Background Behavioural and psychological symptoms of dementia (BPSD) are difficult to manage, particularly in acute care settings. As virtual reality (VR) technology becomes increasingly accessible and affordable, there is growing interest among clinicians to evaluate VR therapy in hospitalized patients, as an alternative to administering antipsychotics/sedatives or using physical restraints associated with negative side effects. Objectives Validate and refine the proposed research protocol for a randomized controlled trial (RCT) that evaluates the impact of VR therapy on managing BPSD in acute care hospitals. Special attention was given to ascertain the processes of introducing non-pharmacological interventions in acute care hospitals. Methods Ten patients 65 years or older (mean = 87) previously diagnosed with dementia, admitted to an acute care hospital, were recruited over 3-month period into a prospective longitudinal pilot study. The intervention consisted of viewing 20-min of immersive 360° VR using a head-mounted display. Baseline and outcomes data were collected from the hospital electronic medical records, pre/post mood-state questionnaires, Neuropsychiatric Inventory (NPI) score, and standardized qualitative observations. Comprehensive process data and workflow were documented, including timestamps for each study task and detailed notes on personnel requirements and challenges encountered. Results Of 516 patients admitted during the study, 67 met the inclusion/exclusion criteria. In total, 234 calls were initiated to substitute decision makers (SDM) of the 67 patients for the consenting process. Nearly half (45.6%) of SDMs declined participation, and 40% could not be reached in time before patients being discharged, resulting in 57 eligible patients not being enrolled. Ten consented participants were enrolled and completed the study. The initial VR session averaged 53.6 min, largely due to the administration of NPI (mean = 19.5 min). Only four participants were able to respond reliably to questions. Seven participants opted for additional VR therapy sessions; of those providing feedback regarding the VR content, they wanted more varied scenery (animals, fields of flowers, holiday themes). Few sessions (4/18) encountered technical difficulties. Conclusion The pilot was instrumental in identifying issues and providing recommendations for the RCT. Screening, inclusion criteria, consenting, data collection, and interaction with SDMs and hospital staff were all processes requiring changes and optimizations. Overall, patients with dementia appear to tolerate immersive VR, and with suggested protocol alterations, it is feasible to evaluate this non-pharmacological intervention in acute care hospitals.

Background As virtual reality (VR) technologies become increasingly accessible and affordable, clinicians are eager to try VR therapy as a novel means to manage behavioral and psychological symptoms of dementia, which are exacerbated during acute care hospitalization, with the goal of reducing the use of antipsychotics, sedatives, and physical restraints associated with negative adverse effects, increased length of stay, and caregiver burden. To date, no evaluations of immersive VR therapy have been reported for patients with dementia in acute care hospitals. Objective This study aimed to determine the feasibility (acceptance, comfort, and safety) of using immersive VR therapy for people living with dementia (mild, moderate, and advanced) during acute care hospitalization and explore its potential to manage behavioral and psychological symptoms of dementia. Methods A prospective, longitudinal pilot study was conducted at a community teaching hospital in Toronto. The study was nonrandomized and unblinded. A total of 10 patients aged >65 years (mean 86.5, SD 5.7) diagnosed with dementia participated in one or more research coordinator–facilitated sessions of viewing immersive 360° VR footage of nature scenes displayed on a Samsung Gear VR head-mounted display. This mixed-methods study included review of patient charts, standardized observations during the intervention, and pre- and postintervention semistructured interviews about the VR experience. Results All recruited participants (N=10) completed the study. Of the 10 participants, 7 (70%) displayed enjoyment or relaxation during the VR session, which averaged 6 minutes per view, and 1 (10%) experienced dizziness. No interference between the VR equipment and hearing aids or medical devices was reported. Conclusions It is feasible to expose older people with dementia of various degrees admitted to an acute care hospital to immersive VR therapy. VR therapy was found to be acceptable to and comfortable by most participants. This pilot study provides the basis for conducting the first randomized controlled trial to evaluate the impact of VR therapy on managing behavioral and psychological symptoms of dementia in acute care hospitals.

Background: Due to the high prevalence of post-traumatic stress disorder (PTSD) among veterans, as this population ages, they are more likely to develop dementia and exhibit behavioral and psychological symptoms of dementia (BPSD), including responsive behaviors. BPSDs are linked to adverse clinical outcomes, hospitalization, and earlier mortality and are directly related to increased cost and burden of care. In long-term care institutions, residents' behaviors such as physical (striking out, biting, grabbing, etc.) and/or verbal (cursing, screaming, etc.) reactions are associated with higher staff burnout levels which contribute to absenteeism, high turnover, low engagement, and elevated risk of patient abuse or neglect. Despite their limited effectiveness and association with hastening of cognitive and physical decline, medications (neuroleptic/sedating drugs) are commonly used for people with dementia who exhibit responsive behaviors. In long-term care settings, more than 30% of veterans with high-care needs and 20% of those with low-care needs are prescribed drugs to manage their symptoms and behaviors. There is growing pressure from the medical community to engage in non-pharmacological strategies as the first-line of treatment to reduce BPSDs. Virtual reality (VR) presents a unique opportunity to transport people away from environmental factors that amplify feelings of loneliness, boredom, and discomfort, which are known to trigger responsive behaviors, into natural calming settings (such as a peaceful lake, or a colorful forest). Using immersive VR as a non-pharmacological therapy has been piloted with frail older adults in both community and acute-care settings with promising results. However, to date, there have been no rigorous longitudinal studies of VR therapy in long-term care, in particular, studies that evaluate its potential to reduce responsive behaviors related to triggering events. The current study provided novel opportunities for Perley and Rideau Veterans' Health Centre (Perley Health), which has prioritized reducing resident responsive behaviors and maintaining a healthy workforce.Objective: The purpose of this study was to evaluate the feasibility and potential benefits of introducing VR therapy in a veterans' long-term care health center, with the main goal of reducing responsive behaviors for veterans living with dementia, including responsive behaviors related to experiencing physical and emotional pain. This includes evaluating VR therapy with respect to acceptability, comfort, enjoyment, relaxation, and its ability to promote reminiscence. Of special interest was the impact of VR therapy in cases where responsive behaviors were triggered by a predictable environmental event (e.g., bathing, toileting, etc.).Methods: This was a prospective, longitudinal, non-randomized interventional study that employed convenience sampling. Veterans residing in this long-term care setting who exhibited responsive behaviors were recruited and grouped into two categories according to how they usually exhibited responsive behaviors: Group T—responsive behaviors were triggered by known activities or events in a relatively predictable way (e.g., sundowning, wound care), and Group S—initiation of responsive behaviors did not follow specific predictable patterns. Residents in both groups received the VR therapy intervention, which consisted of watching 360° VR video footage of natural and social scenes using an Oculus Go head-mounted-display. Group T received “targeted” VR therapy sessions occurring just before or during events that could trigger responsive behaviors (e.g., before bathing). Group S received “scheduled” VR therapy sessions akin to other recreational activities (e.g., at a mutually convenient time during the day). Intended data collection consisted of baseline scores from validated tools including the Pain Assessment for Advanced Dementia (PAINAD), Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS), and Palliative Performance Scale and daily clinical progress notes extracted from patients' electronic records during the study period, as well as intervention data-collection tool comprising a quantitative survey (for residents' feedback when possible) and qualitative structured observations during the intervention by recreational therapists (RTs). Also described are the changes implemented to data collection and analyses as a number of methodological challenges arose during the study.Results: Thirty-three veterans (mean age 91.6 years, SD 5.9) with varying degrees of cognitive impairment: 3% (1/33) borderline intact, 15% (5/33) mild impairment, 61% (20/33) moderate impairment, 12% (4/33) moderately severe impairment, and 6% (2/33) severe impairment participated in the study. The number of sessions per participant ranged from 2 to 6, with an average of 3.3 (SD = 1) sessions per participant. A total of 111 VR therapy sessions took place, 98 of which were scheduled (88%) and 13 were targeted (12%). The RTs reported that targeted sessions were particularly difficult to conduct due to staffing/resource constraints. In 61% (68/111) of all sessions, no responsive behaviors were observed during, or soon after, the VR therapy, and no pro re nata (PRN) medications had to be administered during the sessions. In 46% (6/13) of targeted sessions, participants did not exhibit responsive behaviors usually triggered by a specific environmental event. The majority (63%, 70/111) of participants found the technology comfortable, and in 47% (52/111) of sessions, the RTs reported that VR therapy made the resident feel good or better than they felt before the session. In 33% (37/111) of all sessions, residents reminisced about the past and in 67% (74/111) of sessions residents reported wanting to try VR again.Conclusion: Findings indicate that VR therapy is overall acceptable and enjoyable for veterans living with dementia with varying degrees of cognitive and physical impairments. Staff at the veterans' center continued to use scheduled VR therapy as a recreational tool beyond the study period. Notwithstanding the difficulties in administering targeted sessions, there was observational evidence of the potential to reduce environmentally triggered responsive behaviors; this warrants further exploration of approaches to improve protocol feasibility in support of studying treatment effectiveness. Finally, manufacturers and providers of VR therapy should consider ways in which content, equipment, and administration can be customized and optimized for this particularly frail and diverse population.

Background: Many veterans with dementia placed in long term care exhibit responsive behaviours such as physical and verbal responsiveness (e.g., shouting, hitting, biting, grabbing). Responsive behaviours lead to negative clinical outcomes, staff burnout, contribute to absenteeism, low engagement, and an elevated risk of abuse or neglect. Virtual Reality (VR) has shown great promise in relieving stress and improving quality of life in frail older adults and has been increasingly explored as a non-pharmacological therapy for people with dementia. Ongoing studies are evaluating the clinical outcomes of VR-therapy for this population, but the challenges and learnings of the healthcare providers who administer VR-therapy remain under-reported.Objective: Capture the experiences of Recreational Therapists (RTs) who conducted study sessions and administered VR-therapy to residents with dementia as part of a clinical trial that took place at the Perley and Rideau Veterans’ Health Centre. We collected: RTs’ feedback on the process of conducting research, specifically with respect to technical, environmental and personal challenges, learnings, and recommendations.Methods: In-depth interviews were conducted with all seven RTs who administered VR-therapy and collected data for a trial that took place from January-December 2019. Interviews were audio-recorded, transcribed, anonymized, and imported into the NVivo analysis tool, where two independent researchers coded the interviews into themes.Results: RTs reported ease in learning to use the VR-technology, main challenges were unfamiliarity with, and insufficient time allocated to, conducting research. Scheduled VR-therapy sessions were physically and emotionally easier for the RTs to administer. Despite RTs hesitations to place the VR-equipment on frail individuals in distress, RTs reported positive impacts on managing responsive behaviours during these few targeted sessions, especially for participants for whom the trigger was related to physical pain rather than emotional distress. Staff have continued to offer scheduled VR-therapy sessions beyond the duration of the study.Conclusion: The experience of using VR in the veteran resident population is generally positive. Areas for improvements including better support to the RTs regarding to novel interventions and research method. Feedback received from RTs in this study provides critical information to support successful, sustainable implementation of VR-therapy, both for further evaluation and as a regular activity program. Failure to consider the experiences of these vital stakeholders when developing novel interventions contributes to the gap between efficacy in research and effectiveness in practice.

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BACKGROUND As Virtual Reality (VR) technologies become increasingly accessible and affordable, clinicians are eager to try VR-therapy as a novel means to manage Behavioural and Psychological Symptoms of Dementia (BPSD) which are exacerbated during acute-care hospitalization, with the goal of reducing the use for antipsychotics, sedatives, and physical restraints, associated with negative side-effects, increased length of stay, and caregiver burden. To date no evaluations of immersive VR-therapy have been reported for patients with dementia in acute-care hospitals. OBJECTIVE Determine the feasibility (acceptance, comfort, safety) of using immersive VR-therapy for people living with dementia (mild, moderate, and advanced) during acute-care hospitalization, and explore its potential to manage BPSD. METHODS A prospective longitudinal pilot-study was conducted at a community teaching hospital in Toronto. Ten patients over 65 years (mean = 87) diagnosed with dementia, participated in one or more sessions of viewing immersive 360° VR-footage of nature scenes displayed on Samsung Gear-VR head-mounted-display. The mixed-methods study included patient chart review, standardized observations during intervention, and pre- and post-intervention semi-structured interviews about the VR experience. RESULTS All recruited participants completed the study. Seven out of ten participants displayed enjoyment or relaxation during a VR session, which averaged 6 minutes per viewing. One participant experienced dizziness; no interference between VR equipment and hearing aids or medical devices was reported. CONCLUSIONS It is feasible to expose older adults with various degrees of dementia admitted to an acute-care hospital, to immersive VR-therapy. This pilot provides the basis for conducting the first RCT to evaluate the impact of VR-therapy on managing BPSD in acute-care hospitals. CLINICALTRIAL Research Ethics Board ID: 748-1806-Mis-321 Clinical Trials.gov registration: NCT03941119

Background Virtual Reality (VR) is increasingly considered a valuable therapy tool for managing behavioural and psychological symptoms (BPSDs) and quality of life (QoL) in dementia (Parsons, 2013). However, rigorous studies are still needed to evaluate its impact in acute care settings (Appel, 2021). This study evaluated the impact of VR‐therapy on managing BPSDs, falls, and length of stay (LoS) and QoL for inpatients with dementia admitted to an acute care hospital. Method An open longitudinal interventional randomized controlled trial was conducted between April 2019 and March 2020 (ClinicalTrials.gov, ID:NCT03941119). A total of 69 participants (age ≥65, diagnosis of dementia, did not meet exclusion criteria) (Figure 1) who were randomly assigned either followed standard of care (Control Arm, n = 35 or received VR‐therapy every 1‐3 days (Intervention Arm, n = 34) (Figure 2). VR‐therapy entailed watching 360‐degree‐VR‐films on a HMD for up to 20 minutes (Figures 3 and 4). Instances of daily BPSDs documented in EMR nursing notes were categorized based on the Neuropsychiatric Inventory (NPI). QoL measures included the Quality of Life in Late‐Stage Dementia scale (QUALID) and semi‐structured interviews conducted at scheduled visits. Structured observations (including the standardized “ObsRVR” tool) and interviews were used to measure treatment feasibility (Figure 5). Result VR‐therapy had a statistically significant effect (p = .014) in reducing aggressivity (i.e., physical aggression and loud vociferation). A sentiment analysis of patient responses to the semi‐structured interviews on QoL revealed a statistically significant impact of VR therapy (p = .013). No statistically significant impact of VR therapy was found for other BPSDs (e.g., apathy), falls, or LoS or QoL as measured by the QUALID. VR‐therapy was overall an acceptable and enjoyable experience for participants and no adverse events occurred as a result of VR‐therapy. Conclusion Immersive VR‐therapy appears to have an effect on aggressive behaviours and QoL in acute care patients with dementia. Although the RCT was stopped before reaching the intended sample size due to COVID‐19 restrictions, trends in the results are promising. We suggest conducting future trials with larger samples and, in some cases, more sensitive data collection instruments.