Delayed/underdiagnosis and/or undertreatment are norms in psychogeriatrics. For instance, it takes up to 3.2 years on average to diagnose Alzheimer’s dementia (AD) from the onset of symptoms in the US currently. Many geriatric mental health issues, such as neuropsychiatric symptoms of dementia, do not have efficacious treatment. Even when strong evidence is available for efficacy, interventions such as problem-solving therapy and reminiscence therapy remain inaccessible to geriatric patients due to a myriad of barriers such as transportation, cost, and the lack of a caregiver. The COVID-19 pandemic has further exposed disparities in geriatric mental health care among rural and ethnic minorities. Immersive virtual reality (iVR), when used optimally, may bridge some of these gaps by: (a) early diagnosis of dementia, (b) immersive cognitive training, (c) functional rehabilitation using real-life scenarios, and (d) personalized and scalable treatments of late-life depression and neuropsychiatric symptoms of dementia.
iVR has become more sophisticated in the past decade allowing for more successful clinical applications. Desirable features of iVR include its flexibility which allows for personalized and safe training, interactive quality which lends itself to testing, training and task-based activities, gathering of rich data that could detect subtle changes in cognition over time, and lastly VR helps enable the expression and perception of multiple senses, motor behaviors, and emotions (Bauer and Andringa, Reference Bauer and Andringa2020). Apart from limited reports of disorientation and nausea (cybersickness), iVR seems to be safe and well accepted in the geriatric population. Thus, iVR provides intervention methods that are cost-effective, accessible, flexible, and comprehensive for patients who find it difficult to attend outpatient appointments due to distance, lack of transport, disability, and COVID-19 concerns, etc. Although iVR has shown to be successful in testing, screening, cognitive training, and some applications such as exposure therapy, Skurla etal. make a strong case that geriatric research is merely scratching at the surface.
In this issue, Skurla etal. summarize the VR literature in geriatric mental health from 2008 to October 2020 (Skurla etal., Reference Skurla, Rahman, Salcone, Mathias, Shah, Forester and Vahia2021). They found that although the field is dominated by cross-sectional studies, an increasing number of randomized controlled trials are being reported. Cognitive deficits and posttraumatic stress disorder were the most common reasons for the use of VR in older adults. Testing, screening, and training were the main uses of VR in these studies. Testing articles examined the capability and validity of using VR with older adults, training articles investigated cognitive effects of using VR, and screening articles assessed VR test’s ability to make a distinction between healthy controls and older adults with various diagnoses of cognitive impairment.
Skurla etal. found that most of the VR studies used less sophisticated versions and computer screen and mouse were used most commonly to interact with the virtual scenes. They found that more recent articles have used more sophisticated versions of VR and head-mounted devices to provide for an immersive experience. They found evidence for VR applications providing greater validity than traditional interventions and allowing for creativity and innovation in the design of the task environment. However, a lack of standardized VR environments across multiple studies was seen as a limitation of the extant literature limiting the generalizability of the findings. The Virtual Super Market environment for instance was included in three studies but were all published by the same authors. Another limitation was the lack of standardization of outcome measures. Articles that examined VR as a method for therapeutic intervention used different mood scales (Beck Depression Inventory, the Impact of Events Scale Revised, and the Symptoms Checklist Revised) and neuropsychological tests (Trail-Making Test, Digit Span, and Stroop test) to assess patients’ symptoms and cognitive performance. Despite the aforementioned limitations, Skurla etal. found several strengths of the use of VR. Testing articles found that VR correlated with accepted neuropsychological measures of cognitive skills, training articles illustrated that VR has the ability to improve cognitive skills such as spatial cognition, memory, executive function, and activities of daily living, and screening articles presented evidence in support of using VR as a cognitive screening tool. VR also is found to have the potential to detect mild cognitive impairment (MCI) and AD and also distinguish between them. Because of these findings, VR technology might allow clinicians to detect cognitive impairment earlier and facilitate performance-based assessments of functioning. These findings also present evidence for using VR as a training tool for cognitive impairment in older adults; this training could include enhancing functional skills such as cooking and navigation.
The findings of Skurla etal. are in keeping with other reviews. Overall, cognitive disorders have been the primary focus of iVR studies in geriatric populations. Preliminary studies of patients with early dementia and MCI have focused on providing mental stimulation, a connection to autobiographical memory through reminiscence, and ways to enhance their quality of life (D’Cunha etal., Reference D’cunha2019). Findings from these studies suggest that VR interventions that incorporate cognitive training can improve domains of cognition important for activities of daily living; VR was effective in triggering reminiscence when participants reenacted memories; and that VR may have emotional and social benefits while enhancing older adults’ quality of life and their sense of control. Another review showed small to medium positive effects for VR interventions on key outcome variables including physical fitness, cognition, and emotion in patients with preexistent cognitive impairment (Kim etal., Reference Kim, Pang and Kim2019). Another review found that iVR can be used to discriminate people with AD from controls/other dementia processes and demonstrates potential for detecting preclinical AD, but there is limited evidence that iVR can improve real-world functioning, and it is less clear whether iVR will have specific cognitive benefits (Clay etal., Reference Clay, Howett, Fitzgerald, Fletcher, Chan and Price2020). Overall, iVR seems to be a better tool for cognitive training with the elderly than non-immersive VR because it creates more flow, motivation, and fun, and the realism immersive VR uses helps to transfer learned skills from the VR environment to real life.
Future directions: more studies are needed using iVR interventions for mood/anxiety disorders in older adults, using latest advancements in VR technology and head-mounted devices. Skurla etal. raise a good point that iVR studies from low-income countries are much needed. Likewise, there is a need for reaching out to rural and minority communities and applying the interventions to non-English languages. Practical and ethical questions concerning the use of VR with severely impaired older adults need to be addressed, as well as privacy and confidentiality issues when using VR technology. A huge potential that is understudied is the possibility of using the virtual reality paradigms remotely using web-based platforms. Use of such devices is particularly relevant during the COVID-19 pandemic and might keep people safe while assessing, testing, and providing therapeutic interventions while people stay safe at their own home. Web-based platforms could also improve the reach of iVR interventions to rural geriatric populations, a subgroup that is underrepresented in research. Studies focusing on elucidating mechanisms of action of iVR strategies are much needed. There are limited number of preliminary studies using galvanic skin response and heart rate variability to gauge the “immersiveness” of the iVR interventions (Saredakis etal., Reference Saredakis, Keage, Corlis and Loetscher2021). Functional neuroimaging has the potential to inform brain activation during interaction with iVR platforms.
As the authors pointed out, virtual reality can be used to treat neuropsychiatric symptoms of dementia due to their high ecological validity and ability to personalize treatments according to the subject. Apathy treatment for example can be tailored using premorbid interest for individual participants. Preliminary results have shown that patients with mild to moderate dementia can tolerate virtual reality quite well and have minimal side effects. The data also pointed out to tailoring VR for apathy treatment. Although the current literature is limited to small single-session studies, a 45-subject 3-arm cluster-randomized study of iVR with head-mounted devices versus laptop for reminiscence therapy is under way in Australia (Saredakis etal., Reference Saredakis, Keage, Corlis and Loetscher2021).
In conclusion, the developmental of affordable, wireless, head-mounted displays, and sophisticated immersive experiences tailored to a particular patient could make virtual reality a scalable and effective intervention for many old age mental health problems.
You have
Access
Delayed/underdiagnosis and/or undertreatment are norms in psychogeriatrics. For instance, it takes up to 3.2 years on average to diagnose Alzheimer’s dementia (AD) from the onset of symptoms in the US currently. Many geriatric mental health issues, such as neuropsychiatric symptoms of dementia, do not have efficacious treatment. Even when strong evidence is available for efficacy, interventions such as problem-solving therapy and reminiscence therapy remain inaccessible to geriatric patients due to a myriad of barriers such as transportation, cost, and the lack of a caregiver. The COVID-19 pandemic has further exposed disparities in geriatric mental health care among rural and ethnic minorities. Immersive virtual reality (iVR), when used optimally, may bridge some of these gaps by: (a) early diagnosis of dementia, (b) immersive cognitive training, (c) functional rehabilitation using real-life scenarios, and (d) personalized and scalable treatments of late-life depression and neuropsychiatric symptoms of dementia.
iVR has become more sophisticated in the past decade allowing for more successful clinical applications. Desirable features of iVR include its flexibility which allows for personalized and safe training, interactive quality which lends itself to testing, training and task-based activities, gathering of rich data that could detect subtle changes in cognition over time, and lastly VR helps enable the expression and perception of multiple senses, motor behaviors, and emotions (Bauer and Andringa, Reference Bauer and Andringa2020). Apart from limited reports of disorientation and nausea (cybersickness), iVR seems to be safe and well accepted in the geriatric population. Thus, iVR provides intervention methods that are cost-effective, accessible, flexible, and comprehensive for patients who find it difficult to attend outpatient appointments due to distance, lack of transport, disability, and COVID-19 concerns, etc. Although iVR has shown to be successful in testing, screening, cognitive training, and some applications such as exposure therapy, Skurla etal. make a strong case that geriatric research is merely scratching at the surface.
In this issue, Skurla etal. summarize the VR literature in geriatric mental health from 2008 to October 2020 (Skurla etal., Reference Skurla, Rahman, Salcone, Mathias, Shah, Forester and Vahia2021). They found that although the field is dominated by cross-sectional studies, an increasing number of randomized controlled trials are being reported. Cognitive deficits and posttraumatic stress disorder were the most common reasons for the use of VR in older adults. Testing, screening, and training were the main uses of VR in these studies. Testing articles examined the capability and validity of using VR with older adults, training articles investigated cognitive effects of using VR, and screening articles assessed VR test’s ability to make a distinction between healthy controls and older adults with various diagnoses of cognitive impairment.
Skurla etal. found that most of the VR studies used less sophisticated versions and computer screen and mouse were used most commonly to interact with the virtual scenes. They found that more recent articles have used more sophisticated versions of VR and head-mounted devices to provide for an immersive experience. They found evidence for VR applications providing greater validity than traditional interventions and allowing for creativity and innovation in the design of the task environment. However, a lack of standardized VR environments across multiple studies was seen as a limitation of the extant literature limiting the generalizability of the findings. The Virtual Super Market environment for instance was included in three studies but were all published by the same authors. Another limitation was the lack of standardization of outcome measures. Articles that examined VR as a method for therapeutic intervention used different mood scales (Beck Depression Inventory, the Impact of Events Scale Revised, and the Symptoms Checklist Revised) and neuropsychological tests (Trail-Making Test, Digit Span, and Stroop test) to assess patients’ symptoms and cognitive performance. Despite the aforementioned limitations, Skurla etal. found several strengths of the use of VR. Testing articles found that VR correlated with accepted neuropsychological measures of cognitive skills, training articles illustrated that VR has the ability to improve cognitive skills such as spatial cognition, memory, executive function, and activities of daily living, and screening articles presented evidence in support of using VR as a cognitive screening tool. VR also is found to have the potential to detect mild cognitive impairment (MCI) and AD and also distinguish between them. Because of these findings, VR technology might allow clinicians to detect cognitive impairment earlier and facilitate performance-based assessments of functioning. These findings also present evidence for using VR as a training tool for cognitive impairment in older adults; this training could include enhancing functional skills such as cooking and navigation.
The findings of Skurla etal. are in keeping with other reviews. Overall, cognitive disorders have been the primary focus of iVR studies in geriatric populations. Preliminary studies of patients with early dementia and MCI have focused on providing mental stimulation, a connection to autobiographical memory through reminiscence, and ways to enhance their quality of life (D’Cunha etal., Reference D’cunha2019). Findings from these studies suggest that VR interventions that incorporate cognitive training can improve domains of cognition important for activities of daily living; VR was effective in triggering reminiscence when participants reenacted memories; and that VR may have emotional and social benefits while enhancing older adults’ quality of life and their sense of control. Another review showed small to medium positive effects for VR interventions on key outcome variables including physical fitness, cognition, and emotion in patients with preexistent cognitive impairment (Kim etal., Reference Kim, Pang and Kim2019). Another review found that iVR can be used to discriminate people with AD from controls/other dementia processes and demonstrates potential for detecting preclinical AD, but there is limited evidence that iVR can improve real-world functioning, and it is less clear whether iVR will have specific cognitive benefits (Clay etal., Reference Clay, Howett, Fitzgerald, Fletcher, Chan and Price2020). Overall, iVR seems to be a better tool for cognitive training with the elderly than non-immersive VR because it creates more flow, motivation, and fun, and the realism immersive VR uses helps to transfer learned skills from the VR environment to real life.
Future directions: more studies are needed using iVR interventions for mood/anxiety disorders in older adults, using latest advancements in VR technology and head-mounted devices. Skurla etal. raise a good point that iVR studies from low-income countries are much needed. Likewise, there is a need for reaching out to rural and minority communities and applying the interventions to non-English languages. Practical and ethical questions concerning the use of VR with severely impaired older adults need to be addressed, as well as privacy and confidentiality issues when using VR technology. A huge potential that is understudied is the possibility of using the virtual reality paradigms remotely using web-based platforms. Use of such devices is particularly relevant during the COVID-19 pandemic and might keep people safe while assessing, testing, and providing therapeutic interventions while people stay safe at their own home. Web-based platforms could also improve the reach of iVR interventions to rural geriatric populations, a subgroup that is underrepresented in research. Studies focusing on elucidating mechanisms of action of iVR strategies are much needed. There are limited number of preliminary studies using galvanic skin response and heart rate variability to gauge the “immersiveness” of the iVR interventions (Saredakis etal., Reference Saredakis, Keage, Corlis and Loetscher2021). Functional neuroimaging has the potential to inform brain activation during interaction with iVR platforms.
As the authors pointed out, virtual reality can be used to treat neuropsychiatric symptoms of dementia due to their high ecological validity and ability to personalize treatments according to the subject. Apathy treatment for example can be tailored using premorbid interest for individual participants. Preliminary results have shown that patients with mild to moderate dementia can tolerate virtual reality quite well and have minimal side effects. The data also pointed out to tailoring VR for apathy treatment. Although the current literature is limited to small single-session studies, a 45-subject 3-arm cluster-randomized study of iVR with head-mounted devices versus laptop for reminiscence therapy is under way in Australia (Saredakis etal., Reference Saredakis, Keage, Corlis and Loetscher2021).
In conclusion, the developmental of affordable, wireless, head-mounted displays, and sophisticated immersive experiences tailored to a particular patient could make virtual reality a scalable and effective intervention for many old age mental health problems.
Conflict of interest
Neither of the authors have any conflict of interest to report.
Description of authors’ roles
AMP: Literature review, manuscript preparation; PRP: Conceptualization, critical review.