI. While most research is conducted under specific of each stage, in a way that others can adopt and adapt it. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Providing details regarding the HCD-based digital games for Now Is the Time to Develop Usable VR for Persons persons living with dementia/MCI is crucial if we are to learn Living With Dementia/MCI from each other, which in turn will result in appropriate, viable, The popularity of VR and its potential to be adopted during and and replicable methodologies [32]. Clear methodology and after the COVID-19 pandemic are unprecedented (eg, careful processes for collaborating with persons living with telemedicine [82]). The pandemic has significant adverse effects dementia/MCI are particularly important to ensure their needs on the well-being of persons living with dementia/MCI in LTC and perspectives are considered in the conceptualization, design, homes. These challenges should be quickly and efficiently and development. While our process still has room for addressed. VR is well positioned to mitigate some of these improvement, this research provides a real-world scenario, challenges; however, there is much work to be done to realize exposes major challenges, and highlights important design this opportunity. First, the design of custom-made solutions aspects that should be considered when creating immersive using VR that can be safely implemented in LTC homes during games for persons living with dementia/MCI. COVID-19 requires close collaboration with therapists and staff, who are finding their time more limited during COVID-19 While serious games for persons living with dementia/MCI because of work demands. Second, playtesting with end users offer much promise, they are far from realizing their full (and especially persons living with dementia/MCI) is very potential. The time, money, and other resources required to challenging or impossible because, at best, they need support design, develop, and implement a VR system must be clearly from the therapists to start using the system and, at worst, are offset by the benefits for the end users. To achieve this, more simply unavailable for research because of COVID-19 efforts must be made by the content creators toward defining, restrictions. In our process, we relied on iterative objective (eg, refining, and implementing strategies that support the inclusion data recorded from the system) and subjective (eg, opinions and of persons living with dementia/MCI and their care partners in observations) feedback from exercise therapists and persons the creating process. Accessible solutions should reflect the living with dementia/MCI who playtested to guide our design abilities, values, and needs of the end users to support the uptake process. In their absence, we have been relying on recordings and enhance sustainable use of the technology. that team members watch remotely when in-person playtesting Lessons Learned Through the Creation and Piloting is not an option; however, this is significantly slower and less of Seas the Day informative. Leave the Laboratory to Create a Cohesive and Therapists Are Problem Solvers and Game Designers Complementary Team by Nature We challenge researchers to leave their laboratories and seek Therapists are constantly looking for new approaches to engage out industry and other nonacademic partners. These partners persons living with dementia/MCI in different therapeutic and substantially contribute to the design, scalability of the solution, leisure activities (usually on a tight budget and a busy schedule). and enable the team to take a larger, systems-based approach. They are accustomed to thinking outside the box to develop Connecting with and involving partners from the beginning novel solutions to difficult problems. For instance, the idea of enabled us to collaboratively define project scope, methods, using an animal character to guide a “tour” around the tropical and outcomes that complemented and benefited all partners. environment to modulate exercise intensity came from a This approach was crucial to building trust, motivating therapist when we asked: “How do you think we can make the engagement, and creating shared feelings of success when rowing activity more fun and engaging for persons living with milestones were achieved. In our case, our industry partner goals dementia/MCI?”. As guided by the therapists, we are exploring are well-aligned with our project, this is, they have novel ways of visualizing data to provide therapists and their complementary leadership (eg, the Vice President is an clients with objective measures of exercise (to be presented in experienced nurse), and have a genuine interest in making a a forthcoming paper). This aspect is challenging as it is a blend positive change in the lives of persons living with of system capabilities and information that results in new forms dementia/MCI. This synergy helped to provide momentum of data that are readily understood by therapists. To design this, through roadblocks. Our LTC partner was keen about the project therapists need to envision how the gaming system could be from the onset. They supported the project by approving their used to augment and improve the conventional methods as well therapists to be core members of the research and offering to as what information they were not currently working with but pay for backfill (eg, someone to do the therapists’ job while would be helpful to have. In our case, inviting therapists as they were working on our project). This resulted in therapists members of our research team created a sense of belonging, as key team members who guided the process, including long-term commitment, and ownership of the project, which facilitating access to LTC, learning about exercise with older allowed everyone to feel more comfortable, honest, and direct adults, and access to persons living with dementia/MCI, all of when discussing ideas or exchanging opinions. In short, having which have been found to be significant barriers to the therapists as co-designers of our exergame was a very fruitful development of supportive technologies for persons living with and enriching experience. dementia/MCI [14]. Limitations Found When Older Adults Use VR Technology In addition to the lessons learned, limitations presented through the use of VR technology must be addressed. The weight and https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al cost of the headsets have continuously decreased over the last Limitations and Future Work decades, making VR headsets increasingly accessible and Our process has several limitations. While the research was comfortable. Further, limitations arise from the physical designed to include end users in several playtesting sessions hardware of headset itself, as HMDs can be bulky both in size throughout the project, the COVID-19 outbreak critically limited and in weight. Improper fitting of HMDs can cause further our access to both persons living with dementia/MCI and discomfort and strain on the neck muscles and indeed feelings exercise professionals working with this population. Collecting of discomfort and dislike of wearing a headset have been information from a homogeneous group of fragile older adults previously reported in the literature [83]. We have used Oculus during a global pandemic situation involves multiple challenges Quest 1 and 2, which weigh approximately 500 g, and have such as (1) the constantly changing regulations and provided participants with a detailed manual as well as governmental policies in developed countries and (2) the one-on-one support with the setup process prior to and during individual measures adopted by LTC homes to protect the the data collection to help minimize strain and correct placement residents. The recruitment of persons living with dementia/MCI of the headset. was carried out by exercise professionals in the LTC homes, whereas the recruitment of the community-dwelling older adults Technology know-how, ranging from limited to no previous for the pilot was by a snowball sampling method. Both experience to expert users [84-86], is a barrier for uptake of VR recruitment processes have limitations related to the little control in older adults as well as other populations. Once a user has researchers have over the participants and their demographics gained access to the device, further limitations may appear. For as well as the potential lack of representativeness of the recruited example, to have agency and to be able to explore a virtual participants. Besides, due to the qualitative nature of the HCD environment, the user must be able to use hand controllers to process, the sample size is normally low due to the in-depth interact with their surroundings. As previous research has found analysis required to create engaging game mechanics using that hand controllers can be complicated for some older adults, playtesting methods and comprehensive player-centric models. especially those living with MCI or dementia, this can limit their interaction with the environment [67]. Therefore, the use Nevertheless, the feedback collected during the playtesting of haptic gloves or other controller-free interfaces has been sessions carried out before the COVID-19 pandemic allowed recommended as they may be more intuitive to use [83,87]. collecting rich information on player’s preferences regarding Indeed, our playtesting sessions with community-dwelling older visuals, interaction issues in the virtual environment, and adults indicated some issues when using the controllers. perceptions about the use of VR technology. Additionally, we were able to engage community exercise professionals who had Cybersickness is also a concern, with symptoms of nausea, a history of working in LTC homes. We also managed to engage sweating, salivation, apathy, headache, abdominal discomfort, community-dwelling older adults to co-develop the deployment disorientation, postural instability, oculomotor disturbance, and protocol, which was invaluable in helping us to refine the eyestrain being the most commonly reported [88-91]. In VR, protocol for deploying the system and related testing for at-home the dynamic environments are designed to induce a high degree exercise training programs. Our HCD process did not intend to of immersion enabling an illusory perception of self-motion, create generalizable models (eg, user personas, empathy maps) known as vection. However, because a user is usually stationary of persons living with dementia/MCI [3] and their preferences (eg, standing of sitting), the vestibular and proprioceptive organs for playing VR games. We intended to collect usable receive minimal afferent input which can cause sensory conflict, information that could inform our game design process and leading participants to experience cybersickness. Given that provide insights into which game elements were more suitable cybersickness has been associated with detriments in user to elicit the required movements (Table 2) while keeping the performance, safety, immersion, presence, and acceptance fun of exergaming. [39,88,91-94], it is necessary to examine how this may impact the participants who partake in our exergame intervention. As the game was initially created to be played by persons living Although our pilot project did not lead to any reports of with dementia/MCI, some community-dwelling older adults cybersickness, we were provided with feedback regarding the found the game was not very challenging, especially as they directionality of rowing being incongruent with reality, which became more accustomed to it. While there is nothing impeding may lead to future participants experiencing cybersickness. healthy older adults to get benefits from playing Seas the Day, the challenges and game design process were tailored to those Finally, there is a risk of injury from one’s external environment with cognitive impairment, therefore it is not surprising that when using an immersive HMD virtual environment [95-97]. healthy older adults may find the game and game activities easy During this period, users of VR have limited, if any, visibility to accomplish. Therefore, generatability of the findings should of the real world as well as limited real-world aural stimulation be carefully considered because we have playtested the game as many virtual environments include visual and sound cues with 2 groups of very different older adults that are designed to be immersive and distract attention away (community-dwelling and persons living with dementia/MCI). from the real world. These factors can lead to collisions with This research represents a first stage in this project. Future work real-world objects that can cause injury. Suggestions to mitigate includes evaluating the effectiveness of the VR system in 2 such an outcome range from engaging in VR in a safe area with populations: persons living with dementia/MCI in LTC assisted protected railings to sitting while playing [95]. As such, Seas by exercise therapists (once COVID-19 allows it) and the Day has been designed to be played while seated and while community dwelling-older adults at home. remaining within the guardian setup. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al We will also continue to develop the technology; the next stage VR exergames that are tailored to older adults with cognitive of our research will focus on the development of intelligent impairment. The results of our process demonstrate a replicable algorithms to create adaptive gaming experiences that include model of interaction that blends the needs and preferences of physiological (eg, cardiovascular [98]) and kinematic (eg, motor end users with those of exercise providers. The value of control [99]) data to modulate gameplay. In addition, our game including end users and exercise therapists’ feedback throughout development will focus on creating new game scenarios to the game design process results in an enriched game design provide a more diverse, multithematic, and enjoyable virtual with elements familiar to and preferred by end users that are farming experience. potentially effective in eliciting desired exercise movements that produce measurable health outcomes. Also, the inclusion Conclusions of an appropriate industry partner that specializes in VR content This research provides insights into how HCD can be used to development was crucial to producing a set of exergames with actively involve multiple stakeholders (including end users, characteristics that are closer to a finalized product (Multimedia researchers, and industry partners) in designing and developing Appendix 3). Acknowledgments The authors thank the exercise professionals that were involved in the different design stages of the project. Professionals: Maggie Douglas, Janelle Way, Dagmara Klisz, Kristin Frye, and Zack Henderson from the LTC home; and Brian Fhest, Eliza Reid, Amanda Serschen, and Katelyn Corke from YMCA. Also, the VR Vision company led by Roni Cega (CEO) and Joannah Apelo (SVP, Operations and Healthcare) and their team comprising David Tucciarone, Wei Yuen, Ahmad Askri, Alex Pryor, Karah Sharma. This study is supported by a Natural Sciences and Engineering Research Council of Canada (NSERC) Engage Grant (to SC), the Network for Aging Research, and a University of Waterloo Trailblazer Grant (to MB-C and SC). Conflicts of Interest None declared. Multimedia Appendix 1 VR equipment sanitizing protocol. [PDF File (Adobe PDF File), 713 KB-Multimedia Appendix 1] Multimedia Appendix 2 Cognitive and physical assessments. [PDF File (Adobe PDF File), 545 KB-Multimedia Appendix 2] Multimedia Appendix 3 Seas the day is an interactive experience created to foster wellbeing in persons living with dementia using virtual reality. A collaborative design process involving exercise professionals, persons living with dementia, kinesiologists, the VR Vision design and development team and researchers in human factors from the University of Waterloo. [MP4 File (MP4 Video), 132145 KB-Multimedia Appendix 3] References 1. Hendriks N, Slegers K, Wilkinson A. 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Virtual Reality World 1994;2(4):16. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 20 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al 97. Muñoz JE, Cameirão M, Bermúdez i Badia S, Rubio Gouveia E. Closing the loop in exergaming - health benefits of biocybernetic adaptation in senior adults. 2018 Presented at: CHI PLAY '18: The annual symposium on Computer-Human Interaction in Play; October 28-31, 2018; Melbourne, VIC, Australia p. 329-339. [doi: 10.1145/3242671.3242673] 98. Muñoz JE, Cao S, Boger J. Kinematically adaptive exergames: personalizing exercise therapy through closed-loop systems. New York, NY: IEEE; 2019 Presented at: 2019 IEEE International Conference on Artificial Intelligence and Virtual Reality (AIVR); December 9-11, 2019; San Diego, CA p. 125. [doi: 10.1109/AIVR46125.2019.00026] 99. Norman DA, Draper SW. User Centered System Design: New Perspectives on Human-Computer Interaction. Hillsdale, NJ: Lawrence Erlbaum Associates; 1986. Abbreviations ADLs: activities of daily living HCD: human-centered design HMD-VR: head-mounted displayed-virtual reality LTC: long-term care MCI: mild cognitive impairment ROM: range of motion SWOT: strengths, weaknesses, opportunities, and threats VR: virtual reality Edited by N Zary; submitted 27.04.21; peer-reviewed by N Martin, SR Ramos; comments to author 05.06.21; revised version received 24.06.21; accepted 24.09.21; published 19.01.22 Please cite as: Muñoz J, Mehrabi S, Li Y, Basharat A, Middleton LE, Cao S, Barnett-Cowan M, Boger J Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic JMIR Serious Games 2022;10(1):e29987 URL: https://games.jmir.org/2022/1/e29987 doi: 10.2196/29987 PMID: 35044320 ©John Muñoz, Samira Mehrabi, Yirou Li, Aysha Basharat, Laura E Middleton, Shi Cao, Michael Barnett-Cowan, Jennifer Boger. Originally published in JMIR Serious Games (https://games.jmir.org), 19.01.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 21 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic

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Abstract

Background: Advancements in supporting personalized health care and well-being using virtual reality (VR) have created opportunities to use immersive games to support a healthy lifestyle for persons living with dementia and mild cognitive impairment (MCI). Collaboratively designing exercise video games (exergames) as a multistakeholder team is fundamental to creating games that are attractive, effective, and accessible. Objective: This research extensively explores the use of human-centered design methods that involve persons living with dementia in long-term care facilitates, exercise professionals, content developers, game designers, and researchers in the creation of VR exergames targeting physical activity promotion for persons living with dementia/MCI. Methods: Conceptualization, collaborative design, and playtesting activities were carried out to design VR exergames to engage persons living with dementia in exercises to promote upper limb flexibility, strength, and aerobic endurance. We involved a total of 7 persons living with dementia/MCI, 5 exercise professionals, 5 community-dwelling older adults, a VR company for content creation, and a multidisciplinary research team with game designers, engineers, and kinesiology experts. Results: An immersive VR exergame called Seas the Day was jointly designed and developed and it is freely available to be played in state-of-the-art VR headsets (Oculus Quest 1, 2). A model for the triadic interaction (health care institution, industry partner, academia) is also presented to illustrate how different stakeholders contribute to the design of VR exergames that consider/complement complex needs, preferences, and motivators of an underrepresented group of end users. Conclusions: This study provides evidence that a collaborative multistakeholder design results in more tailored and context-aware VR games for persons living with dementia. The insights and lessons learned from this research can be used by others to co-design games, including remote engagement techniques that were used during the COVID-19 pandemic. (JMIR Serious Games 2022;10(1):e29987) doi: 10.2196/29987 KEYWORDS virtual reality; exergames; persons living with dementia; physical activity; head mounted displays; participatory design; co-development; gaming; older adults; elderly; design; dementia; VR; user-centered; physical activity; exercise; COVID-19 https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al meaningful to them in a way that respects and reflects their Introduction needs, abilities, and perceptions of personhood. As persons living with dementia have wide and dynamic preferences and Background abilities that are difficult (sometimes impossible) to simulate Technology has a key role to play in supporting people of all or speculate about, it is crucial to have their voice as a central abilities’ fundamental rights to inclusion and participation. The part of the design process of technologies intended for them. essential purpose of technology is enabling people to do things While actively involving persons living with dementia in they could not otherwise do. However, applications need to be technology development has already started and multiple articles specifically adapted to the needs and abilities of end users for have documented valuable insights [2,3,13], the adoption rate them to be accessible and meaningful [1]. Top–down approaches is quite low and appropriate/effective methods for supporting where designers independently create technologies can lead to their involvement are still being explored. well-intended but poorly suited solutions, especially for older This paper presents the participatory cocreation of Seas the Day, adults (defined here as aged 60+) with cognitive, physical, or an exergame (ie, a game that is intended to promote exercise) sensory impairments, such as people living with mild cognitive designed to include persons living with dementia/MCI as core impairment (MCI) or dementia [2-4]. To meet the needs of such end users. Seas the Day uses immersive head-mounted virtual end user groups, a multistakeholder team has been shown to reality (VR) to encourage players to engage in exercises that better understand the experiences, challenges, and adoption of can be beneficial for their health and well-being. The research technology from different perspectives (eg, end users, health described in this paper was guided by the question: “How can care professionals, service providers, researchers from multiple human-centered participatory design methods be used to involve disciplines, industry designers/developers, and engineers) to multiple stakeholder groups in the collaborative creation of VR form a holistic view [1]. Combining this diversity of knowledge exergames to promote physical and mental well-being among enables creation of novel solutions that can be effective, usable, persons living with dementia/MCI?”. We present our work as and adoptable by the end users [5]. Human-centered design a case study of a collaborative co-design wherein we discuss (HCD) is an approach where solutions are created by focusing main considerations, roles, and lessons learned through our on understanding the context, needs, behavior, and preferences process of co-designing VR exergames for persons living with of the people whom the solution will serve. In HCD, the end dementia/MCI; this includes strategies that were adopted to users’ needs, system requirements, and technology specifications steer the design process while being involved in the COVID-19 are defined using data from observations, interviews, and pandemic, a situation that brings many challenges due to the participatory design activities. Participatory design is one of limited access to the target stakeholder groups. We describe the techniques used in HCD in which end users and other how we tackled previously reported issues in designing games stakeholders are actively involved as partners throughout the targeting older adults with cognitive impairment, in particular: design process [4,6]. (1) creating solutions that are designed with and for persons Adopting participatory and collaborative design approaches in living with dementia/MCI by identifying where exceptional HCD has been shown to result in the development of effective needs (eg, cognitive, physical, sensory impairment, and solutions and improve the effectiveness of serious games in technology literacy) of this population exist and complementing promoting healthy lifestyles among the end users [7]. However, them [14]; (2) integrating players’ needs and preferences early many requirements of these approaches are reported as barriers in the design process [15]; and (3) balancing both attractiveness that can be difficult to overcome [8]. For instance, increased and effectiveness to create enjoyable and useful immersive time and effort are required to come to a common and shared experiences [8]. This research highlights specific considerations understanding of the problem and possible solutions [9]. As a regarding designing exergames for head-mounted displayed-VR result, technology development still predominantly relies on (HMD-VR) technology and specifies how using HMD-VR conventional and less participatory approaches that often come impacted the design choices we made throughout the iterative at the cost of a greater chance of misalignment of the technology and participatory process. with the intended user population [5]. This is particularly the Supporting Aging in Persons Living With Dementia case when designing solutions for people with complex needs or impairments. For instance, understanding the desires, needs, Using Physical Activity: The Opportunity of and abilities of older adults with cognitive impairment can be Exergames extremely complex, dynamic, and unpredictable considering Dementia is an umbrella term for a number of progressive the physical and cognitive challenges faced by this population diseases and disorders, such as Alzheimer disease, Lewy Bodies, [10]. While there is a general agreement on the importance of and Parkinson disease. Symptoms of dementia involve having a multistakeholder co-design approach to design, implicit deterioration in cognitive function including impairment in complexities such as different viewpoints (eg, people from memory, reasoning skills, and the ability to perform everyday different sectors or schools of thought), conflicts of interest (eg, activities as well as changes in behavior and mood [16,17]. MCI intellectual property of the designed solutions), and access to is a high-risk state for dementia where individuals experience end users that are willing to participate in the design process a decline in cognitive abilities, which is not yet sufficient to limit widespread adoption [11]. hinder functional independence. There is ample evidence on numerous physical and psychological health benefits of regular As put forward by Dixon and Lazar [12], technology for persons physical activity participation for older adults [18]. For persons living with dementia should support activities that are https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al living with dementia or those with MCI in particular, physical in response to the COVID-19 pandemic, older adults are facing activity has been recognized as a practical and side effect–free restrictions of physical activity behaviors that can lead to short- therapeutic strategy for both mitigating and managing the and long-term adverse health consequences [42,43]. For those symptoms of MCI and dementia. Regular participation in living in long-term care (LTC) homes or apartment buildings physical activity can improve functional performance, mobility, where going outdoors requires moving through shared spaces, activities of daily living (ADLs) among persons living with risks for physical inactivity and its various adverse health dementia and those with MCI, and may have a positive impact outcomes are even higher. Reduced social connection and on their global cognition and balance [19-21]. increased feelings of loneliness may also decrease older adults’ motivation for physical activity during the COVID-19 pandemic While some guidelines recommend that persons living with [44-46]. dementia/MCI exercise at least twice a week [22], other guidelines recommend they participate at the same level of To mitigate the negative impacts of COVID-19 on the health activity as healthy older adults—150 minutes of moderate and well-being of older adults (with and without cognitive intensity or 75 minutes of vigorous aerobic physical activity impairment), various remote and technological solutions have and strength training twice a week [21]. However, despite strong been suggested, such as [47-50]. Concurrently, literature evidence supporting physical and mental benefits of physical indicates the growing feasibility of using exergaming strategies activity for persons living with dementia/MCI, physical activity to enhance physical activity among older adults during the participation and adherence are particularly restricted in this COVID-19 pandemic [51-54]. For example, VR exergaming population due to the motor and cognitive changes associated has been introduced as a coping strategy to facilitate older with the condition. Various individual, social, and environmental adults’ at-home physical activity and enhance favorable health barriers such as lack of motivation, low levels of self-efficacy, outcomes among this population [55,56]. This can be due to the apathy, poor access to exercise opportunities, lack of fact that virtual environments are customizable and can be dementia-appropriate exercise programs or safe and accessible tailored to the participants’ functional and cognitive abilities, community infrastructure, transportation challenges, and societal including those with MCI/dementia. For individuals reluctant stigma have been reported as contributors to sedentary behavior to participate in exercise, the immersive and interactive among persons living with dementia/MCI [23-26]. environment of VR can provide an engaging, entertaining, and motivational means of exercising and target desired physical Given the increasing number of dementia cases worldwide activity outcomes through the gameplay [57]. (expected to double by 2050) [27] and considering the significant health benefits of regular physical activity, it is While there is promising potential for VR exergames to support imperative to develop innovative and effective strategies to older adults, research on preferences of VR exergames among facilitate physical activity participation and maintenance among older adults with various cognitive abilities is limited. both healthy older adults and those living with cognitive Additionally, the availability of custom-made content and impairment. Serious or applied games, such as exergames, are easy-to-use VR hardware often limit the technology uptake by one plausible strategy to promote physical activity among older older adults [58]. Moreover, public health measures to contain adults by motivating participation through the enjoyment of the spread of COVID-19 have made it more challenging to carry play [28]. VR exergaming is a novel strategy that can encourage out participatory and collaborative cocreation activities with physical activity participation and offer exercise routines that vulnerable end users such older adults and persons living with require minimal guidance and supervision from the therapists dementia/MCI during the pandemic. Therefore, despite the [29,30]. The multisensory and immersive environment of VR growing need and technological advances in VR systems (eg, exergames (especially those employing HMD-VR) have been standalone headsets), the use of VR exergames to promote previously employed as a therapeutic tool to promote the health exercise among older adults is still very limited. and wellness of older adults and to support rehabilitation [31,32]. What We Know About Serious Games and Cocreation Studies that explored VR exergames for older adults have shown for Persons Living With Dementia positive results and demonstrated that exercising using In order to provide a comprehensive understanding of what has exergaming systems can benefit motor learning and neural been done in the field of serious games for persons living with plasticity [33-37]. VR exergaming has been found to be a dementia/MCI, we present below a comprehensive review of feasible strategy to complement conventional exercise the literature, specifically literature covering VR technologies. interventions [32,38]. The rise of consumer-level HMDs and accessibility of the Exergaming During the COVID-19 Pandemic content have fostered the creation of literature related to both Older adults are among the most vulnerable and profoundly nonimmersive and immersive VR systems adopted for dementia impacted during the COVID-19 outbreak and its physical and care. Examples are reflected in the following publications: (1) mental health impacts [39]. Staying physically active during a review of nonimmersive games and simulations including the COVID-19 pandemic is particularly important for older tools for ADL to “brain” games (eg, games for cognitive training adults because physical activity is a protective factor against or assessment) [59]; (2) a review on the cost-effectiveness of viral infections that can increase the immune response as well exergaming interventions and their impact on physical, as the positive benefits toward supporting overall physical and cognitive, emotional, and social functioning of persons living mental well-being [40,41]. However, with the contact with dementia/MCI, which revealed that only 3 studies met the restrictions, isolation measures, and exercise facilities closure inclusion criteria (eg, randomized controlled trials, participants https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al diagnosed with dementia, exergames); (3) a minireview of 10 for those who do not enjoy or have trouble participating in studies on interactive interventions to promote well-being of group-based exercises. They wanted interventions that were not persons living with dementia/MCI revealed that virtual only interactive and engaging, but also inclusive and informed experiences were enjoyable for the participants and improved by the participant’s therapeutic goals. They were also interested their mood and apathy [60]; and (4) the effectiveness of VR in exploring what kinds of objective data could be automatically (full-immersive and semi-immersive) for persons living with collected through gameplay to track changes/progress in physical dementia/MCI was reviewed in a recent meta-analysis of 11 and cognitive function over time. studies concluding that immersive VR is a cost-effective, The multistage collaborative design process that ensued occurred comprehensive, flexible, and potentially useful tool for over the span of 15 months and was driven by multidisciplinary patient-centered care [61]. researchers, exercise therapists, VR game developers, persons The future of VR technologies to foster interactive and living with dementia/MCI in LTC facilities, and therapeutic experiences for persons living with dementia/MCI community-dwelling older adults. The process is divided into presents several challenges that have been repeatedly mentioned 2 main stages: (1) ideation and planning and iterative design in most of the reviews. These challenges can be grouped as and (2) development process. A special emphasis has been put follows: (1) the need to establish practical guidelines for VR in describing the techniques, activities conducted, and people design and implementation for people with cognitive involved during each stage. impairments [61]; (2) the need for less anecdotal, more Preliminary Work on VR and Exergames for Persons consistent, and more therapeutically and scientifically valid Living With Dementia/MCI interventions (eg, randomized controlled trials) to systematically The design process described in this paper is heavily inspired document the effectiveness of VR interventions in persons living by previous research conducted before COVID-19 by our with dementia/MCI [62]; (3) the opportunity to include research team where a set of VR exergames were prototyped noninvasive measurements (eg, gameplay metrics, physiological and tested. Initially created as a proof of concept, a set of signals) and system intelligence (eg, machine learning [63]) to activities in a virtual farm setting was created to engage persons better examine changes, propose novel ways for tracking the living with dementia/MCI in the use of HMD-VR [65,66]. VR intervention progress, and better quantify its impact [60]; Important insights from that study were as follows: (1) end users and (4) the need to improve the rationale behind specific game had positive perceptions of the exergame experience using elements (eg, mechanics, technology) and their impact on the HMDs and were able to engage in the exercise program, (2) outcome measures (eg, cognitive, physical) in order to better involving health care professionals and persons living with define the goals of the interactive interventions [64]. For dementia/MIC in the design process was incredibly beneficial instance, there is a need to better define the role of the level of to creating usable VR environments for persons living with immersion offered by the technology (eg, HMDs, 2D screens) dementia/MCI, and (3) qualitative and quantitative measures in game user experience variables such as engagement or demonstrated comparative results between exercising with the replayability. VR exergaming program and conventional human-guided exercises. Results from this pilot study were crucial to define Methods the next steps and to identify opportunities of using HMD-VR Cocreation of the Seas the Day Exergame technology in promoting physical activity among persons living with dementia/MCI [67]. Furthermore, an analysis of the main This section describes how we carried out our co-design of the strengths, weaknesses, opportunities, and threats (SWOT) was Seas the Day VR exergame, including presenting the ideation conducted to better shape the next steps of the project (Table stages, involvement of stakeholders, and a table summarizing 1). This approach is conventionally used among companies for the iterative and collaborative design and development process, strategy building, marketing, and project planning. A focus of which was partially carried out during the COVID-19 pandemic. the SWOT analysis was to consider how rapidly evolving VR Our process of cocreating Seas the Day was sparked by technology could be used to create a solution that could be conversations with exercise therapists in LTC facilities. They adopted by persons living with dementia/MCI in dementia care expressed a desire for additional ways to engage persons living and by elder care institutions. with dementia/MCI in exercise routines that are fun, particularly https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al a b Table 1. SWOT analysis of VR exergames previously developed and piloted [67]. Strengths Weaknesses Opportunities Threats Demonstrated feasibility of Hard to replicate due to hard- Use less cumbersome VR sys- Difficulty in technology uptake • • • • ware and software limitations tem (eg, standalone rather than due to system’s complexity and using HMD-VR in persons Discomfort of sweating while desktop) cost living with dementia using HMDs Include engaging game me- Content and platform sustain- • • Successfully scaffolded a hu- More suitable for stretching chanics and integrate gamified ability man-centered design process than conditioning exercises activities Design and development time with persons living with demen- Limited visual aesthetics Simplify and improve data longer than time for student • • tia Interactivity errors that can logging MASc degree Included 3 activities placed in lead to frustration Facilitate system calibration Potential motion sickness for • • different scenarios (diversity) Can get monotonous if used Explore metrics to track physi- some people • • Simplified interaction (guided too frequently cal and cognitive performance Users with hearing or visual through voice instructions) Data logging system can be Include full-body interaction impairments might not be able • • Included a calibration process difficult to interpret to engage fully in content for range of motion SWOT: strengths, weaknesses, opportunities, and threats. VR: virtual reality. HMD-VR: head-mounted displayed-virtual reality. communities to identify potential candidates. One of the Ideation and Planning researchers met with company representatives, presented the project vision, and discussed ways to establish collaboration. Overview This stage consisted of a set of activities carried out by the A healthy, robust, and valued partnership is grounded in multidisciplinary research team to identify, define, and plan for perceived benefits that are equal to or greater than the research approaches and goals, game design concepts, and investment for each partner. The nature of the stakeholder with prototyping methodologies required to create VR exergames their specific interests, key people, required investment (eg, using HCD methodologies. The process is described in 2 main time, activities), and benefits are summarized in Figure 1. The stages as follows: main investment for the LTC facility is represented as the time spent by the exercise professionals to partake in the participatory Defining Research Approach and Partnering With design process, playtesting sessions, and performance evaluation Industry of persons living with dementia/MCI participating in the design The initial research team was formed by academic researchers, process. Additional resources, rooms in the home to meet about including professors and graduate students (master’s, PhD, and the project, availability of the exercise professionals and other postdoctoral) with interests/expertise in engineering, human personnel, and use of display devices (eg, projectors or TV factors, and assistive technologies (n=3); kinesiology and screens) for facilitating discussions were part of the LTC applied health sciences with a focus on exercise programming stakeholder investment (in-kind contribution). As a benefit, the and delivery for older adults with and without cognitive LTC facility will get a discount on the final product for 5 years impairments (n=4); and a game designer with experience in and will have a tailored solution that implements needs and health care applications (n=1) as well as exercise professionals ideas from their staff and residents, thus facilitating technology from a local LTC home (n=5). Among the exercise uptake. A shared intellectual property agreement was also professionals, kinesiologists and recreational therapists with negotiated that defined up-front how innovation from the project more than 10 years of experience were engaged and were would be shared in a way that was deemed to be equitable to champions during the design process. The strategy to engage the researchers, industry partner, and LTC facility. exercise therapists consisted of inviting interested professionals To facilitate technology deployment, the industry partner of the LTC homes to be part of the research team, involving provided 2 state-of-the-art, standalone VR equipment (eg, them in the decision-making processes, and inviting them to Oculus Quest) for both the research team and the LTC facilities. take part in the strategic planning of the participatory design As part of their in-kind investment, the company allocated a process. specialized development team to create the virtual environments The next step was to find an industry partner interested in as well as to conduct research on new gameplay metrics. The conducting participatory game design who had related company also spearheaded the development of the business experience/expertise and know-how in developing custom-made model of the envisioned system to provide a sustainable and VR content and commercialization in health care. This step was financially feasible proposal to the team. The benefit for the particularly challenging as human-centered and participatory industry partner is having the exclusivity of commercializing design research with older adults has mostly been conducted in the product as well as gaining experience and insights on academic settings [11]; this is mainly due to differences in the working closely with both potential clients and a time frames between academia and industry as well as relative multidisciplinary research team. By engaging with academia, novelty of the technology. Our strategy to find our industry the industry partner is eligible to receive government grants to partner consisted of researching local company directories and https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al support research and tax breaks; our team has taken advantage design of evidence-based games). The involvement of an of both. industry partner also increased the chances of creating immersive exergames that are widely accessible (eg, through Finally, the research team had the mission of carefully planning purchase, freemium) for both health care and academic settings and managing every step of the process; this included creating compared with when no perspective or active stakeholder is activities to appropriately engage all of the stakeholders by involved in commercialization during the design process. designating academic subteams with graduate students, research assistants, and principal investigators aligned to the different The output of this planning process is a detailed and structured research outputs. Having an industry partner facilitated the Work Plan that is shaped and agreed upon by all stakeholders designing and development of usable and scalable games and and that serves as the guide for the design that allows for the allowed the researchers to stay more focused on the scientific creation of the activities, timelines, and milestones for the team. aspects of the activities (eg, game user research, evaluation, Figure 1. Components of the triadic interaction between the research team, industry partners, and LTC homes. LTC: long-term care; MCI: mild cognitive impairment; PLWD: person living with dementia/MCI; R&D: research and development; VR: virtual reality. limitations [21,22] and risks of using HMD-VR technology Defining the Game Design Concepts and Requirements with older adults [68]), we consulted with team members who for VR Exergaming in Persons Living With have expertise in exercise therapy on multiple occasions via Dementia/MCI dedicated ideation meetings. This resulted in our decision to focus our design on exergames targeting upper limb movements Purpose that have been shown to improve endurance, flexibility, and After assembling the multidisciplinary team, a series of design balance. This decision is supported by the results of a systematic activities (described below) were conducted to explore the review on the effects of exercise on persons living with different perspectives of the team and to create cohesion, dementia/MCI in care homes, which reported that exercise empathy, and mutual understanding. Because some of the team intervention that combined aerobic, strengthening, and stretching members were not familiar with the symptoms and abilities activities had the greatest benefit [69]. We intentionally designed associated with MCI and dementia, we used existing user and developed seated exergames to increase player’s safety and personas to describe some of the characteristics as well as the reduce risk of falls [15,70] while simultaneously incorporating most representative needs and motivations to facilitate the guidelines that consider both physical and cognitive capabilities exchange of information among the team members [15,59]. for exergames in persons living with dementia/MCI [71]. Three researchers who were new to MCI/dementia shadowed A list of desired movements and targeted joints along with their 3 exercise sessions in LTC to gain some first-hand experience correlation with physical fitness was defined (Table 2), which with exercise programming and delivery for persons living with considers (1) exercise routines carried out in the LTC facilities dementia/MCI in this setting. with persons living with dementia/MCI, (2) recommendations Physical Activity and Therapeutic Requirements for exercise prescription in older adults [72], and (3) physical To narrow down the scope of physical activities to ones that challenges specific to persons living with dementia/MCI (eg, are appropriate for this population (including considering on average a decrease in mobility, balance, and strength) [21,69]. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al a b Table 2. List of movements to be included in the VR exergames for persons living with dementia/MCI . Targeted joint/limb Desired movement(s) Application for persons living with dementia/MCI Cervical Neck flexion and extension (bending the head forward and backward) • • ROM Neck rotation (turning the head to the left and right) Flexibility/Mobility ADL Shoulder Shoulder flexion (frontal arm raise) ROM • • Shoulder abduction and adduction (side arm reach) Flexibility/mobility • • Shoulder rotation (360° circumduction) Endurance • • Overhead arm stretch ADL • • Elbow/Wrist Elbow flexion and extension (biceps curls) ROM • • Elbow supination and pronation (outward and inward rotation of the Flexibility/mobility • • forearm) Endurance Wrist flexion and extension (tilting toward the palm and tilting toward ADL • • the back of the hand) Trunk Trunk flexion and extension (bending forward and backward) ROM • • Lateral flexion (side bending) Flexibility/mobility • • Trunk rotation Weight shifting and postural balance (seated) • • Core strength ADL VR: virtual reality. MCI: mild cognitive impairment. ROM: range of motion. ADLs: activities of daily living. One-Page Level Design Concept Ideation and Brainstorming Activities To facilitate the communication across the research team and Three main activities were conducted to conceptualize the VR stakeholders, a 1-page game level design (Figure 2A) [74] was exergames: (1) literature review of exergame design used where exercise components (eg, stages, intensity) were frameworks, (2) inclusion of simplified game design elements outlined and 4 different game levels were initially proposed. to improve communication among stakeholders, and (3) The farm theme was chosen as suggested by the results of our brainstorming sessions. pilot study and because of its broad acceptability among persons Exergaming and Design Frameworks living with dementia/MCI and exercise therapists [66]. The game is named Exerfarm Valley and its concept consists of 4 A literature review was conducted to explore existing design different levels that recreate a productive farm: fishing, frameworks used to create engaging and effective exergaming harvesting, horse caring, and beekeeping; these activities were experiences [73]. One of the design frameworks specialized in chosen from a list of activities generated through discussions exergaming for healthy lifestyle promotion, called the dual flow with the exercise therapists and researchers and in consideration model [8], was used to guide the design process. In the dual with their mapping to the movements defined in Table 2. flow model, the design is guided by balancing both effectiveness Exerfarm Valley was envisioned by the game designers, and attractiveness in exergames to maximize the level of integrating the input from different stakeholders and considering engagement while keeping the beneficial aspect of the games. other similar exergaming approaches found in the literature The implementation of the dual flow model framework was [15,70]. The initial design was presented and discussed with achieved by mapping the 3 main components of an exercise the research team for further refinement. Each game level has training session (ie, warm-up, conditioning, and cool-down) 3 different stages including specific activities that reflect with individual activities suggested by persons living with warm-up, conditioning, and cool-down movements. In the dementia/MCI and their therapists [65]. These activities were iterative design and development stage, details of each game integrated in each stage of the exercise session (ie, warming up, level were discussed and integrated to facilitate a more concrete conditioning, cool-down) using a different game mechanic for and streamlined development process. For instance, Figure 2B each one considering the recommended exercise intensity and shows the design of the rowing/fishing level (called Seas the duration. Day) after discussing it with the development team. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Figure 2. One-page level design of the Exerfarm Valley concept. (A) Four-level design sketch representing the activities and main game levels envisioned (including Seas the Day). (B) Seas the Day level design discussed with the development team of the virtual reality company specifying the spatial characteristic of the elements in the virtual environment. participants to the different perspectives of the team and (2) Envisioning and Brainstorming collect ideas on the activities and narratives of the envisioned To further explore the initial design, 2 brainstorming sessions games. The scenario was defined as instructions that were given were conducted to create paper prototypes and discuss possible as follows: game mechanics and scenarios of the VR exergames. • Target population: persons living with dementia/MCI in The first brainstorming session (Figure 3A) was carried out LTC settings (persons living with dementia/MCI personas with (1) 2 VR specialists (from our industry partner), (2) 3 health were used [75]); care professionals (1 per each institution: university, LTC • Game purpose: engage players in seated upper limb partner, industry), (3) 2 external researchers with experience in exercises wearing a standalone VR headset; and designing digital technologies for persons living with • Interaction structure: 15 minutes of exergaming using the dementia/MCI, and (4) 2 graduate students with experience in VR headset eliciting physical activity responses according user experience design. The goal of the session was to create to the warm-up, conditioning, and cool-down stages multidisciplinary subgroups to (1) introduce and expose (exertion cards were used to filter the ideas [76]). Figure 3. Brainstorming sessions. (A) Introductory session carried out involving multiple stakeholders of the project. (B) Exploratory sessions carried out with exercise therapists to introduce the head-mounted displayed-virtual reality technology and collect ideas about game mechanics. The final result encompassed a set of ideas of virtual activities company to start off with the prototyping process; having the for various game levels (eg, fishing, rowing, animal care). These industry partner as an active stakeholder in the brainstorming ideas were used to create a game design document (ie, document session was invaluable to building a shared understanding of detailing the envisioned game specifying game elements such the opportunities and challenges as well as creating a backdrop as mechanics and aesthetics) to be used as an input for the VR with which they could frame ideas. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al The second brainstorming session (Figure 3B) was conducted approximately every 2 weeks during a 6-month period. Versions in 2 LTC facilities with 11 exercise professionals: (1) 2 physical of the games were installed on the VR equipment and then therapists, (2) 3 kinesiologists, (3) 3 recreational therapists, and playtested by the research team, end users, or therapists to (4) 3 kinesiology students. The session aimed at exploring ideas collect feedback and prepare a playtesting report suggesting on exercise movements, activities, and game mechanics. The required changes and potential improvements for the new game concept was introduced by defining the farm theme and prototype. Playtesting sessions were carried out both in-person the 3 intended stages (warm-up, conditioning, cool-down) with (before the COVID-19 pandemic) and virtually via audiovisual their respective timing and intensities. The goal of the session conference platforms (during the COVID-19 pandemic). While was twofold: (1) to gather therapists’ feedback on the use of the the exergame was initially designed with and for persons living HMD-VR technology in promoting physical activity in persons with dementia, because of the limitations of accessing persons living with dementia/MCI and (2) to collect ideas on specific living with dementia/MCI in LTC due to the pandemic, we activities, feedback modalities, and instructions in each stage. conducted a remote, 1-week pilot with community-dwelling We used a large paper layout dividing the 3 stages and older adult volunteers who agreed to receive the headsets at specifying the exercise intensities and asked the therapists to their home and play our exergame 3 times. The development write down or sketch the specific activities they would like to was initially focused on the creation of experimental game see on each stage, providing as many details as possible. Three mechanics associated with the movements and therapeutic researchers analyzed the qualitative results using an affinity requirements previously discussed. Other game design elements diagram approach after moving the concepts to sticky notes and such as aesthetics and story were gradually added to our clustering the ideas to build affinity maps [77]. These generated exergame, based on feedback from the end users and other themes centered around (1) the feasibility and requirements of stakeholders during the playtesting sessions. In total, 3 using standalone HMD-VR devices in the LTC (eg, network playtesting sessions were conducted with 7 persons living with connectivity, privacy, and adaptation of existing spaces or dementia/MCI (6 females; mean age 81.3 years) from 2 LTC elements) and (2) specific game mechanics that can be used by homes, a total of 9 exercise providers (both from LTC and persons living with dementia/MCI in the envisioned Fishing community, including the ones in the research team) with (Figure 2A) game level (eg, exploring while rowing, fishing experience in dementia care (7 females; mean age 38.1 years), with rod, hand-biking, scuba diving, and beach activities such and the researchers to evaluate different aspects of the exergame. as stretching or playing sports). Table 3 summarizes the objectives, participants, and insights of each playtesting session. After completing the first playtesting Iterative Design, Development, and Playtesting session with persons living with dementia/MCI, the COVID-19 An iterative, agile, and cyclical human-centered development pandemic and public health restrictions forced us to halt process was carried out to merge research concepts, design in-person research, resulting in access restrictions to persons requirements, and technical feasibility to shape the requirements living with dementia/MCI and exercise providers at LTC homes. of the prototype. Each iteration consisted of short Similarly, other preplanned participatory design activities to prototyping–testing–evaluation cycles, coordinating the research continue cocreating and playtesting different game design team, exercise therapists, end users, and the development team concepts with exercise professionals and persons living with from our VR partner. Playable prototypes were developed dementia/MCI had to be paused. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Table 3. Playtesting sessions. Playtesting name Objectives Participants Methods Main insights Rowing and de- Game mechanics: 7 persons liv- Face-to-face playtest- • • All players learned easily how to row in VR using sired visual ele- Rowing forward ing with demen- ing: the prototype ments (number of Rowing backward tia 20 minutes interac- Rowing backward/forward and turning left/right • • sessions: 2) Rowing turning 5 exercise thera- • • tion were intuitive for most participants (left, right) pists (from Individual, a When asked about desired visual elements, end LTC facilities) semistructured Game aesthetics: users preferred animals (eg, fishes and birds), na- Overseen by exer- ture and landscape (eg, sunset, mountains), and Desired visual ele- cise therapists ments other boats and more people. Debrief with the One player could not complete the test because the therapists at the Game technology: headset was uncomfortable. end of the session. Motion sickness • Therapists mentioned the importance of adding and comfort cues or elements to guide the navigation. COVID-19 outbreak Rowing improve- Game mechanics: 4 community exer- Remote playtesting: Add configurable menu to define (1) session dura- ments and game cise providers with tion, (2) player’s position calibration to facilitate Rowing and navi- 1-hour discussion • • level design experience in demen- rowing. gation around the Online (through (number of ses- tia care (who were Add configurable menu to define (1) session dura- level designed Zoom) sions: 1) not working in LTC) tion, (2) player’s position calibration to facilitate (Figure 3B) Semistructured fo- rowing. Modify world physics to have more natural cus group Game aesthetics: tree shaking and water waving effects. Oars aspect and Adding cues to guide participants (eg, signs, audio positioning clips). Game objects and water effects Game technology: Capture player’s re- sponses and behaviors Conditioning and Game mechanics: Research team Remote playtesting: Add strategies to avoid getting stuck while rowing. cool-down (without LTC exer- Better define the virtual world limits by adding Rowing and fish- 1-hour discussion • • stages, rowing cise therapists) buoys regarding the dolphin: (1) sounds should be ing cohesion online (through and fishing inte- added to facilitate prompting, (2) dolphin’s behav- Dolphin as exer- Zoom) gration (number ior should help in meeting exercise intensities in cise intensity of sessions: 3) conditioning. modulator Variables such as attention paid to the animals in Game technology: the scenario as well as the response of players to haptic stimulus can be used to quantify reaction Player’s responses time. and behaviors Game aesthetic, Consider movement limitations when fishing to story avoid persons living with dementia from getting Narrative to aid frustrated. engagement LTC: long-term care. VR: virtual reality. activities that encourage exercise movements that have been Results shown to be beneficial to persons living with dementia/MCI [21,69]. Seas the Day places the players in a tropical Seas the Day: Final Game and System Overview environment surrounded by animals, hills, and water. Three (Description) activities lasting a total of 15 minutes were created (Figure 4 Seas the Day is an immersive HMD-VR experience that and Textbox 1) to align with the design requirements and needs transports seated players to a virtual seaside with different identified in conceptualization and playtesting sessions. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Figure 4. Seas the day screenshots showing the game levels of Tai Chi (warm up, left), rowing (conditioning, middle), and fishing (cool-down, right). Textbox 1. Activities to align with design requirements and needs identified in conceptualization and playtesting sessions. Tai Chi (warm-up, 3 minutes) A set on a beach with a sunset in the horizon and birds seen and heard in the virtual scene. Players start the experience with a short Tai Chi routine that encourages upper limb movements that are connected with the virtual scene (Figure 4A). To guide players in performing the correct movements, a leaf-shifting metaphor is used wherein players are instructed to hold a floating leaf with 2 hands and guide it through trajectory paths drawn up in front of the players. Examples of the incorporated Tai Chi movements for range of motion are “wings of a bird” (moving arms to the side followed by a folding-like movement of the arms toward the chest), “open the door” (raising arms straight up and bring down with elbows bent) and “flower shifting with the breeze” (hands moving side to side). Rowing (conditioning, 9 minutes) The activity invites players to explore the tropical environment while rowing in a boat using 2 wooden oars attached to their virtual hands. This stage has been created as a conditioning phase as the rowing game mechanic involves exercising the muscle groups described in Table 2 aiming to improve strength and aerobic fitness (Figure 4B). As shown in Figure 4C, this game level has different spaces to explore such as a marsh, small archipelagos, and a valley and rocky spots among others. Hanging bridges, waterfalls, and thatched cottages are some of the objects that players will see while rowing. Five different animals have been included based on the suggestions collected in the playtesting sessions: fish, dolphins, dogs, cows, rabbits, and birds. To guide players, 2 aids have been included: (1) a virtual dolphin that swims specific paths and encourages players to follow along and to explore the virtual environment while keeping an adequate pace, and (2) voice-over narrations recorded by an experienced exercise therapist aiming to guide players on the movements and activities to perform. Following the dolphin is optional and, if players do not wish to do so, they will still be able to explore the environment at their own pace and preference. In this way, players are encouraged to keep exploring the environment by rowing the boat while multiple stimuli appear at different times and places to make the conditioning exercise more enjoyable. Figure 4B shows a screenshot of the rowing activity with the virtual boat, virtual hands, the environment, and the dolphin. Fishing (cooldown, 3 minutes) The activity comes after rowing, where players are transported to a fishing scene where they are encouraged to fish using a rod attached to their virtual hands. Neck rotations, elbow flexion, and elbow extensions are the main movements included in this game mechanic (Figure 4C). Fish are placed in the visual periphery (180°) and jump intermittently. The players are asked to use one of their hands to throw the fishing line to a targeted spot. Once in the water, the bait is ready for the fish to take; when one does so, the controller will start vibrating and players have to “pull” the rod out to hook the fish. Once hooked, players have to carry out a series of 6-10 repetitions of the desired movement (elbow flexion–extension) to get the fish and put it inside a bucket in the boat. By bringing the fishing rod close to the other hand, the players will be able to switch the hand used to hold the rod and repeat the fishing process. Figure 4C shows a screenshot of the moment where the player catches a fish and brings it to the boat. The game rewards the fishing efforts by displaying the fish in front of the player and moving it to the bucket. Main Characteristics Key features of Seas the Day are presented in Textbox 2. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Textbox 2. Key features of Seas the Day. Three exercise stages with 3 game mechanics Seas the Day has been specifically designed to align with exercise recommendations for persons living with dementia/mild cognitive impairment (MCI) by creating an experience that is accessible and autonomously adjusts the exercise intensity for appropriate warm-up, conditioning, and cooldown stages of the exercise training. This is achieved by proposing different game mechanics (ie, Tai Chi, rowing, fishing) for each subgame that are suitable for persons living with dementia/MCI using data from playtesting sessions along with exercise professionals’ recommendations. Game mechanics were designed to be intuitive, realistic, and adapted to the older population (ie, no buttons required, no teleportation) without frustrating those with limited mobility, as suggested by guidelines for exergames for persons living with dementia/MCI [71]. The main goal was for the game mechanics to achieve a balance between the serious intent of the game while keeping the fun and joy of playing in an immersive environment [74]. Narrative guiding players through the activities From the playtesting sessions and previous research [67], we noticed that guiding players in performing targeted activities was a key component to create an effective gameplay experience and to elicit the desired physical responses. Thus, a game narrative approach was integrated into Seas the Day by using voice clips recorded by an exercise therapist within the research team with expertise guiding persons living with dementia through exercise therapy. Narrative has been found to be an experience booster in both exergaming and virtual reality (VR) experiences that enhances engagement [78], positively impacts perception of physical activity [79], and reduces motion sickness [80]. For instance, the following script was used as a voice over to encourage players to initiate and guide rowing: “There is nothing better than a trip in a rowboat! You’re holding the oars for the boat in your hands. Can you see the dolphin? I think she wants to play...let’s try to follow her!” Automatic data logging Seas the Day includes a data logging system that automatically captures movement and game variables during the gameplay. After each session, the system creates a data file containing the time series reflecting the changes of the game variables for the session and stores it in the headset internal memory. Examples of game events being recorded are (1) Tai Chi (time that players were following the path, time to complete each exercise); (2) Rowing (boat speed, distance traveled, number of strokes [total, right, and left oar], boat collisions, dolphin status [eg, away, following], birds approaching the boat, and time for the player to respond to it); and (3) Fishing (number of fish caught, pulling the rod up [repetitions], fish taking the bait, and time for the player to respond). As capturing physical and cognitive performance of players was a feature frequently discussed among exercise therapists and the research team, Seas the Day includes experimental variables in all the game levels that aim to capture (1) head and upper limb range of motion of players using kinematic variables (eg, position and acceleration from headset and controllers) and (2) reaction time using game events associated with cognitive function (eg, birds approaching/landing on the boat, pull out the controller after vibration when fishing). Configurable options to customize the exercise session To facilitate the customization of the experience, a configuration menu was integrated where therapists can modify components of the exercise session: (1) duration of 10, 15, or 20 minutes was given for each session; the distribution of time for each exercise stage is automatically configured and (2) calibration of the position in the boat for rowing with adjustable height of the avatar’s position to ensure that rowing can be performed smoothly. Novel standalone VR systems (as the Oculus Quest 2) also have improved the calibration by including inside-out tracking technology (the cameras are in the headset and therefore, the calibration of the player position is automatic). Seas the Day is freely available to be played using the Oculus Quest 1 and 2 headsets and can be found at Reality Well platform [4] and at the Oculus digital store [81]. The game complements a suite of VR content (360 videos, 3D tours, and interactive games) created by our VR industry partner and is (to the authors’ knowledge) the first effort toward creating content through a participatory design process (involving various stakeholders such as the company, research team, persons living with dementia/MCI, and exercise therapists) and making the game available to anyone who wishes to use it. The study protocol, including safety and hygiene procedures Pilot of At-Home System Deployment With for using HMD-VR devices safely at home and within the Community-Dwelling Older Adult Volunteers COVID-19 context, was approved by the University Ethics Because of subsequent access restrictions to our target Board (Multimedia Appendix 2). We then shipped the equipment population (persons living with dementia/MCI) due to the to our community-dwelling older adult test group members; COVID-19 pandemic, we decided to carry out a final pilot shipping was done via a prepaid courier service. Five playtesting and co-design session with community-dwelling community-dwelling older adults were added as test group older adults. The goal of this pilot was to gather feedback members, and the remote activities in Textbox 3 were carried regarding the exergame and overall user experience as well as out. to co-develop a workable protocol for remote deployment in Upon completion of the pilot playtesting and remote assessment the community of the system, using the exergame, and remote sessions, our older adult team members indicated several physical and cognitive assessments to quantify potential important aspects related to their experiences and opportunities outcomes of playing our VR exergame (Multimedia Appendix for improvement, which are summarized in the 4 categories in 1). The resulting protocol will be used in our future feasibility Textbox 4. study, which aims to remotely deploy the exergame with 20 community-dwelling older adults. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Textbox 3. Remote activities for the community-dwelling older adults. Week 1: Introduction to virtual reality and conducting assessments An Oculus Quest 2 virtual reality (VR) headset with the Seas the Day exergame was shipped to the participants along with a custom-designed, printed manual to facilitate the technology uptake at home. Remote sessions with a research assistant were also conducted on how to use the system and play the games. A battery of assessments were conducted during Week 1 to estimate cognitive and physical abilities: (1) Cognitive function (Montreal Cognitive Assessment, Verbal Fluency Test, Oral Trail Making Test, Flanker Test, 4 perceptual tasks [response time, simultaneity judgment, sound-induced flash illusion, temporal order judgment]); (2) Mental well-being (Geriatric Depression Scale and Physical Activity Affect Scale); and (3) Physical activity (Physical Activity Scale in Elderly, Exercise Self-efficacy). Week 2: Playing Seas the Day Older adult test group members were asked to play the exergames 3 times during Week 2 at their convenience with a maximum of 1 time per day. They were asked to play the game for 15-20 minutes while seated, and when finished playing, rate their level of perceived physical exertion and enjoyment. We also asked them to make notes regarding their observations and thoughts about the VR exergaming experience. Week 3: Debrief with the research team Two activities were conducted during this week: (1) a 30-minute long semistructured interview with each older adult, and (2) a 90-minute long focus group with all 5 older adults, members of the research team, and a member from our industry partner. The purpose of conducting interviews and the focus group session was to better understand experiences and to collaboratively figure out how to improve the protocol. Textbox 4. Aspects related to experiences of older adult team members and opportunities for improvement. Study process and remote support The older adults in the test group enjoyed the social aspect of high levels of interaction with the researchers but felt communication through email was overwhelming. They stated the Week 1 process and assessments needed to be simplified to avoid confusion, such as not finding the correct links or having difficulties to complete the tasks. Test group members also wanted to know more about the purpose of assessments, their test scores, and final results of the future study. They suggested having more introductory sessions with the virtual reality (VR) equipment to facilitate the use of the system (eg, calibration, content selection, exiting the game) and improve rapport with the research team. Overall, the experience of receiving and shipping back the headset and printed material was satisfactory. Exergaming experience and playability Overall, playing the exergame was perceived as a positive experience and the virtual environment produced a pleasant and engaging exercise experience for the test group. They reported that the most challenging part of the game was when they were asked to row while following a virtual dolphin. The rowing mechanics were perceived to be unrealistic for people with previous rowing experience, although it was easy to follow for other users. The members of the test group found the game easy to play, and the voice and sound effects were considered to be relaxing. Playing the game was perceived as a light-intensity physical activity for all 5 test group members; some suggested making the gameplay more challenging and others wished there were more diverse activities to do. Finally, some participants indicated interest in knowing more about the exergaming design and development process and how our study results may impact future development of the games. VR technology experience The experience of using the VR hardware for at-home exercise was generally positive but still challenging for most participants. While the instructions in the custom-made VR manual were found to be sufficient (although somewhat lengthy), issues related to calibration, buttons, and locating the controllers in the physical environment after wearing the headset were mentioned during the interviews and focus group sessions. Some participants also reported the need to ask for family members technology support while playing (eg, for troubleshooting or calibration). Launching and exiting the game were also challenges among test group members who were interacting with a VR system for the first time. None of 5 community-dwelling older adults in the test group reported motion sickness or feeling disorientated after the sessions. However, during the introductory session, 1 of the older adults in the test group had difficulties to launch the game and, while troubleshooting with the research team, she spent more than 30 minutes using the VR and reported feeling nauseous. Remote assessment The test group found performing the online assessments challenging. The computer-based tasks were perceived as being monotonous and repetitive, which resulted in test group members feeling bored or overwhelmed by the amount of time spent in the assessments. A more integrated accompaniment of researchers was suggested to better support participants when completing the online tasks. There was a disparity in technology that was used and some test group members reported having difficulties in completing the tasks when using certain devices (eg, touch computers with small keyboards). circumstances (including adhering to COVID-19 restrictions), Discussion a key contribution of our work is to demonstrate a working model that blends the interests, investments, key stakeholders, Principal Findings and benefits of an interaction among the academics and private Our research assembled a collaboration of disparate institutions that develop dementia-centered solutions with the professionals and people with lived experience to form a potential of being adopted in LTCs as well as generates a cohesive, productive, and focused multidisciplinary team to sustainable business model for the private sector. The second create engaging and tailored exergames that can promote key contribution of this research is establishing and describing physical activity for older adults, including persons living with a process, including the purpose, inputs, methods, and outputs dementia/MCI. While most research is conducted under specific of each stage, in a way that others can adopt and adapt it. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al Providing details regarding the HCD-based digital games for Now Is the Time to Develop Usable VR for Persons persons living with dementia/MCI is crucial if we are to learn Living With Dementia/MCI from each other, which in turn will result in appropriate, viable, The popularity of VR and its potential to be adopted during and and replicable methodologies [32]. Clear methodology and after the COVID-19 pandemic are unprecedented (eg, careful processes for collaborating with persons living with telemedicine [82]). The pandemic has significant adverse effects dementia/MCI are particularly important to ensure their needs on the well-being of persons living with dementia/MCI in LTC and perspectives are considered in the conceptualization, design, homes. These challenges should be quickly and efficiently and development. While our process still has room for addressed. VR is well positioned to mitigate some of these improvement, this research provides a real-world scenario, challenges; however, there is much work to be done to realize exposes major challenges, and highlights important design this opportunity. First, the design of custom-made solutions aspects that should be considered when creating immersive using VR that can be safely implemented in LTC homes during games for persons living with dementia/MCI. COVID-19 requires close collaboration with therapists and staff, who are finding their time more limited during COVID-19 While serious games for persons living with dementia/MCI because of work demands. Second, playtesting with end users offer much promise, they are far from realizing their full (and especially persons living with dementia/MCI) is very potential. The time, money, and other resources required to challenging or impossible because, at best, they need support design, develop, and implement a VR system must be clearly from the therapists to start using the system and, at worst, are offset by the benefits for the end users. To achieve this, more simply unavailable for research because of COVID-19 efforts must be made by the content creators toward defining, restrictions. In our process, we relied on iterative objective (eg, refining, and implementing strategies that support the inclusion data recorded from the system) and subjective (eg, opinions and of persons living with dementia/MCI and their care partners in observations) feedback from exercise therapists and persons the creating process. Accessible solutions should reflect the living with dementia/MCI who playtested to guide our design abilities, values, and needs of the end users to support the uptake process. In their absence, we have been relying on recordings and enhance sustainable use of the technology. that team members watch remotely when in-person playtesting Lessons Learned Through the Creation and Piloting is not an option; however, this is significantly slower and less of Seas the Day informative. Leave the Laboratory to Create a Cohesive and Therapists Are Problem Solvers and Game Designers Complementary Team by Nature We challenge researchers to leave their laboratories and seek Therapists are constantly looking for new approaches to engage out industry and other nonacademic partners. These partners persons living with dementia/MCI in different therapeutic and substantially contribute to the design, scalability of the solution, leisure activities (usually on a tight budget and a busy schedule). and enable the team to take a larger, systems-based approach. They are accustomed to thinking outside the box to develop Connecting with and involving partners from the beginning novel solutions to difficult problems. For instance, the idea of enabled us to collaboratively define project scope, methods, using an animal character to guide a “tour” around the tropical and outcomes that complemented and benefited all partners. environment to modulate exercise intensity came from a This approach was crucial to building trust, motivating therapist when we asked: “How do you think we can make the engagement, and creating shared feelings of success when rowing activity more fun and engaging for persons living with milestones were achieved. In our case, our industry partner goals dementia/MCI?”. As guided by the therapists, we are exploring are well-aligned with our project, this is, they have novel ways of visualizing data to provide therapists and their complementary leadership (eg, the Vice President is an clients with objective measures of exercise (to be presented in experienced nurse), and have a genuine interest in making a a forthcoming paper). This aspect is challenging as it is a blend positive change in the lives of persons living with of system capabilities and information that results in new forms dementia/MCI. This synergy helped to provide momentum of data that are readily understood by therapists. To design this, through roadblocks. Our LTC partner was keen about the project therapists need to envision how the gaming system could be from the onset. They supported the project by approving their used to augment and improve the conventional methods as well therapists to be core members of the research and offering to as what information they were not currently working with but pay for backfill (eg, someone to do the therapists’ job while would be helpful to have. In our case, inviting therapists as they were working on our project). This resulted in therapists members of our research team created a sense of belonging, as key team members who guided the process, including long-term commitment, and ownership of the project, which facilitating access to LTC, learning about exercise with older allowed everyone to feel more comfortable, honest, and direct adults, and access to persons living with dementia/MCI, all of when discussing ideas or exchanging opinions. In short, having which have been found to be significant barriers to the therapists as co-designers of our exergame was a very fruitful development of supportive technologies for persons living with and enriching experience. dementia/MCI [14]. Limitations Found When Older Adults Use VR Technology In addition to the lessons learned, limitations presented through the use of VR technology must be addressed. The weight and https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al cost of the headsets have continuously decreased over the last Limitations and Future Work decades, making VR headsets increasingly accessible and Our process has several limitations. While the research was comfortable. Further, limitations arise from the physical designed to include end users in several playtesting sessions hardware of headset itself, as HMDs can be bulky both in size throughout the project, the COVID-19 outbreak critically limited and in weight. Improper fitting of HMDs can cause further our access to both persons living with dementia/MCI and discomfort and strain on the neck muscles and indeed feelings exercise professionals working with this population. Collecting of discomfort and dislike of wearing a headset have been information from a homogeneous group of fragile older adults previously reported in the literature [83]. We have used Oculus during a global pandemic situation involves multiple challenges Quest 1 and 2, which weigh approximately 500 g, and have such as (1) the constantly changing regulations and provided participants with a detailed manual as well as governmental policies in developed countries and (2) the one-on-one support with the setup process prior to and during individual measures adopted by LTC homes to protect the the data collection to help minimize strain and correct placement residents. The recruitment of persons living with dementia/MCI of the headset. was carried out by exercise professionals in the LTC homes, whereas the recruitment of the community-dwelling older adults Technology know-how, ranging from limited to no previous for the pilot was by a snowball sampling method. Both experience to expert users [84-86], is a barrier for uptake of VR recruitment processes have limitations related to the little control in older adults as well as other populations. Once a user has researchers have over the participants and their demographics gained access to the device, further limitations may appear. For as well as the potential lack of representativeness of the recruited example, to have agency and to be able to explore a virtual participants. Besides, due to the qualitative nature of the HCD environment, the user must be able to use hand controllers to process, the sample size is normally low due to the in-depth interact with their surroundings. As previous research has found analysis required to create engaging game mechanics using that hand controllers can be complicated for some older adults, playtesting methods and comprehensive player-centric models. especially those living with MCI or dementia, this can limit their interaction with the environment [67]. Therefore, the use Nevertheless, the feedback collected during the playtesting of haptic gloves or other controller-free interfaces has been sessions carried out before the COVID-19 pandemic allowed recommended as they may be more intuitive to use [83,87]. collecting rich information on player’s preferences regarding Indeed, our playtesting sessions with community-dwelling older visuals, interaction issues in the virtual environment, and adults indicated some issues when using the controllers. perceptions about the use of VR technology. Additionally, we were able to engage community exercise professionals who had Cybersickness is also a concern, with symptoms of nausea, a history of working in LTC homes. We also managed to engage sweating, salivation, apathy, headache, abdominal discomfort, community-dwelling older adults to co-develop the deployment disorientation, postural instability, oculomotor disturbance, and protocol, which was invaluable in helping us to refine the eyestrain being the most commonly reported [88-91]. In VR, protocol for deploying the system and related testing for at-home the dynamic environments are designed to induce a high degree exercise training programs. Our HCD process did not intend to of immersion enabling an illusory perception of self-motion, create generalizable models (eg, user personas, empathy maps) known as vection. However, because a user is usually stationary of persons living with dementia/MCI [3] and their preferences (eg, standing of sitting), the vestibular and proprioceptive organs for playing VR games. We intended to collect usable receive minimal afferent input which can cause sensory conflict, information that could inform our game design process and leading participants to experience cybersickness. Given that provide insights into which game elements were more suitable cybersickness has been associated with detriments in user to elicit the required movements (Table 2) while keeping the performance, safety, immersion, presence, and acceptance fun of exergaming. [39,88,91-94], it is necessary to examine how this may impact the participants who partake in our exergame intervention. As the game was initially created to be played by persons living Although our pilot project did not lead to any reports of with dementia/MCI, some community-dwelling older adults cybersickness, we were provided with feedback regarding the found the game was not very challenging, especially as they directionality of rowing being incongruent with reality, which became more accustomed to it. While there is nothing impeding may lead to future participants experiencing cybersickness. healthy older adults to get benefits from playing Seas the Day, the challenges and game design process were tailored to those Finally, there is a risk of injury from one’s external environment with cognitive impairment, therefore it is not surprising that when using an immersive HMD virtual environment [95-97]. healthy older adults may find the game and game activities easy During this period, users of VR have limited, if any, visibility to accomplish. Therefore, generatability of the findings should of the real world as well as limited real-world aural stimulation be carefully considered because we have playtested the game as many virtual environments include visual and sound cues with 2 groups of very different older adults that are designed to be immersive and distract attention away (community-dwelling and persons living with dementia/MCI). from the real world. These factors can lead to collisions with This research represents a first stage in this project. Future work real-world objects that can cause injury. Suggestions to mitigate includes evaluating the effectiveness of the VR system in 2 such an outcome range from engaging in VR in a safe area with populations: persons living with dementia/MCI in LTC assisted protected railings to sitting while playing [95]. As such, Seas by exercise therapists (once COVID-19 allows it) and the Day has been designed to be played while seated and while community dwelling-older adults at home. remaining within the guardian setup. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al We will also continue to develop the technology; the next stage VR exergames that are tailored to older adults with cognitive of our research will focus on the development of intelligent impairment. The results of our process demonstrate a replicable algorithms to create adaptive gaming experiences that include model of interaction that blends the needs and preferences of physiological (eg, cardiovascular [98]) and kinematic (eg, motor end users with those of exercise providers. The value of control [99]) data to modulate gameplay. In addition, our game including end users and exercise therapists’ feedback throughout development will focus on creating new game scenarios to the game design process results in an enriched game design provide a more diverse, multithematic, and enjoyable virtual with elements familiar to and preferred by end users that are farming experience. potentially effective in eliciting desired exercise movements that produce measurable health outcomes. Also, the inclusion Conclusions of an appropriate industry partner that specializes in VR content This research provides insights into how HCD can be used to development was crucial to producing a set of exergames with actively involve multiple stakeholders (including end users, characteristics that are closer to a finalized product (Multimedia researchers, and industry partners) in designing and developing Appendix 3). Acknowledgments The authors thank the exercise professionals that were involved in the different design stages of the project. Professionals: Maggie Douglas, Janelle Way, Dagmara Klisz, Kristin Frye, and Zack Henderson from the LTC home; and Brian Fhest, Eliza Reid, Amanda Serschen, and Katelyn Corke from YMCA. Also, the VR Vision company led by Roni Cega (CEO) and Joannah Apelo (SVP, Operations and Healthcare) and their team comprising David Tucciarone, Wei Yuen, Ahmad Askri, Alex Pryor, Karah Sharma. This study is supported by a Natural Sciences and Engineering Research Council of Canada (NSERC) Engage Grant (to SC), the Network for Aging Research, and a University of Waterloo Trailblazer Grant (to MB-C and SC). Conflicts of Interest None declared. Multimedia Appendix 1 VR equipment sanitizing protocol. [PDF File (Adobe PDF File), 713 KB-Multimedia Appendix 1] Multimedia Appendix 2 Cognitive and physical assessments. [PDF File (Adobe PDF File), 545 KB-Multimedia Appendix 2] Multimedia Appendix 3 Seas the day is an interactive experience created to foster wellbeing in persons living with dementia using virtual reality. A collaborative design process involving exercise professionals, persons living with dementia, kinesiologists, the VR Vision design and development team and researchers in human factors from the University of Waterloo. [MP4 File (MP4 Video), 132145 KB-Multimedia Appendix 3] References 1. Hendriks N, Slegers K, Wilkinson A. 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Virtual Reality World 1994;2(4):16. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 20 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Muñoz et al 97. Muñoz JE, Cameirão M, Bermúdez i Badia S, Rubio Gouveia E. Closing the loop in exergaming - health benefits of biocybernetic adaptation in senior adults. 2018 Presented at: CHI PLAY '18: The annual symposium on Computer-Human Interaction in Play; October 28-31, 2018; Melbourne, VIC, Australia p. 329-339. [doi: 10.1145/3242671.3242673] 98. Muñoz JE, Cao S, Boger J. Kinematically adaptive exergames: personalizing exercise therapy through closed-loop systems. New York, NY: IEEE; 2019 Presented at: 2019 IEEE International Conference on Artificial Intelligence and Virtual Reality (AIVR); December 9-11, 2019; San Diego, CA p. 125. [doi: 10.1109/AIVR46125.2019.00026] 99. Norman DA, Draper SW. User Centered System Design: New Perspectives on Human-Computer Interaction. Hillsdale, NJ: Lawrence Erlbaum Associates; 1986. Abbreviations ADLs: activities of daily living HCD: human-centered design HMD-VR: head-mounted displayed-virtual reality LTC: long-term care MCI: mild cognitive impairment ROM: range of motion SWOT: strengths, weaknesses, opportunities, and threats VR: virtual reality Edited by N Zary; submitted 27.04.21; peer-reviewed by N Martin, SR Ramos; comments to author 05.06.21; revised version received 24.06.21; accepted 24.09.21; published 19.01.22 Please cite as: Muñoz J, Mehrabi S, Li Y, Basharat A, Middleton LE, Cao S, Barnett-Cowan M, Boger J Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic JMIR Serious Games 2022;10(1):e29987 URL: https://games.jmir.org/2022/1/e29987 doi: 10.2196/29987 PMID: 35044320 ©John Muñoz, Samira Mehrabi, Yirou Li, Aysha Basharat, Laura E Middleton, Shi Cao, Michael Barnett-Cowan, Jennifer Boger. Originally published in JMIR Serious Games (https://games.jmir.org), 19.01.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/1/e29987 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e29987 | p. 21 (page number not for citation purposes) XSL FO RenderX

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Published: Jan 19, 2022

Keywords: virtual reality; exergames; persons living with dementia; physical activity; head mounted displays; participatory design; co-development; gaming; older adults; elderly; design; dementia; VR; user-centered; physical activity; exercise; COVID-19

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