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The Long-term Effects of Immersive Virtual Reality Reminiscence in People With Dementia: Longitudinal Observational Study

The Long-term Effects of Immersive Virtual Reality Reminiscence in People With Dementia:... Background: Novel nonpharmacological therapies are being developed to prevent cognitive decline and reduce behavioral and psychological symptoms in patients with dementia. Virtual reality (VR) reminiscence was reported to improve anxiety, apathy, and cognitive function immediately after intervention in individuals at residential aged care facilities. However, its effect on elderly patients with dementia and how long this effect could last remain unknown. Objective: The aim of this paper is to investigate the effect of immersive VR reminiscence in people with dementia both immediately after and 3-6 months after intervention. Methods: A pilot study was conducted in 2 dementia care units. VR reminiscence therapy sessions were conducted twice per week for a 3-month period. Cognitive function, global status, depressive symptoms, and caregiver burden were assessed before and immediately after VR intervention in 20 participants. Subsequently, 7 participants were reassessed 3-6 months after the VR intervention. Wilcoxon sign-rank test was used for statistical comparisons of the changes. Results: There were no significant changes in cognitive function, global status, and caregiver burden immediately after the VR intervention, but there was a significant reduction in depressive symptoms (P=.008). Moreover, compared with the cognitive function immediately after VR, it kept declining 3-6 months after. Conclusions: Immersive VR reminiscence can improve mood and preserve cognitive function in elderly patients with dementia during the period of the intervention. Studies using a control group and comparing the use of VR with traditional forms of reminiscence should be conducted in the future to confirm and expand on these findings. (JMIR Serious Games 2022;10(3):e36720) doi: 10.2196/36720 KEYWORDS virtual reality; reminiscence; dementia; long-term care had a strong impact on society and the economy [1]. Behavioral Introduction and psychological symptoms of dementia (BPSD) are frequently noted in patients with dementia, causing distress, reducing the Over the past few decades, as the elderly population has rapidly individual’s quality of life, exacerbating cognitive and functional increased, the prevalence of dementia has also continuously impairment, and increasing caregiver stress [2]. Although increased in high-income countries, and cognitive decline has https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang pharmacological interventions are recommended for the identified by the staff at the dementia care units based on the treatment of cognitive impairment and BPSD in Alzheimer inclusion and exclusion criteria. The inclusion criteria were (1) disease (AD) and other types of dementia, polypharmacy may those diagnosed with all-cause dementia by experienced cause side effects in the elderly population. Novel and effective physicians, based on the National Institute on Aging and nonpharmacological therapies are therefore required. Alzheimer's Association diagnostic criteria [12]; and (2) attended the dementia care units between July 2020 and March 2021. Virtual reality (VR) is a computer-generated environment that Participants were excluded if (1) they had poor recognition of has been developed in recent years. Using headsets, it can the VR images even after adjusting the mounting position of provide a fully immersive, highly engaging, and realistic the headset; and (2) their cognitive function was too low or their experience. VR is often used for recreational purposes, but it is BPSD was too severe, making assessment difficult. increasingly being used in medical training, rehabilitation, and therapy [3-5]. Current research suggests that immersive VR is Ethics Approval safe and well tolerated, and it can promote engagement and The participants and their relatives were informed of the details provide an enjoyable experience for people with dementia [6-8]. of the study prior to their inclusion, and appropriate written informed consent was obtained. The Kaohsiung Medical Reminiscence therapy, one of the most popular psychosocial University Hospital Institutional Review Board interventions, involves the discussion of past activities, events, (KMUHIRB-SV(II)-20190049) approved the study protocol. and experiences, usually with the aid of tangible prompts, such as photographs or music [9]. Reminiscence therapy has been VR Apparatus shown to have some positive effects for people with dementia The VIVE Pro VR head-mounted display (HMD) was used to by increasing their quality of life, cognition, communication, deliver the immersive VR experience to the participants. It is a and mood, although the noted effects were small [9]. stand-alone HMD providing stereoscopic vision at a resolution Reminiscence therapy using immersive VR may be more of 2880 x 1600 per eye with a 90 Hz refresh rate. Two effective as it would be more realistic than traditional controllers were paired with the HMD to enable the participants reminiscence therapy and could lead to increased engagement. to interact with the VR environment. In previous studies, immersive VR reminiscence therapy was shown to reduce anxiety and apathy while improving semantic Preparation of VR Content verbal fluency, immediately after a short intervention program Computer graphics VR images were created based on a historical in elderly individuals residing in aged care facilities with type of residence that was commonly found throughout Taiwan different cognitive statuses [10,11]. However, the long-term in 1960-1980 AD (Figure 1). Photographs, narration, and music effects in people with dementia remain unknown. of personal past significance to the participants were provided Therefore, we conducted a study to investigate the immediate by the family or caregivers on an individual basis. These and 3-6–month effects of immersive VR reminiscence therapy materials were transformed into digital forms and integrated in people with dementia. into the VR content. The participants could use the controllers to turn on the radio to play the music and to look through the Methods photo album and browse the photographs with a voice narrating the past meaningful situation and events about the photographs. Recruitment They could also use the controller to hold rice to feed chickens, which was traditional in many old villages. The participants were recruited from 2 dementia care units in Kaohsiung city, Taiwan. Potentially suitable participants were https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang Figure 1. Scenes from the computer generated virtual reality reminiscence. Computer graphics images based on (A) a historical type of residence that was commonly found throughout Taiwan between 1960-1980 AD. (B) The participants could use the controllers to turn on the radio to play music and (C) to open the photo album to browse the photographs with a voice narrating. (D) They could also use the controllers to hold rice to feed chickens, which was traditional in older villages. a quantitative assessment of attention, concentration, orientation, Implementation short-term memory, long-term memory, language abilities, The VR intervention was administered twice per week over a visual construction, list-generating fluency, abstraction, and period of 3 months. The participants viewed and interacted with judgment [13]. Pilot testing has demonstrated its usefulness in the VR content for approximately 10 to 12 minutes each time. monitoring disease progression and in providing profiles of The HMD images were mirrored to a laptop to enable the cognitive impairment [13]. researcher to see what the participants were viewing and Mini-Mental State Examination interacting with. The participants remained seated during the VR intervention to reduce motion sickness when using the HMD Cognitive impairment was also assessed using the MMSE, and to also minimize the risk of falls in the elderly. During VR which assesses orientation, immediate recall, calculation or intervention, there was a conversation between the researcher attention, delayed recall, naming, repetition, 3-stage command, and the participant regarding the content being viewed. The reading, writing, and constructional praxis. The total score is participants were provided with the controllers to enable them 30, and a lower score indicates more severe cognitive to interact with the VR space, and the researcher was beside impairment [14]. them to assist and guide them when needed. Clinical Dementia Rating Assessment of Questionnaire and Scores The global status of dementia was defined according to the Before and after the VR intervention, the participants were CDR. The CDR is a widely used clinical staging instrument for assessed on their cognitive function using the Cognitive Abilities characterizing the manifestation and severity of dementia. It is Screening Instrument (CASI), the Mini-Mental State generated from a semistructured interview with the patient and Examination (MMSE), the global status by Clinical Dementia a knowledgeable informant evaluating six cognitive domains Rating (CDR), and the depressive symptoms by Center for (memory, orientation, judgment and problem solving, Epidemiological Studies Depression (CESD). Caregiver burden community affairs, home and hobbies, and personal care). The was evaluated using the Zarit Caregiver Burden Interview (ZBI). overall CDR is derived by providing ratings for each of the six domains, where a score of 0 indicates normal; a score of 0.5 Cognitive Abilities Screening Instrument signifies uncertain or very mild impairment; and a score of 1, The CASI was used to objectively assess overall cognitive 2, or 3 corresponds to mild, moderate, or severe impairment function. The CASI has a score range of 0 to 100 and provides https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang [15]. The scores for the six domains can then be added together Comparisons of scores before and immediately after VR (CDR Sum of Boxes [CDR-SB]). intervention, as well as immediately after and 3-6 months after VR intervention, were performed using the Wilcoxon sign-rank Center for Epidemiological Studies Depression test. Analyses were performed using SPSS 26.0 (IBM Depressive symptoms were assessed using the CESD, a 20-item Corporation). A 2-tailed P value of <.05 was considered to self-administered questionnaire. On a 4-point Likert scale indicate a statistically significant difference. ranging from 0 (none) to 3 (5 days or more), the participants were asked to rate the frequency with which each item occurred Results every week. Higher scores indicate more severe depressive symptoms [16]. Baseline Demographic Characteristics, Cognitive Function, and Global Status Zarit Caregiver Burden Interview A total of 25 individuals were enrolled in the study at the The ZBI is a well-known self-reporting measure of perceived beginning; 2 (8%) were excluded because they left the dementia burden among caregivers. The instrument measures the care units, and 3 (12%) were excluded as they were unable to caregiver’s emotion, psychological health, well-being, social receive a postintervention evaluation due to physical problems. and family life, finances, and degree of control over one’s life. The baseline demographic characteristics, cognitive function, The version used contains 22 items, and each item on the and global status of the 20 participants who completed the study questionnaire is a statement that the caregiver is asked to endorse are shown in Table 1. The participants’ mean age was 79.0 (SD on a 5-point Likert scale (0: never; 1: rarely; 2: sometimes; 3: 7.8) years; 45% (9/20) were male and 55% (11/20) were female. quite frequently; and 4: nearly always) [17]. Higher scores The mean education level was 10.8 (SD 4.3) years. The mean indicate higher caregiver burden. CASI score was 55.5 (SD 15.6), and the mean MMSE score Statistical Analysis was 15.4 (SD 5.5). According to CDR, 2/20 (10%) participants had very mild dementia, 15/20 (75%) participants had mild Data were collected from July 2020 to March 2021. In the dementia, and 3/20 (15%) participants had moderate dementia. results, the data are presented as mean (SD) or as a proportion. Table 1. Baseline demographic characteristics, cognitive function, and global status of the participants. Characteristics Values (N=20) Age (years), mean (SD) 79.0 (7.8) Sex, n (%) Male 9 (45) Female 11 (45) Education (years), mean (SD) 10.8 (4.3) 55.5 (15.6) CASI , mean (SD) 15.4 (5.5) MMSE , mean (SD) CDR , n (%) 0.5 2 (10) 1 15 (75) 2 3 (15) CDR sum of boxes, mean (SD) 7.3 (3.0) CASI: Cognitive Assessment Screening Instrument. MMSE: Mini-Mental State Examination. CDR: Clinical Dementia Rating. CASI and its subdomains, CDR-SB, and ZBI scores before and The Immediate Effect of VR Reminiscence immediately after VR intervention, while the scores for CESD The immediate effects of immersive VR on cognition, global significantly decreased from 6.15 (SD 5.73) to 3.15 (SD 4.26; status, depressive symptoms, and caregiver burden are shown P=.008). in Table 2. There were no significant differences in the MMSE, https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang Table 2. The immediate effect of virtual reality (VR) reminiscence on cognition, global status, depressive symptoms, and caregiver burden. The comparison of scores before and after VR were evaluated by Wilcoxon sing-rank test. Characteristics Before VR, mean (SD) Immediately after VR, mean (SD) P value 15.40 (5.47) 14.95 (5.13) .48 MMSE 55.47 (15.64) 54.46 (16.64) .22 CASI Remote memory (0-10) 8.75 (1.80) 8.25 (2.51) .13 Orientation (0-18) 6.65 (3.86) 6.85 (3.68) .52 Attention (0-8) 5.85 (1.43) 5.65 (1.63) .54 Concentration (0-10) 5.85 (2.91) 5.95 (3.12) .77 Recent memory (0-12) 1.59 (1.55) 1.66 (1.88) .46 Fluency (0-10) 3.30 (2.00) 3.40 (2.42) .95 Language (0-10) 7.58 (2.39) 7.45 (1.99) .70 Abstraction (0-6) 3.00 (1.69) 2.80 (1.32) .30 Judgment (0-6) 4.65 (1.27) 4.75 (1.21) .74 Visual construction (0-10) 8.25 (2.75) 7.70 (3.33) .10 7.26 (3.00) 7.33 (2.43) .64 CDR sum of boxes d e 6.15 (5.73) 3.15 (4.26) CESD .008 34.65 (15.98) 31.20 (14.05) .14 ZBI MMSE: Mini-Mental State Examination. CASI: Cognitive Assessment Screening Instrument. CDR: Clinical Dementia Rating. CESD: Center for Epidemiological Studies Depression. Significant value is shown in italics. ZBI: Zarit Caregiver Burden Interview. after VR in these 7 participants; however, the CASI score The Long-term Effect of VR Reminiscence significantly decreased 3-6 months after VR, compared to Among the 20 participants, 7 (35%) were followed up 3-6 immediately after VR (52.14, SD 15.71 vs 57.50, SD 12.40; months after the VR intervention. No significant changes in P=.03; Tables 3 and 4; Figure 2). MMSE, CASI and CDR-SB were noted before and immediately Table 3. Cognition and global status before and immediately after virtual reality (VR) reminiscence in 7 participants. The comparison of scores were evaluated by Wilcoxon sign-rank test. Characteristics Before VR, mean (SD) Immediately after VR, mean (SD) P value 15.57 (4.76) 16.29 (4.07) .67 MMSE 58.80 (12.48) 57.50 (12.40) .50 CASI 6.50 (1.61) 6.86 (1.28) .10 CDR sum of boxes MMSE: Mini-Mental State Examination. CASI: Cognitive Assessment Screening Instrument. CRD: Clinical Dementia Rating. https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang Table 4. Cognition and global status immediately after and 3-6 months after virtual reality (VR) reminiscence in 7 participants. The comparison of scores were evaluated by Wilcoxon sign-rank test. Characteristics Immediately after VR, mean (SD) 3-6 months after VR, mean (SD) P value 16.29 (4.07) 16.00 (5.23) .75 MMSE b c 57.50 (12.40) 52.14 (15.71) CASI .03 6.86 (1.28) 7.93 (2.86) .31 CDR sum of boxes MMSE: Mini-Mental State Examination. CASI: Cognitive Assessment Screening Instrument. Significant value shown in italics. CDR: Clinical Dementia Rating. Figure 2. Mini-Mental State Examination (MMSE) and Cognitive Abilities Screening Instrument (CASI) scores before, immediately after, and 3-6 months after virtual reality (VR) reminiscence in 7 participants. Data are shown as mean (SD) for quantitative variables. A comparison of a) MMSE and b) CASI scores before and immediately after VR as well as immediately after VR and 3-6 months after VR were evaluated by Wilcoxon sign-rank test (P<.05 is statistically significant); i: immediately. tailored VR reminiscence and found that it could improve apathy Discussion and semantic verbal fluency immediately after the intervention. However, more than half of the participants in that study had Principal Results no or minimal cognitive impairment. Contrary to these previous In this paper, we investigated the potential effects of immersive studies, we recruited participants who were attending dementia VR reminiscence therapy in people with dementia, as well as care units to explore the effect of immersive VR reminiscence studying how long the effects could last. Although there were in individuals with dementia. no obvious changes in cognition, global status, and caregiver People with dementia have a high incidence of depression, burden after the VR intervention, the depressive symptoms which reduces the quality of life for both patients and caregivers improved significantly after VR therapy. Compared to the CASI and is associated with increased costs and reduced cognition scores immediately after VR, the scores after 3-6 months were [18]. Although reminiscence therapy may have some benefits significantly decreased. In other words, immersive VR in reducing depression in people with dementia, its effectiveness reminiscence may improve mood and preserve cognitive should be tested further [19]. In a multicenter randomized function in elderly patients with dementia during the period of controlled trial, reminiscence therapy failed to improve intervention. To the best of our knowledge, this is the first study depressive symptoms in older adults with dementia [20,21], to explore not only the possible effects of immersive VR whereas in our study, VR reminiscence significantly reduced reminiscence but also the effect period in people with dementia. depressive symptoms. As an interesting and enjoyable tool, VR Comparison With Prior Work intervention may be more effective than traditional reminiscence Although the use of VR is being developed in many different in improving mood. Further studies comparing VR reminiscence fields, evidence regarding reminiscence interventions with with traditional forms of reminiscence should be conducted in immersive VR in patients with dementia remains limited. Niki the future. et al [10] found that immersive VR reminiscence could reduce Based on previous studies, it was not known how long the anxiety in the elderly living in a nursing home, without causing effects of VR could last. Therefore, we reassessed 7 of the study serious side effects. However, most of their participants had participants 3-6 months after the VR intervention, and we found preserved cognitive function at baseline. Saredakis et al [11] that their cognitive function kept declining after discontinuing recruited 17 older adults residing in an aged care facility for the intervention. Because more than half of the etiology of https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang dementia is AD, a degenerative disease with an average MMSE Limitations decrease of 1.15 points and a CASI decrease of 4.27 points per There were some limitations to this study. First, there was no year [22], the fact that there was no obvious change in cognition control group or a group receiving traditional reminiscence during the VR intervention implies that the VR reminiscence therapy; therefore, the results of this study must be carefully therapy may maintain cognition or reduce cognitive decline in interpreted. Second, the number of subjects was small, especially people with dementia. Further studies with maintained VR in the reassessed cases. Studies with larger sample sizes should intervention should be conducted to confirm this. be conducted in the future to validate our findings. Third, the staff at the dementia care units identified the potentially suitable It is reasonable that enough sessions of VR are required to obtain participants for the study; therefore, the effects may not be therapeutic effects. In a previous study promoting VR applicable to all cases of dementia. Fourth, our VR reminiscence reminiscence in people with dementia, there were no significant was not totally personalized because computer graphics take a changes in the psychological and behavioral symptoms and in lot of time to create and are expensive. Some VR images were the quality of life after a short course of intervention, even different from those in the subjects’ own memories, and using though the caregivers assessed the experience as potentially personalized content has been demonstrated to be more effective beneficial for most participants [23]. Park et al [24] suggested than using generic content [27]. To combat this, we collected that reminiscence therapy of more than 8 sessions might be personal photographs and music from the participants’ past required to obtain any therapeutic effects. Therefore, in our experiences, which could be used to tailor the VR experience. study, the VR intervention was administered twice per week Despite the reported limitations, this study is a pilot study to with a period of 3 months. explore not only the potential effect of immersive VR Our study design was different from that of most previous reminiscence but also how long the effect existed in people with studies, and our participants could use the controllers to interact dementia. We also objectively evaluated the possible effects on with the virtual environment. Interactive VR has been found to caregiver burden. During the COVID-19 pandemic, digital increase the sense of presence and to have a positive effect on therapeutics such as VR are important for facilitating remote the immersive experience [25]. Recent research has found that health care and for reducing the risk of cluster infections. the use of VR in providing interactions may be an alternative Conclusions way of delivering stimulation to people with dementia who do not participate in other lifestyle activities [26], and interactions Our study found that immersive VR reminiscence may improve can be recorded during the VR experience. In future studies, mood and preserve cognitive function in elderly patients with recording of the participants’ limb movement while they use dementia during the period of the intervention. Studies using a the controllers could enable analysis of the speed and accuracy control group and comparing the use of VR with traditional of their movements. forms of reminiscence should be conducted in the future to confirm and develop these findings. Acknowledgments This study was supported by grants from National Health Research Institutes Grant (PH-110-GP-08, PH-111-GP-08), Ministry of Science and Technology (MOST 108-2745-8-037-011-), Kaohsiung Medical University Research Center (KMU-TC110B03), and Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan (KMTTH-110-027). We also thank HamaStar Technology Co, Ltd for their assistance. Conflicts of Interest None declared. References 1. Brookmeyer R, Johnson E, Ziegler-Graham K, Arrighi HM. Forecasting the global burden of Alzheimer's disease. Alzheimers Dement 2007 Jul;3(3):186-191. [doi: 10.1016/j.jalz.2007.04.381] [Medline: 19595937] 2. Black W, Almeida OP. A systematic review of the association between the Behavioral and Psychological Symptoms of Dementia and burden of care. Int Psychogeriatr 2004 Sep;16(3):295-315. [doi: 10.1017/s1041610204000468] [Medline: 15559754] 3. Dascal J, Reid M, IsHak WW, Spiegel B, Recacho J, Rosen B, et al. 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[doi: 10.1080/09602010802586216] [Medline: 19235628] Abbreviations AD: Alzheimer disease BPSD: behavioral and psychological symptoms of dementia CASI: Cognitive Abilities Screening Instrument CDR-SB: Clinical Dementia Rating-Sum of Boxes CDR: Clinical Dementia Rating CESD: Center for Epidemiological Studies Depression HMD: head-mounted display MMSE: Mini-Mental State Examination VR: virtual reality ZBI: Zarit Caregiver Burden Interview Edited by N Zary; submitted 21.01.22; peer-reviewed by YT Lin, J Guendouzi; comments to author 12.06.22; revised version received 14.06.22; accepted 09.07.22; published 25.07.22 Please cite as: Huang LC, Yang YH JMIR Serious Games 2022;10(3):e36720 URL: https://games.jmir.org/2022/3/e36720 doi: 10.2196/36720 PMID: ©Ling-Chun Huang, Yuan-Han Yang. Originally published in JMIR Serious Games (https://games.jmir.org), 25.07.2022. 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The Long-term Effects of Immersive Virtual Reality Reminiscence in People With Dementia: Longitudinal Observational Study

Huang, Ling-Chun; Yang, Yuan-Han
JMIR Serious Games , Volume 10 (3) – Jul 25, 2022
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10.2196/36720
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Abstract

Background: Novel nonpharmacological therapies are being developed to prevent cognitive decline and reduce behavioral and psychological symptoms in patients with dementia. Virtual reality (VR) reminiscence was reported to improve anxiety, apathy, and cognitive function immediately after intervention in individuals at residential aged care facilities. However, its effect on elderly patients with dementia and how long this effect could last remain unknown. Objective: The aim of this paper is to investigate the effect of immersive VR reminiscence in people with dementia both immediately after and 3-6 months after intervention. Methods: A pilot study was conducted in 2 dementia care units. VR reminiscence therapy sessions were conducted twice per week for a 3-month period. Cognitive function, global status, depressive symptoms, and caregiver burden were assessed before and immediately after VR intervention in 20 participants. Subsequently, 7 participants were reassessed 3-6 months after the VR intervention. Wilcoxon sign-rank test was used for statistical comparisons of the changes. Results: There were no significant changes in cognitive function, global status, and caregiver burden immediately after the VR intervention, but there was a significant reduction in depressive symptoms (P=.008). Moreover, compared with the cognitive function immediately after VR, it kept declining 3-6 months after. Conclusions: Immersive VR reminiscence can improve mood and preserve cognitive function in elderly patients with dementia during the period of the intervention. Studies using a control group and comparing the use of VR with traditional forms of reminiscence should be conducted in the future to confirm and expand on these findings. (JMIR Serious Games 2022;10(3):e36720) doi: 10.2196/36720 KEYWORDS virtual reality; reminiscence; dementia; long-term care had a strong impact on society and the economy [1]. Behavioral Introduction and psychological symptoms of dementia (BPSD) are frequently noted in patients with dementia, causing distress, reducing the Over the past few decades, as the elderly population has rapidly individual’s quality of life, exacerbating cognitive and functional increased, the prevalence of dementia has also continuously impairment, and increasing caregiver stress [2]. Although increased in high-income countries, and cognitive decline has https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang pharmacological interventions are recommended for the identified by the staff at the dementia care units based on the treatment of cognitive impairment and BPSD in Alzheimer inclusion and exclusion criteria. The inclusion criteria were (1) disease (AD) and other types of dementia, polypharmacy may those diagnosed with all-cause dementia by experienced cause side effects in the elderly population. Novel and effective physicians, based on the National Institute on Aging and nonpharmacological therapies are therefore required. Alzheimer's Association diagnostic criteria [12]; and (2) attended the dementia care units between July 2020 and March 2021. Virtual reality (VR) is a computer-generated environment that Participants were excluded if (1) they had poor recognition of has been developed in recent years. Using headsets, it can the VR images even after adjusting the mounting position of provide a fully immersive, highly engaging, and realistic the headset; and (2) their cognitive function was too low or their experience. VR is often used for recreational purposes, but it is BPSD was too severe, making assessment difficult. increasingly being used in medical training, rehabilitation, and therapy [3-5]. Current research suggests that immersive VR is Ethics Approval safe and well tolerated, and it can promote engagement and The participants and their relatives were informed of the details provide an enjoyable experience for people with dementia [6-8]. of the study prior to their inclusion, and appropriate written informed consent was obtained. The Kaohsiung Medical Reminiscence therapy, one of the most popular psychosocial University Hospital Institutional Review Board interventions, involves the discussion of past activities, events, (KMUHIRB-SV(II)-20190049) approved the study protocol. and experiences, usually with the aid of tangible prompts, such as photographs or music [9]. Reminiscence therapy has been VR Apparatus shown to have some positive effects for people with dementia The VIVE Pro VR head-mounted display (HMD) was used to by increasing their quality of life, cognition, communication, deliver the immersive VR experience to the participants. It is a and mood, although the noted effects were small [9]. stand-alone HMD providing stereoscopic vision at a resolution Reminiscence therapy using immersive VR may be more of 2880 x 1600 per eye with a 90 Hz refresh rate. Two effective as it would be more realistic than traditional controllers were paired with the HMD to enable the participants reminiscence therapy and could lead to increased engagement. to interact with the VR environment. In previous studies, immersive VR reminiscence therapy was shown to reduce anxiety and apathy while improving semantic Preparation of VR Content verbal fluency, immediately after a short intervention program Computer graphics VR images were created based on a historical in elderly individuals residing in aged care facilities with type of residence that was commonly found throughout Taiwan different cognitive statuses [10,11]. However, the long-term in 1960-1980 AD (Figure 1). Photographs, narration, and music effects in people with dementia remain unknown. of personal past significance to the participants were provided Therefore, we conducted a study to investigate the immediate by the family or caregivers on an individual basis. These and 3-6–month effects of immersive VR reminiscence therapy materials were transformed into digital forms and integrated in people with dementia. into the VR content. The participants could use the controllers to turn on the radio to play the music and to look through the Methods photo album and browse the photographs with a voice narrating the past meaningful situation and events about the photographs. Recruitment They could also use the controller to hold rice to feed chickens, which was traditional in many old villages. The participants were recruited from 2 dementia care units in Kaohsiung city, Taiwan. Potentially suitable participants were https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang Figure 1. Scenes from the computer generated virtual reality reminiscence. Computer graphics images based on (A) a historical type of residence that was commonly found throughout Taiwan between 1960-1980 AD. (B) The participants could use the controllers to turn on the radio to play music and (C) to open the photo album to browse the photographs with a voice narrating. (D) They could also use the controllers to hold rice to feed chickens, which was traditional in older villages. a quantitative assessment of attention, concentration, orientation, Implementation short-term memory, long-term memory, language abilities, The VR intervention was administered twice per week over a visual construction, list-generating fluency, abstraction, and period of 3 months. The participants viewed and interacted with judgment [13]. Pilot testing has demonstrated its usefulness in the VR content for approximately 10 to 12 minutes each time. monitoring disease progression and in providing profiles of The HMD images were mirrored to a laptop to enable the cognitive impairment [13]. researcher to see what the participants were viewing and Mini-Mental State Examination interacting with. The participants remained seated during the VR intervention to reduce motion sickness when using the HMD Cognitive impairment was also assessed using the MMSE, and to also minimize the risk of falls in the elderly. During VR which assesses orientation, immediate recall, calculation or intervention, there was a conversation between the researcher attention, delayed recall, naming, repetition, 3-stage command, and the participant regarding the content being viewed. The reading, writing, and constructional praxis. The total score is participants were provided with the controllers to enable them 30, and a lower score indicates more severe cognitive to interact with the VR space, and the researcher was beside impairment [14]. them to assist and guide them when needed. Clinical Dementia Rating Assessment of Questionnaire and Scores The global status of dementia was defined according to the Before and after the VR intervention, the participants were CDR. The CDR is a widely used clinical staging instrument for assessed on their cognitive function using the Cognitive Abilities characterizing the manifestation and severity of dementia. It is Screening Instrument (CASI), the Mini-Mental State generated from a semistructured interview with the patient and Examination (MMSE), the global status by Clinical Dementia a knowledgeable informant evaluating six cognitive domains Rating (CDR), and the depressive symptoms by Center for (memory, orientation, judgment and problem solving, Epidemiological Studies Depression (CESD). Caregiver burden community affairs, home and hobbies, and personal care). The was evaluated using the Zarit Caregiver Burden Interview (ZBI). overall CDR is derived by providing ratings for each of the six domains, where a score of 0 indicates normal; a score of 0.5 Cognitive Abilities Screening Instrument signifies uncertain or very mild impairment; and a score of 1, The CASI was used to objectively assess overall cognitive 2, or 3 corresponds to mild, moderate, or severe impairment function. The CASI has a score range of 0 to 100 and provides https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang [15]. The scores for the six domains can then be added together Comparisons of scores before and immediately after VR (CDR Sum of Boxes [CDR-SB]). intervention, as well as immediately after and 3-6 months after VR intervention, were performed using the Wilcoxon sign-rank Center for Epidemiological Studies Depression test. Analyses were performed using SPSS 26.0 (IBM Depressive symptoms were assessed using the CESD, a 20-item Corporation). A 2-tailed P value of <.05 was considered to self-administered questionnaire. On a 4-point Likert scale indicate a statistically significant difference. ranging from 0 (none) to 3 (5 days or more), the participants were asked to rate the frequency with which each item occurred Results every week. Higher scores indicate more severe depressive symptoms [16]. Baseline Demographic Characteristics, Cognitive Function, and Global Status Zarit Caregiver Burden Interview A total of 25 individuals were enrolled in the study at the The ZBI is a well-known self-reporting measure of perceived beginning; 2 (8%) were excluded because they left the dementia burden among caregivers. The instrument measures the care units, and 3 (12%) were excluded as they were unable to caregiver’s emotion, psychological health, well-being, social receive a postintervention evaluation due to physical problems. and family life, finances, and degree of control over one’s life. The baseline demographic characteristics, cognitive function, The version used contains 22 items, and each item on the and global status of the 20 participants who completed the study questionnaire is a statement that the caregiver is asked to endorse are shown in Table 1. The participants’ mean age was 79.0 (SD on a 5-point Likert scale (0: never; 1: rarely; 2: sometimes; 3: 7.8) years; 45% (9/20) were male and 55% (11/20) were female. quite frequently; and 4: nearly always) [17]. Higher scores The mean education level was 10.8 (SD 4.3) years. The mean indicate higher caregiver burden. CASI score was 55.5 (SD 15.6), and the mean MMSE score Statistical Analysis was 15.4 (SD 5.5). According to CDR, 2/20 (10%) participants had very mild dementia, 15/20 (75%) participants had mild Data were collected from July 2020 to March 2021. In the dementia, and 3/20 (15%) participants had moderate dementia. results, the data are presented as mean (SD) or as a proportion. Table 1. Baseline demographic characteristics, cognitive function, and global status of the participants. Characteristics Values (N=20) Age (years), mean (SD) 79.0 (7.8) Sex, n (%) Male 9 (45) Female 11 (45) Education (years), mean (SD) 10.8 (4.3) 55.5 (15.6) CASI , mean (SD) 15.4 (5.5) MMSE , mean (SD) CDR , n (%) 0.5 2 (10) 1 15 (75) 2 3 (15) CDR sum of boxes, mean (SD) 7.3 (3.0) CASI: Cognitive Assessment Screening Instrument. MMSE: Mini-Mental State Examination. CDR: Clinical Dementia Rating. CASI and its subdomains, CDR-SB, and ZBI scores before and The Immediate Effect of VR Reminiscence immediately after VR intervention, while the scores for CESD The immediate effects of immersive VR on cognition, global significantly decreased from 6.15 (SD 5.73) to 3.15 (SD 4.26; status, depressive symptoms, and caregiver burden are shown P=.008). in Table 2. There were no significant differences in the MMSE, https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang Table 2. The immediate effect of virtual reality (VR) reminiscence on cognition, global status, depressive symptoms, and caregiver burden. The comparison of scores before and after VR were evaluated by Wilcoxon sing-rank test. Characteristics Before VR, mean (SD) Immediately after VR, mean (SD) P value 15.40 (5.47) 14.95 (5.13) .48 MMSE 55.47 (15.64) 54.46 (16.64) .22 CASI Remote memory (0-10) 8.75 (1.80) 8.25 (2.51) .13 Orientation (0-18) 6.65 (3.86) 6.85 (3.68) .52 Attention (0-8) 5.85 (1.43) 5.65 (1.63) .54 Concentration (0-10) 5.85 (2.91) 5.95 (3.12) .77 Recent memory (0-12) 1.59 (1.55) 1.66 (1.88) .46 Fluency (0-10) 3.30 (2.00) 3.40 (2.42) .95 Language (0-10) 7.58 (2.39) 7.45 (1.99) .70 Abstraction (0-6) 3.00 (1.69) 2.80 (1.32) .30 Judgment (0-6) 4.65 (1.27) 4.75 (1.21) .74 Visual construction (0-10) 8.25 (2.75) 7.70 (3.33) .10 7.26 (3.00) 7.33 (2.43) .64 CDR sum of boxes d e 6.15 (5.73) 3.15 (4.26) CESD .008 34.65 (15.98) 31.20 (14.05) .14 ZBI MMSE: Mini-Mental State Examination. CASI: Cognitive Assessment Screening Instrument. CDR: Clinical Dementia Rating. CESD: Center for Epidemiological Studies Depression. Significant value is shown in italics. ZBI: Zarit Caregiver Burden Interview. after VR in these 7 participants; however, the CASI score The Long-term Effect of VR Reminiscence significantly decreased 3-6 months after VR, compared to Among the 20 participants, 7 (35%) were followed up 3-6 immediately after VR (52.14, SD 15.71 vs 57.50, SD 12.40; months after the VR intervention. No significant changes in P=.03; Tables 3 and 4; Figure 2). MMSE, CASI and CDR-SB were noted before and immediately Table 3. Cognition and global status before and immediately after virtual reality (VR) reminiscence in 7 participants. The comparison of scores were evaluated by Wilcoxon sign-rank test. Characteristics Before VR, mean (SD) Immediately after VR, mean (SD) P value 15.57 (4.76) 16.29 (4.07) .67 MMSE 58.80 (12.48) 57.50 (12.40) .50 CASI 6.50 (1.61) 6.86 (1.28) .10 CDR sum of boxes MMSE: Mini-Mental State Examination. CASI: Cognitive Assessment Screening Instrument. CRD: Clinical Dementia Rating. https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang Table 4. Cognition and global status immediately after and 3-6 months after virtual reality (VR) reminiscence in 7 participants. The comparison of scores were evaluated by Wilcoxon sign-rank test. Characteristics Immediately after VR, mean (SD) 3-6 months after VR, mean (SD) P value 16.29 (4.07) 16.00 (5.23) .75 MMSE b c 57.50 (12.40) 52.14 (15.71) CASI .03 6.86 (1.28) 7.93 (2.86) .31 CDR sum of boxes MMSE: Mini-Mental State Examination. CASI: Cognitive Assessment Screening Instrument. Significant value shown in italics. CDR: Clinical Dementia Rating. Figure 2. Mini-Mental State Examination (MMSE) and Cognitive Abilities Screening Instrument (CASI) scores before, immediately after, and 3-6 months after virtual reality (VR) reminiscence in 7 participants. Data are shown as mean (SD) for quantitative variables. A comparison of a) MMSE and b) CASI scores before and immediately after VR as well as immediately after VR and 3-6 months after VR were evaluated by Wilcoxon sign-rank test (P<.05 is statistically significant); i: immediately. tailored VR reminiscence and found that it could improve apathy Discussion and semantic verbal fluency immediately after the intervention. However, more than half of the participants in that study had Principal Results no or minimal cognitive impairment. Contrary to these previous In this paper, we investigated the potential effects of immersive studies, we recruited participants who were attending dementia VR reminiscence therapy in people with dementia, as well as care units to explore the effect of immersive VR reminiscence studying how long the effects could last. Although there were in individuals with dementia. no obvious changes in cognition, global status, and caregiver People with dementia have a high incidence of depression, burden after the VR intervention, the depressive symptoms which reduces the quality of life for both patients and caregivers improved significantly after VR therapy. Compared to the CASI and is associated with increased costs and reduced cognition scores immediately after VR, the scores after 3-6 months were [18]. Although reminiscence therapy may have some benefits significantly decreased. In other words, immersive VR in reducing depression in people with dementia, its effectiveness reminiscence may improve mood and preserve cognitive should be tested further [19]. In a multicenter randomized function in elderly patients with dementia during the period of controlled trial, reminiscence therapy failed to improve intervention. To the best of our knowledge, this is the first study depressive symptoms in older adults with dementia [20,21], to explore not only the possible effects of immersive VR whereas in our study, VR reminiscence significantly reduced reminiscence but also the effect period in people with dementia. depressive symptoms. As an interesting and enjoyable tool, VR Comparison With Prior Work intervention may be more effective than traditional reminiscence Although the use of VR is being developed in many different in improving mood. Further studies comparing VR reminiscence fields, evidence regarding reminiscence interventions with with traditional forms of reminiscence should be conducted in immersive VR in patients with dementia remains limited. Niki the future. et al [10] found that immersive VR reminiscence could reduce Based on previous studies, it was not known how long the anxiety in the elderly living in a nursing home, without causing effects of VR could last. Therefore, we reassessed 7 of the study serious side effects. However, most of their participants had participants 3-6 months after the VR intervention, and we found preserved cognitive function at baseline. Saredakis et al [11] that their cognitive function kept declining after discontinuing recruited 17 older adults residing in an aged care facility for the intervention. Because more than half of the etiology of https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang dementia is AD, a degenerative disease with an average MMSE Limitations decrease of 1.15 points and a CASI decrease of 4.27 points per There were some limitations to this study. First, there was no year [22], the fact that there was no obvious change in cognition control group or a group receiving traditional reminiscence during the VR intervention implies that the VR reminiscence therapy; therefore, the results of this study must be carefully therapy may maintain cognition or reduce cognitive decline in interpreted. Second, the number of subjects was small, especially people with dementia. Further studies with maintained VR in the reassessed cases. Studies with larger sample sizes should intervention should be conducted to confirm this. be conducted in the future to validate our findings. Third, the staff at the dementia care units identified the potentially suitable It is reasonable that enough sessions of VR are required to obtain participants for the study; therefore, the effects may not be therapeutic effects. In a previous study promoting VR applicable to all cases of dementia. Fourth, our VR reminiscence reminiscence in people with dementia, there were no significant was not totally personalized because computer graphics take a changes in the psychological and behavioral symptoms and in lot of time to create and are expensive. Some VR images were the quality of life after a short course of intervention, even different from those in the subjects’ own memories, and using though the caregivers assessed the experience as potentially personalized content has been demonstrated to be more effective beneficial for most participants [23]. Park et al [24] suggested than using generic content [27]. To combat this, we collected that reminiscence therapy of more than 8 sessions might be personal photographs and music from the participants’ past required to obtain any therapeutic effects. Therefore, in our experiences, which could be used to tailor the VR experience. study, the VR intervention was administered twice per week Despite the reported limitations, this study is a pilot study to with a period of 3 months. explore not only the potential effect of immersive VR Our study design was different from that of most previous reminiscence but also how long the effect existed in people with studies, and our participants could use the controllers to interact dementia. We also objectively evaluated the possible effects on with the virtual environment. Interactive VR has been found to caregiver burden. During the COVID-19 pandemic, digital increase the sense of presence and to have a positive effect on therapeutics such as VR are important for facilitating remote the immersive experience [25]. Recent research has found that health care and for reducing the risk of cluster infections. the use of VR in providing interactions may be an alternative Conclusions way of delivering stimulation to people with dementia who do not participate in other lifestyle activities [26], and interactions Our study found that immersive VR reminiscence may improve can be recorded during the VR experience. In future studies, mood and preserve cognitive function in elderly patients with recording of the participants’ limb movement while they use dementia during the period of the intervention. Studies using a the controllers could enable analysis of the speed and accuracy control group and comparing the use of VR with traditional of their movements. forms of reminiscence should be conducted in the future to confirm and develop these findings. Acknowledgments This study was supported by grants from National Health Research Institutes Grant (PH-110-GP-08, PH-111-GP-08), Ministry of Science and Technology (MOST 108-2745-8-037-011-), Kaohsiung Medical University Research Center (KMU-TC110B03), and Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan (KMTTH-110-027). We also thank HamaStar Technology Co, Ltd for their assistance. Conflicts of Interest None declared. References 1. Brookmeyer R, Johnson E, Ziegler-Graham K, Arrighi HM. Forecasting the global burden of Alzheimer's disease. Alzheimers Dement 2007 Jul;3(3):186-191. [doi: 10.1016/j.jalz.2007.04.381] [Medline: 19595937] 2. Black W, Almeida OP. A systematic review of the association between the Behavioral and Psychological Symptoms of Dementia and burden of care. Int Psychogeriatr 2004 Sep;16(3):295-315. [doi: 10.1017/s1041610204000468] [Medline: 15559754] 3. Dascal J, Reid M, IsHak WW, Spiegel B, Recacho J, Rosen B, et al. 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Information Processing & Management 2020 May;57(3):102105 [FREE Full text] [doi: 10.1016/j.ipm.2019.102105] https://games.jmir.org/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Huang & Yang 27. Yasuda K, Kuwabara K, Kuwahara N, Abe S, Tetsutani N. Effectiveness of personalised reminiscence photo videos for individuals with dementia. Neuropsychol Rehabil 2009 Aug;19(4):603-619. [doi: 10.1080/09602010802586216] [Medline: 19235628] Abbreviations AD: Alzheimer disease BPSD: behavioral and psychological symptoms of dementia CASI: Cognitive Abilities Screening Instrument CDR-SB: Clinical Dementia Rating-Sum of Boxes CDR: Clinical Dementia Rating CESD: Center for Epidemiological Studies Depression HMD: head-mounted display MMSE: Mini-Mental State Examination VR: virtual reality ZBI: Zarit Caregiver Burden Interview Edited by N Zary; submitted 21.01.22; peer-reviewed by YT Lin, J Guendouzi; comments to author 12.06.22; revised version received 14.06.22; accepted 09.07.22; published 25.07.22 Please cite as: Huang LC, Yang YH JMIR Serious Games 2022;10(3):e36720 URL: https://games.jmir.org/2022/3/e36720 doi: 10.2196/36720 PMID: ©Ling-Chun Huang, Yuan-Han Yang. Originally published in JMIR Serious Games (https://games.jmir.org), 25.07.2022. 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/2022/3/e36720 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e36720 | p. 9 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Jul 25, 2022

Keywords: virtual reality; reminiscence; dementia; long-term care

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