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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 21-28

Virtual reality and its therapeutic uses in the elderly: A narrative clinical review


1 Clinical Psychologist, Desousa Foundation, Mumbai, Maharashtra, India
2 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Date of Submission24-Feb-2020
Date of Decision17-Apr-2020
Date of Acceptance04-Jun-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Off SV Road, Santacruz West, Mumbai - 400 054, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_8_20

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  Abstract 


Virtual reality (VR) as a form of therapy has made rapid strides in the field of psychiatry and neurorehabilitation. This paper is a narrative clinical review that provides an overview of the use of VR therapy (VRT) in care for elderly. It covers various uses of VR in elderly care that span from dementia, neurorehabilitation, and stroke to role of VR in psychotherapeutic management for the elderly. The uses of VR as therapy for dementia and various areas that it focuses on such as executive function, cognition, memory, and visuospatial navigation are discussed. The role of VRT in cognitive training and motor rehabilitation after stroke along with exergames is analyzed as well. The paper also looks at VR as a part of the treatment for treatment-resistant hallucinations and geriatric depression. Using VR as an adjuvant to psychotherapy and in reminiscence therapy is also discussed. The article ends by discussing the advantages and disadvantages of VR in the elderly along with future research needs in the area.

Keywords: dementia, elderly, geriatric depression, hallucinations, motor rehabilitation, psychotherapy, reminiscence therapy, stroke, virtual reality


How to cite this article:
Lodha P, De Sousa A, Karia S. Virtual reality and its therapeutic uses in the elderly: A narrative clinical review. J Geriatr Ment Health 2020;7:21-8

How to cite this URL:
Lodha P, De Sousa A, Karia S. Virtual reality and its therapeutic uses in the elderly: A narrative clinical review. J Geriatr Ment Health [serial online] 2020 [cited 2020 Sep 26];7:21-8. Available from: http://www.jgmh.org/text.asp?2020/7/1/21/288244




  Introduction Top


Virtual reality therapy (VRT) is the use of virtual reality (VR) technology in the treatment of conditions such as anxiety, depression, posttraumatic stress disorder, schizophrenia, phobias, and pain management.[1] Among the elderly, it has also been used for elderly with cognitive impairment, gait improvement, balance, posture improvement, and Alzheimer's disease as well.[2] The development of VR was originally aimed at entertainment; however, the use of VR has been explored in various treatment modalities and continues to be explored. Using VR, users are engaged in a virtual environment and fully engrossed in the experience.[3] Most VR experiences involve a head-mounted display (HMD), headphones for sound or music, often with noise-cancelling properties, a rumble pad and joystick, or other navigational tool to move through the virtual landscape. Head-tracking systems help to surround the user in the virtual world and make the experience truly immersive.[4] By including stimuli that engage the visual, auditory, tactile, and olfactory systems, VR is distinctly different from watching movies or TV or even playing two-dimensional (2D) games whether handheld or on a console.

The need for VR in elderly care is most strongly felt in this day and age. Some of these conditions include the fact that technological advancements are much more realistic and reachable than ever before and can therefore be applied to almost every area of our lives.[5] At the same time, the older generations are increasing in numbers within the population and are showing lower mortality rates than ever before. More families will be moving into caregiver roles, with one in three households caring for a family member with cognitive impairment. This, coupled with the gradual decrease in the number of professional health-care providers such as nurses, would require older patients to adopt more independent means of maintaining their health.[6],[7]

Other challenges for this population include changes in behaviors and skills during the latter part of life, a decrease in social relations and physical abilities, loss of memory, comprehensive and cognitive functions, loneliness, and boredom.[7],[8] It becomes important to learn new motor skills as well as engage in cognitively stimulating environments, especially at this stage to maximize the quality of life.[9] Assessments for conditions of the elderly like activities of daily living are inaccurate and insensitive to certain deficits. Certain simple, traditional methods such as motor tasks and basic paper-pencil tests do not account for certain conditions and do not record responses for certain assessments accurately.[10]

Gerotechnology is an active discipline focusing on improving the lives of elders, designs technology solutions by taking into account skills and needs in social and cognitive levels specific to this population.[7] This could be applied to provide formal long-term care to build family care networks, improve quality of care and facilitate coordination, support activities of daily living, address safety issues like falls, wandering, etc., play a part in self-care activities like bathing, eating, medication, sleeping, mobility, postural control and also for entertainment purposes to curb boredom.[11] Furthermore, newer approaches such as the application of VR systems are revolutionizing elderly care and improving the quality of life. They are making health care more individualized, accessible, user-friendly, and less labor intensive, underutilized, and cost effective.[12],[13],[14]

Applications of VR have found positive results. Research has shown that virtual, interactive environments stimulate sensory cues that maintain balance and orientation and improve stepping patterns.[15] VR environments can be used for rehabilitation, especially in distance locations, deliver exercise programs, provide intelligent human-friendly residential systems, move beyond the traditional entertainment purposes, and include designs specific to population needs.[16] Overall, the needs of this population can be best met if VR environments take into account multiple research from medicine, psychology, and rehabilitation. It needs to be multidimensional, multisensory, and multidisciplinary to provide holistic care to elders through VR. The present review is a narrative review offering clinical insights into the various facets of VRT while focusing on its use in elderly patients.


  Method of Conducting This Review Top


For identifying articles that focused on VR and the elderly, the terms “virtual reality,” “virtual reality therapy,” “exergames,” “gaming,” and “virtual environment” were used. For identifying articles that focused on specific terms, like “depression,” “stroke,” “dementia,” “brain injury,” “pain,” “neurorehabilitation,” “memory,” “cognition” and other terms were used. These two search strategy results were combined with an “and” statement in databases along with term “elderly” with the time frame being specified from 1995 through 2019. The databases used were Medline, PubMed, Google Scholar, and the Cochrane Database on Systematic Reviews. In total, 396 articles were identified which included reviews, mini reviews, meta-analyses, original research papers, and randomized controlled trials in the elderly.

We included studies of importance with sample sizes of more than 30 participants and that reported either mean scores or percentages with appropriate statistical analysis. This was added to review papers that were reviewed. All authors reviewed all of the articles and the most relevant ones were chosen for this review. A total of 141 papers were chosen for this review and the most relevant ones were included in this paper. This was supplemented with the personal clinical experience of one of the authors (AD) who works regularly with elderly and dementia patients and has further insight into the use of VR in these populations. All the authors are researchers (psychiatrists and psychologists) and working in clinical settings [Figure 1] and [Table 1].
Figure 1: Algorithm for selection of papers included in the review

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Table 1: List of references used in every section

Click here to view



  Role of Virtual Reality Therapy in Dementia Care Top


Dementia can present with behavioral symptoms such as stress, agitation, and extreme mood swings. When a dementia patient is agitated or distressed, they may exhibit compulsive or repetitive behaviors.[17] Patients with dementia may manifest their frustration via repetitive moaning or may trouble their caregivers by constantly asking them questions. They might also indulge in excessive pacing as they are trying to remember a certain memory or item, which might create discomfort and confusion. Interrupting any of these behaviors may cause frustration or irritation as well as it might lead to increased symptoms of anxiety.[18]

Using the technology of VR has proven to be helpful when dealing with lowering symptoms of anxiety. As these patients may not be exposed to situations in person, VR has the techniques to bring it to them via a headset. Researchers have found that viewing nature reduces stress and improves mood, but few studies have focused on the potential of viewing nature to reduce negative emotions associated with dementia.[19] In another study, researchers measured the effectiveness of VR on engagement, apathy, and mood states of people with dementia as well as explore experiences of caregivers. They found that the patients with dementia as well as family members had a positive outcome and suggested that VR may have the potential to improve quality of life.[20]

For dementia patients, memories sometimes become “locked” in their brains, making it hard to recall life events or relatives. Images of a family home or a video tour can bring these memories back to life, helping with recalling past events. When people with dementia can no longer access the memories on their own, using VR to view pictures or watch videos can be useful. VR can stimulate cognition and unlock those memories, potentially slowing the progression of the disease.[21] VRT has been used to produce artificial environments to enhance outdoor exposure for patients with dementia,[22] in cognitive training and enhancing memory,[23] spatial navigation,[24] and gait training.[25]


  Role of Virtual Reality in Cognitive Rehabilitation Top


A common physiological characteristic of aging is a loss of physical as well as cognitive performance. The prevalence of frailty and cognitive impairment increases significantly as age increases. Cognitive training based on computerized tasks and exercises represent a promising solution to engage participants in structured mental activities and enhance their cognitive functions, especially if they incorporate a motivational, playful aspect.[26] Cognitive rehabilitation is used to enable patients to overcome balance functional, cognitive, and emotional deficits due to physical and cognitive impairment and to achieve social adjustment and better quality of life. VR-based innovation offers new chances to the assessment and rehabilitation of frailty and cognitive impairment due a better approximation to the real word with less cost and in less time, as well as higher levels of immersion.[27]

In a study done assessing the prevalence and impact of cognitive decline rises, where they used a set of VR exercises that mimic activities of daily living by which the patient can train different cognitive domains, it was found that there were significant increases between the two assessments for some of the neuropsychological measures: visual memory, attention, and cognitive flexibility. The results also suggested that participants with lower baseline cognitive performance levels improved most after these sessions.[28] A review of VR rehabilitation shows, however, very promising results with this approach, with significant clinical improvements in both memory and attention outcomes. A study was carried out to assess the efficacy of cognitive training, specifically computerized cognitive training and VR cognitive training, programs for individuals living with mild cognitive impairment or dementia, and therefore at high risk of cognitive decline. It was found that there were long-term improvements in cognitive and psychological outcomes, and the intervention groups showed a plateau effect of cognitive functioning.[29]


  Role of Virtual Reality in Memory Training and Reality Orientation Top


VR environments have a major advantage for the assessment of spatial navigation and memory formation, as computer-simulated first-person environments can simulate navigation in a large-scale space. It was reported on many platforms that aging has a negative effect on navigation and performance.[30] Especially in unfamiliar environments, older adults experience greater navigational difficulties. Such difficulties can discourage older adults from exploring new environments and negatively affect their independence and overall quality of life. These age-related navigation difficulties derive from a decline in the relevant visuospatial abilities and memory capacity, both of which vary widely across individuals.[31] Most memory systems, including visuospatial memory that has been necessary for navigation, seem to weaken across the life span. As memory declines, people make more misattribution errors, that is, an actual experience of an event may be misplaced in time, place, or source when retrieved from memory.[32] A virtual environment experiment was done to test this theory, where they found that using a mixed virtual environment method with older adults improved recall accuracy as well as visuospatial learning; both are important tools in memory training.[33] A study aiming at assessing memory function in elderly patients with cognitive deficits saw that VR memory training tasks helped improve memory function by enhancing focused attention.[34] Memory training, in real-life settings via using the VR techniques have been a strong aim of many researchers who have an inclination to explore the subjective sense of remembering. Memory and attention are combined on many occasions as they were necessary for navigation as it may imply deficits in spatial memory. Using VR scenarios helps the elderly to have an orientation to the realistic view, as well as practice on the skills they feel are lost.[35]


  Role of Virtual Reality in Stroke Rehabilitation Top


The role of VR in stroke rehabilitation in the elderly has been aimed at improvements in daily activities to improve the quality of independent living and enhanced improvement in activities of daily living.[36] The role of VR in motor rehabilitation in patients with stroke has aimed to provide repeated performance of tasks that involves multiple sensory processes and different sensory modalities including vision, haptic, proprioception, and auditory which enables increases in function.[37] There has been a need for motor relearning where relearned movements have to be organized to accomplish tasks in general. The repeated practice of specific motor skills increases the ability to perform the task and using VR motor tasks are practiced in appropriate environments where sensory inputs modulate their performance.[38]

VR methods have enhanced stroke rehabilitation by modifying not only visual and auditory sensory input but also adding a haptic angle to it. The haptic interface device including gloves, pens, and joysticks with a sense of touch that allows the patient to feel textures and changes in texture. This has been used in the modulation and rehabilitation of joint range of motion and force and improve the subject's performance in higher level difficult tasks.[39] VR also provided a sense of actual presence in, and control over, the simulated environment which was defined as the feeling of being in an environment even if one is not physically present and resulting in behavior that is congruent with the subject's situation in the environment.[40]

An large number of distinct VR applications are being developed for intervention and assessment of the motor rehabilitation needs including upper and lower extremity function, balance and locomotion.[41] Nowadays, with the advances in computers and low cost motion trackers along with haptic devices there has been an enhanced development of low cost stroke rehabilitation applications. This would improve our current understanding of movement and therapy along with rehabilitation interventions.[42] There has also been a need for further research to look at sensorimotor integration, movement production, learning, and transfer as well as psychosocial benefits in stroke rehabilitation.[43]


  Virtual Reality for Neurorehabilitation in the Elderly Top


Given the high incidence of brain injury in the elderly, brain damage rehabilitation in the elderly has been still in its nascent stages.[44] VR has the potential to assist current rehabilitation techniques and improve the impairments, disabilities, and handicaps associated with brain damage in the elderly.[45] The majority of research of VR in traumatic brain rehabilitation has been in the assessment of cognitive abilities; however, there has been now a trend for more studies that encompassed rehabilitation training strategies.[46] Multiple cognitive areas have been improved in traumatic brain injury rehabilitation using VR and this include executive dysfunction,[47] memory,[48] spatial ability impairments,[49] and unilateral visual neglect.[50]

Damage to the brain reduces a person's ability to interact with the physical environment, often leads to a type of environmental impoverishment, and this reduction in environmental interaction is detrimental for the rehabilitation objectives.[51] VR allows the developmental of specific environments that are individual and tailor made to the needs of the individual patient. VR has been easily delivered to the patient via a HMD or screen rather than having to relying on manual help as in real time.[52] This has been coupled with the advent of the functional magnetic resonance imaging scan that measures brain activity during interaction with virtual environments and allows us to ascertain whether exposure to virtual environments can directly influence the damaged brain. This has been a new and exciting area of research and one that may conclusively demonstrate the role of VR in brain injury.[53]


  Role of Virtual Reality in Motor Control Balance and the Role of Exergames/physical Training Component Top


Age-related changes in the neural, sensory, and musculoskeletal system can disturb motion homeostasis and make these people susceptible to falls. What's most specific has been the deficit in control of the support base, with compensatory arm and leg movements elicited by environmental changes leading to gait disturbances in elderly.[54] VR-simulated environment in training of individuals has been in its infancy but promising.[55] VR can be an effective user-centered methodology for eliciting and evaluating the perceptions, reactions, and performance of persons with dementia in simulated environments.[56] This baseline data then can be used to make necessary changes in the environment to make their lives easier. Poor postural control has been another problem in this regard. Computerized posturography techniques have been used to measure improvements in balance.[57] VR can be used to create environment in order to develop reflexes needed for postural control.[57] Dance pad games can assess balance, orientation and thereby predict falls.[15] Exergames have shown a lot of promise to measure the postural data and add to fall prevention strategies in elderly individuals due to high level of enjoyment and motivation associated with otherwise mundane physical exercises.[58]


  Role of Virtual Reality in Geriatric Depression Top


Depression has been a common mental disorder that affects 10%–30% of the elderly population. Medication, psychotherapy, or a combination of the two have been the most common treatment approaches for geriatric depression.[59] While these treatments are often effective, VR has been proving to be another helpful tool in the treatment of geriatric depression.[60] Some of the most common forms of VRT involve immersion therapy; the patient was repeatedly exposed to a situation until it no longer caused them distress. Immersion therapy could also help those struggling with depression.[61] Research confirms that VR is an effective way to reduce social isolation,[62] loneliness,[62] anxiety,[63] depression [61] and pain in older adults.[64]

Depression in the elderly may be misdiagnosed and may be confused with behavioral and psychological of dementia and this fail to receive the right treatment.[65] Exergames persuade elderly to move and act as an instrument to increase social interactions in a way making locomotion instrument for making amends in apathy. The role of VR in alleviating depressive symptoms needs further research.[66]

The role of VR in reducing isolation (social isolation) among elderly has also been studied. Studies have shown that VR games environment support the decreasing cognitive and communicative skills in elderly.[67] VR may not be a direct solution and may not need to replace direct social interaction among elderly, but it has an opportunity to interact with other elderly in a virtual environment. Some precautions in place when introducing this technology, such as doing it in a safe environment and doing the sessions shorter in the beginning, can serve the technology to benefit effectively.[68] Research has shown that the elderly have already benefited from such eHealth solutions once introduced.[69]


  Role of Virtual Reality as Part of Reminiscence Therapy Top


Reminiscence therapy (RT) is a treatment that is offered to people in their later years. With the help of prompts such as photographs, music, and familiar items/objects from the past and other remembrances, the therapist encourages the patient to talk about memories from earlier in life.[70] The recent interest in research has increasingly focused on applying reminiscence work/therapy using multimedia computer systems for people with dementia and their caregivers. Research literature tells us that technology makes available a wide pool of information which can be used as material for reminiscence work.[71] Technology in use for therapy allows for positive results in terms of increased interaction and facilitated communication and offering the person with dementia more control over the types of materials used.[72] The intersection of VR with RT makes it easier for the elderly to immerse in positive environment through the cutting-edge technology available. Technology makes the accessibility and storage of material (memories) to reminisce convenient and VR allows an environment to connect with these easily. VR RT allows patients become animated and happy when viewing pictures of places where they have been. This allows recognition which generates interaction with others that would not have occurred without the VR RT.[73] Scientists have introduced an immersive VR system designed for RT, which allows easy presentation of familiar environments. The system supports highly-realistic image-based rendering (IBR) in an immersive setting.[74] A trial was conducted to study the effectiveness of this system and the results showed that the number of memories generated for a familiar environment were higher than that for an unknown environment in the system used. This indicated that that IBR could convey familiarity of a given scene, which is an essential requirement for the use of VR in RT. Results also showed that the system was as effective as traditional RT protocols, while scores also demonstrated that system was well tolerated by elderly participants.[75] There needs to be greater research with supportive intervention in the understanding and use of VR in RT for the elderly.


  Role of Virtual Reality as an Additional Component to Psychotherapy Top


Apart from the various psychotherapeutic modalities that exist to address the geriatric mental health issues, VR has been a growing and promising therapeutic tool.[76] To further explain, it has been a treatment method in which patients are introduced and then slowly exposed to a traumatic stimulus. Inside virtual environments, patients can safely interact with a representation of their phobia, and researchers do not need to have access to a real version of the phobia itself.[77] VR has also been used for prolonged exposure therapy for trauma that was military related.[78] This has been an interesting area where larger studies in multiple settings are warranted in the area of psychotherapy in the elderly using VR.


  Role of Virtual Reality in Treatment Resistant Hallucinations Top


Schizophrenia has been a chronic and debilitating severe mental illness. Till recently, the focused target of research has been to improve function, improve cognition, social skills, job interview skills and has also helped in augmenting cognitive behavioural therapy in schizophrenia or other mental disorders with psychosis to an extent however, further research is required to better conclusive findings.[79] Mental health professionals using VR in the treatment of psychosis highlight that using VR in the treatment of schizophrenia does not worsen symptoms, does not cause cybersickness, and nor is it linked to hospital readmissions.[80] However, despite the presence of psychopharmacological and psychotherapeutic management, sometimes, schizophrenia remains treatment resistant. Patients continue to suffer from persistent disabling psychotic symptoms, one of the common ones being auditory verbal hallucinations (AVHs). However, immersive VR has shown some promising results in therapeutic effect by enabling patients to engage in a dialogue with a computerized representation of their voices. VRT is a highly novel and promising intervention for refractory AVH in schizophrenia.[81] VR allows patients to talk to an avatar of their hallucinations, explore locations that give them anxiety, and practice talking to others in a variety of threating or nonthreatening situations, gives patients the chance to work through their own fears in a no-risk environment.[82]


  Advantages and Disadvantages of Virtual Reality in Elderly Care Top


Because of the way that it bridges together an older population with a newer approach, this area of application for VR comes with its challenges and promises. VR has facilitated cognitive activity or stimulation, created environments that are three-dimensional, appeared realistic, and included real-life settings for patients. The stimulation was a protective factor against functional losses in old age.[83] It created environments that were safe and which could be controlled to suit the patient's needs while at the same time allowed them to experience autonomy and control.[83]

VR also improves recording of assessments of activities of daily, ensures accurate responses, and can provide immediate and more detailed feedback on the patient's performance.[84] VR setups, especially exergames, are shown to increase motivation and participation, provide an effective distraction from the patient's symptoms, and can even increase exercise behavior because of the fun and engaging nature of these environments. It helps make long-term treatment less monotonous.[85]

It is also much more person-centered, individualized and accessible, with design elements focusing more on particular needs of the patient. It can be adapted to suit each individual's progress and abilities. This population is particularly diverse, and therefore, different types of care settings would have to be created for different care needs of this group.[86]

Such environments also address psychological and cognitive needs, help people connect, improve social health, and have an emotional impact as well. It has increased the degree of learning, allows patients to practice skills, and allows transfer to real world tasks. It also integrates and provides health information such as surgical procedures to professionals, reduces gaps in medical record information, improves documentation, etc.[87]

VR environments have proven to be effective in the treatment of phobias because it is a safe and controlled space, improves postural control and lowers fall risks, improves activities of daily living, provides control and dignity, stimulates the nervous system, helps with reflex control and attention, etc.[88] It, overall, vastly improves the quality of life for such individuals especially in an institutional setting. In terms of disadvantages, or rather challenges of VR in elderly care, the usability of certain technologies has proven to be complex. It is stereotypical that this population is resistant to new advancements and ideas. Rather, the ability to grasp new things might be varied within the population. Not all will be uncomfortable in these settings and there can be gradual familiarization over time.[89]

There is however lack of evidence about the benefits of VR and the kind of outcomes it achieves as compared to other forms of care for the elderly. The main problems that arise are in the areas of awareness, access, acceptance, and adoption of new methods. However, there is no rationale to keep old people away from new technologies, but it is necessary to confirm that they can accept a virtual environment and interact cognitively with it.[90] There are certain economic barriers such as cost of the therapies, their design, and the development process and the patient's financial condition.

Social barriers can also be seen such as patient's discomfort, language, lack of face-to-face interaction, and the idea of cultivating virtual friendships rather than real-life ones.[91]

The recorded responses and monitoring of the patient can also bring up privacy infringement issues as the extent to which certain information should remain private has not been explicitly specified.

The uniqueness of this situation and the use of artificial intelligence brings up issues about the quality of care and certain ethical questions like the lack of reciprocity and emotional connection, and more dehumanized response to care.[92] Realistically, the extent to which virtual realities can provide a realistic experience is questionable and requires more research.[93] Finally, a major criticism is the purpose and method of designing these programs. Most of these virtual realities are designed for the purpose of entertainment and not specifically to the needs of certain disabilities and conditions in the elderly, which will hamper the effectiveness of the programs in elderly care.[94] Future research should focus on repurposing the design of these programs to suit these populations more. The main factors that need to be kept in mind for future programs are cost, usability, maximizing and improving user experience, and having a multidisciplinary approach to ensure that holistic care is provided.


  Conclusion Top


VR has broad-spectrum applications in the elderly and to enhance their mental health. The current paper intended to provide the busy clinician an overview of the potential that VR has in the field of geriatric mental health, dementia, and neurorehabilitation in the elderly. Most of the research in this field is from the West and South East Asian countries. There is a need for further research in the Asian subcontinent and larger diverse samples need to be included. There is also a need for clinical guidelines on the use of VR in the elderly, so that caution may be exercised when using the same. This is a potential area for new research that must be pursued in order to make such therapies cost effective and available to patients of all sectors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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