Are we There Yet? Immersive Virtual Reality to Improve Cognitive Function in Dementia and Mild Cognitive Impairment

Meelad Sayma, BMBS, BSc; Remco Tuijt, BA, MSc; Claudia Cooper, BMBS, MRCPsych, MSc; Kate Walters, BMBS, BMedSci, MRCGP, MMed, MSc, PhD

Disclosures

Gerontologist. 2020;60(7):e502-e512. 

In This Article

Rationale

Dementia has a far-reaching impact on individuals, their families, and society. In the United Kingdom alone, the annual estimated costs of dementia care, including health, social, and unpaid care, are over £25 billion every year (Alzheimer's Society, 2014). This does not account for the wider societal and productivity losses associated with dementia, which could increase this number by a factor of two (Wimo, Winblad, & Jonsson, 2010). As the population ages and increases in size globally, increasing numbers of people will suffer from dementia unless effective health interventions are put in place (Prince et al., 2016). Simultaneously, increasing numbers of people are affected by mild cognitive impairment (MCI), a possible precursor to dementia and although distinct from dementia, individuals with MCI are much more likely to go on to develop dementia (Knopman & Petersen, 2014).

Dementia can be defined as a syndrome with a noticeable decline in at least two of the five cognitive domains; memory, executive functioning, attention, visuospatial skills, and language (Hugo & Ganguli, 2014). As dementia progresses, individuals experience a broad range of difficulties, from loss of attention, loss of memory, to depression and eventually declining insofar to be unable to perform daily activities independently (Silveri, Reali, Jenner, & Puopolo, 2007). Many causes of dementia have few pharmacological therapies, whilst the available medications offer limited benefits and often focus on sedation, furthering a loss of autonomy (Schwarz, Froelich, & Burns, 2012).

As a result, there is now more emphasis on nonpharmacological therapies aiming to delay the decline of cognitive function in dementia and MCI (York Health Economics Consortium, 2017). These therapies range from music therapy targeting language, to animal-assisted therapies aiming to improve attention (Bannan & Montgomery-Smith, 2008; Dashnaw Stiles, 2001). However, cognitive therapies and rehabilitation for the management of dementia appear to show mixed results (Carrion, Folkvord, Anastasiadou, & Aymerich, 2018).

As the volume of people with dementia and cognitive impairment increases and funding for health care becomes more scarce, it will become increasingly difficult to deliver face-to-face therapies, meaning there is a need for cost-effective, wide-scale solutions to be developed (Barr, Bambra, & Whitehead, 2014). The use of mobile health applications to deliver therapies has exploded over the last decade, with demonstrable benefits from, for example, quitting smoking to physical therapies (Ernsting et al., 2017; Lin et al., 2018). For dementia, however, the delivery of mobile health applications presents an added challenge in the loss of attention, making it difficult to engage with these interventions (Forstmeier & Maercker, 2015).

Therapies and training delivered through immersive virtual reality (IVR) have been suggested to enhance attention and reduce distraction in those with other conditions such as in attention deficit hyperactivity disorder and traumatic brain injuries (Bashiri, Ghazisaeedi, & Shahmoradi, 2017; Olk, Dinu, Zielinski, & Kopper, 2018). This shows particular promise in dementia and MCI, with the ability to provide a more personalized feedback experience and create a more stimulating and familiar environment that has the potential to engage persons with the dementia in a unique way (Cohen-Mansfield, Thein, Dakheel-Ali, & Marx, 2010; Leone et al., 2012; Rizzo & Kim, 2005).

Although "virtual reality" has been trialed as a medium to deliver therapies in health care for over 20 years, the use of true virtual reality, one where an individual is immersed in a virtual world they are able to interact with, is only a recent development (Huygelier, Schraepen, van Ee, Vanden Abeele, & Gillebert, 2019; Riva, 2002). IVR has been defined as an immersive experience delivered through a combination of technologies, including a head-mounted display (HMD), headphones with sound/music and noise reduction, a rumble pad, joystick, or another device for manipulation/navigation of the virtual environment (VE; Huygelier et al., 2019; Li, Montano, Chen, & Gold, 2011). As a relatively recent development, health care uses of IVR are only just beginning. As hardware and software capabilities improve, these technologies now have the ability to provide complex and user-friendly therapies.

However, the use of IVR in older people is not well understood, with issues ranging from VR sickness to the more abstract potential of new technology rejection; in addition, there is a wide range in variability in the level of immersion achieved (Benoit et al., 2015; Huygelier et al., 2019; Kim, Park, Choi, & Choe, 2018). As a result, we conducted a systematic review of current IVR interventions for dementia and MCI, to determine the current extent of their use, acceptability, feasibility, and potential effectiveness.

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