Administering Virtual Reality Therapy to Manage Behavioral and Psychological Symptoms in Patients With Dementia Admitted to an Acute Care Hospital: Results of a Pilot Study

Kisonas

et al. 2022

Front. Virtual Real.

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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.

Section: Frontiers Insupporting

confidence: 85%

Virtual Reality for Veteran Relaxation: Can VR Therapy Help Veterans Living With Dementia Who Exhibit Responsive Behaviors?

Kisonas

et al. 2022

Front. Virtual Real.

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“…22 We recently conducted a randomized controlled trial at an acute care hospital, evaluating the effects of VR on BPSD including the need for sitters (people who provide supervision of challenging patients), refusal of care, and use of drugs. 23,24 We found that VR-therapy had a statistically significant effect on reducing the cluster of "aggressiveness" as well as trended towards reducing length of stay.…”

Section: Emotional Changesmentioning

confidence: 79%

Virtual reality to promote wellbeing in persons with dementia: A scoping review

Journal of Rehabilitation and Assistive Technologies Engineerin

Ali

Narag

et al. 2021

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Virtual Reality (VR) technologies have increasingly been considered potentially valuable tools in dementia-related research and could serve as non-pharmacological therapy to improve quality of life (QoL) and wellbeing for persons with dementia (PwD). In this scoping review, we summarize peer-reviewed articles published up to Jan-21, 2021, on the use of VR to promote wellbeing in PwD. Eighteen manuscripts (reporting on 19 studies) met the inclusion criteria, with a majority published in the past 2 years. Two reviewers independently coded the articles regarding A) intended clinical outcomes and effectiveness of the interventions, B) study sample (characteristics of the participants), C) intervention administration (by whom, what setting), D) experimental methods (design/instruments), and E) technical properties of the VR-systems (hardware/devices and software/content). Emotional outcomes were by far the most common objectives of the interventions, reported in seventeen (89.5%) of the included articles. Outcomes addressing social engagement and personhood in PwD have not been thoroughly explored using VR. Based on the positive impact of VR, future opportunities lie in identifying special features and customization of the hardware/software to afford the most benefit to different sub-groups of the target population. Overall, this review found that VR represents a promising tool for promoting wellbeing in PwD, with positive or neutral impact reported on emotional, social, and functional aspects of wellbeing.

“…In older adult populations, VR has been explored as a means to conduct cognitive training, activities of daily living (ADL) exercises, physical rehabilitation exercises, falls prevention exercises, screen for mild cognitive impairment, as well as engage, relieve stress, and improve QoL (Snowdon, 1997;Beason-Held et al, 2013;D'Cunha et al, 2019;Liu et al, 2019;Phu et al, 2019;Clay et al, 2020;Matsangidou et al, 2020). More recently, VR has been suggested as a means to manage BPSDs in people with dementia, with some early studies showing promising results Appel et al, 2021).…”

Section: Discussionmentioning

confidence: 99%

Virtual Reality for Veteran Relaxation (VR2) – Introducing VR-Therapy for Veterans With Dementia – Challenges and Rewards of the Therapists Behind the Scenes

Kisonas

et al. 2021

Front. Virtual Real.

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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.