Virtual Reality: a Potential Cognitive and Physical Training in Aging

“VR is a way to escape the real world into something more fantastic. It has the potential to be the most social technology of all time” (Palmer Luckey)

Who else thought that cutting-edge technologies were just for younger users?

However, looking at the statistics, the World Health Organization (WHO) estimates that the global population is increasing, transforming our environment into a super-aged society by 2030 [1]. Based on the U.S. Department of Health and Human Services the number of people older than 65 in the USA grew by 37.2 million from 2006 to 2016, and worldwide the number of individuals (60+ years old) will double from 600 million in 2020 to 1.2 billion by 2025 and 2 billion by 2050 [2].

Although mortality rates decreased due to higher well-being and socio-economic status, aging is accompanied by physical inactivity and limitations in mobility, cognitive decline, reduced functional capabilities, loss of autonomy and self-care, a tendency towards social isolation, and emotional fluctuations  [3, 4, 5, 6].  This fact has been complicated by a scarcity of healthcare professionals, particularly home health workers, with the consequence of confining older adults in facilities that are not designed to encounter and support their special needs. This event led to a crisis in the entire healthcare system in its role of embracing care for the aging population globally [2].

Therefore, how can technology be adopted to improve the life of senior citizens? Virtual Reality (VR) is an example. Indeed, VR gained attention and was recently implemented in the medical domain to enhance mental and physical health. Likewise, it generates a safe environment when performing daily living activities, besides promoting social interaction and integration. In other words, VR looks like a portable and user-friendly device with the comfort of using it at home!

Nevertheless, we mostly approach VR through video games and work-related 3D project visualizations. Young generations already accept and welcome the use of VR at home, at school, or in recreational activities. But what about older generations? What is their attitude toward VR technologies? Are these technologies ready to leave the Labs and be prescribed for home-based training and therapeutic interventions?

Besides its use as a virtual “answering machine” or “boots” to virtually explore spaces, I will provide evidence that VR can also be implemented as digital health technology to promote physical and mental well-being in seniors.

Virtual reality as health-enhancing technology

Recent research published in BMC Geriatrics (2019) [7] evaluated the effectiveness of VR in supporting physical functionality, and social and emotional well-being in elders, besides the acceptance and the use of this technology by the older population. The pilot study involved the participation of 30 older adults aged 60-95 years in which nine different VR applications were selected. Participants were encouraged to select any of these applications and practice them for 15 minutes twice a week for a total of six weeks. Afterward, participants completed a questionnaire based on the Technology Acceptance Model and previous study results, aimed at evaluating their rate of acceptance while being engaged in the conducted VR training. Results demonstrated the engagement of participants in the adoption of VR technology. Indeed, factors such as usefulness, easiness, social norms, or enjoyment were considered significant and contributing elements in the use and acceptance of VR as a joyful and health-enhancing technology.

More recently, a study of 2022 from McLean Hospital (Belmont) and Harvard Medical School (Boston), MA, USA [8], conducted a systematic review to evaluate and verify objective evidence of VR implementations in clinical settings to identify promising key aspects when translating VR applications into feasible interventions targeting the geriatric population. From a database of 1554 studies and according to specific study information (e.g., sample size, study population, the goal of the research, reliability of results, VR application), only 55 were selected and included in the review analysis. Results showed that among the reviewed research studies, elders with cognitive impairments were the most relevant and target population under investigation. Besides, VR applications did involve mainly testing, training, and screening procedures across different VR environments. Therefore, VR tasks were considered effective applications in evaluating cognitive functions, comparable to the well-established paper-and-pencil cognitive assessments. Moreover, a few limitations were also highlighted. In response to the variety of VR environments when implementing simulations, standard settings should be defined to enhance the reliability and reproducibility of outcomes. In addition, factors such as usability, data privacy, and confidentiality should also be considered, as well as, the democratization and investigation of VR technology also in lower-income countries [8].

Simply wearing immersive headsets generates the assumption and the possibility of identifying novel approaches to improve various health-related physical, psychological, and social aspects. Several VR app studies targeting elders were mostly proposed as alternative approaches with rehabilitation purposes to improve gait, balance, fall prevention, pain management, and also cognitive functioning. Despite the abundance of research, most of it is mainly focused on rehabilitation purposes or other institutional settings, and less is known regarding how immersive VR headsets may enhance health (physical, mental, and psychosocial) in community-dwelling older adults [8]. Based on Joanna Briggs Institute (JBI) methodology, a systematic review published in the Journal of Medical Internet Research (2020) [9] explored this hypothesis by investigating seven peer-reviewed publications that included community-dwelling elders of ≥60 years old residing in care facilities and nursing homes.

Overall, VR apps based on immersive headsets did show to improve several health parameters from pain management, cognitive capabilities (particularly concerning Alzheimer’s diseases), and reduced risk of falls. Among the reviewed studies, six of them demonstrated a significant difference between pre- and post- VR intervention. One study reported improved navigation skills with reduced navigation errors. However, only one study confirmed that VR can be accepted and implemented as an alternative intervention to already existing practices. Besides, none of these research studies did implement a gamification function in their VR applications, potentially affecting engagement and enjoyment. Hence, despite the potential of VR effectiveness in improving health, more data is needed to reinforce the outcome of these findings, besides a closer investigation of other factors such as frailty, usability, and acceptability that might influence the adoption of VR interventions in elders [9].

A protector against social isolation

The positive effect that immersive technology has on seniors is also reflected in social interactions while coping with feelings of loneliness. A project by Kenta Toshima, a researcher in Tokyo, focuses on implementing VR to support nursing home patients across Japan while experiencing and traveling to sites from their memories or places they would have wished to visit but could not go to. To realize this ambitious project, an 8K 360-degree camera was used to capture made-to-order VR experiences by creating wonderful views of different locations that patients would have explored by wearing the VR headset. “By supplementing their physical handicap with technology, the VR travel experiences can help improve the elderly’s motivation for rehabilitation and improve their quality of life. The VR experience makes them feel like they are out of the nursing home and can help ease their anxiety and loneliness,” says Kenta Toshima. Moreover, in contrast to usual applications, the programs were conducted in a nursing home in which multiple patients were immersed in a VR setting while experiencing and sharing the benefits of this technology. Thus, against social isolation and feelings of loneliness, a sense of community and familiarity was created around it.

An effective alternative for training cognitive functions

Mainly focused on enhancing physical health, fewer studies applied immersive VR to improve cognitive functions as an alternative and affordable training approach for seniors. Besides a lack of digital literacy that might appear an obstacle when approaching disruptive technologies, potential opportunities and limitations were discussed in a comprehensive literature review in which immersive VR was examined to improve cognitive skills in elders. Indeed, the development of innovative interventions to slow the progression of age-related cognitive decline would empower agers with autonomy and relieve caregivers’ workload [10]. Compared to traditional computer-based technologies, VR is an immersive and interactive human-computer interface with real-time simulation characterized by a variety of features that make its use unique and engaging. But which are its advantages and core potentials?

Highly flexible training environment

VR creates training settings that are either impossible in real life or too dangerous while guaranteeing safety. It supports the practice of a task’s component before testing the task in its whole complexity. An example relates to hemiparetic stroke patients who can be trained on isolated aspects of walking while overcoming physical limitations and improving motor skills. VR creates a safe training environment. Blind participants and wheelchair users can practice their visuospatial orientation and how to interact with the space around them. Seniors and stroke patients can practice activities of daily living (ADLs) such as cooking, going to a market store, or simply walking around in the street.

Furthermore, in terms of flexibility, training settings can be adjusted based on the user’s needs and capabilities (e.g., number and type of stimuli presented, the feature of stimuli, speed, and order of stimuli presentation). Providing real-time feedback on performance may also reinforce the adaptability of the subject to the device while adjusting the setting accordingly to the subject’s skills and progressions. To promote mental and physical fitness, the possibility to personalize the training setting and tasks has the advantage of embracing any user’s need, particularly when targeting patients (e.g., stroke and neurodegenerative disorders), and progressively supporting training outcomes through exercise and training adjustments.

Decreased dependence on care professionals

In contrast to common rehabilitation programs that are typically time-consuming and demanding, both for patients and caregivers, they are also costly and require visiting a healthcare professional due to the dependence of patients on their training plan and execution. Thus, the randomized controlled study by Yang et al. (2008) [11], demonstrated that VR can effectively be implemented as a rehabilitation program for elders, as a feasible and advantageous alternative. Moreover, whether training remote would empower seniors' autonomy, established guidelines and implementation for remote guidance are still lacking and this aspect may be even more affected by digital illiteracy among elders. Besides, the replacement of human supervision with a virtual coach has also been considered a valuable alternative to reduce the workload of care professionals, although more studies are needed to evaluate this hypothesis [12, 13].

Acquisition and storage of big data

Through VR, a variety of data is acquired in real-time with a high temporal resolution, and also in combination with other neuroimaging techniques (e.g., fMRI), a deeper investigation of VR effects at the single-subject level can be drawn [14]. Kinematic data on motion execution can be tracked and compared with the ideal movement. Through visual feedback, users can supervise their performance and improve their movement to match and achieve the desired outcome (“motion matching”) [15]. Besides the evaluation of physical parameters, VR can track cognitive functions such as working memory and sensorimotor integration. Thus, a few studies have implemented VR to validate psychometric data. However, more data are needed to confirm the reliability of this approach, comparable with well-established neuropsychological assessments evaluating cognitive functions [16].

Cybersickness due to immersiveness

Despite the non-invasiveness of VR, immersive headsets may generate cybersickness, characterized by oculomotor symptoms, disorientation, and nausea. Although cybersickness might affect elders more frequently than youngsters, as reported by previous studies, the incidence of this occurrence is low and can be reduced by higher synchronization and integration of senses [17, 18,19].

Immersiveness empowers training results

Immersive VR based on a 3D compared to a 2D display did show positive training outcomes in young adults on a series of tasks. Particularly, a CAVE-like station compared to a desktop setup would benefit spatial knowledge and according to the level of immersion [20]. Similarly, cognitive functions were positively improved in a chess game in which an immersive HMD setup was compared to a desktop setup [21]. Nevertheless, some studies prove the contrary showing how non-immersive settings may enhance training outcomes in contrast to immersive setups.

Furthermore, several factors were found to positively influence training results such as the emotional salience of the task, the involvement of different senses, and those aspects related to reward (e.g., flow, motivation, and enjoyment) [10]. Indeed, compared to traditional setups, VR evokes emotional salience and a peculiar expression of emotions. This may have an impact on how materials are processed and learned in the VR environment [22]. Therefore, the emotional salience of learned material would be relevant when involving individuals with cognitive complaints in which emotional learning seems not to be affected by the progression and the level of the cognitive impairment [23]. Moreover, multisensory learning through the integration of multi senses (e.g., auditory and visual inputs) has a stronger effect than unisensory learning [24], particularly when a motor component is integrated into the process. This would even enhance reaction times [25], meaning better performance. Lastly, immersiveness has a rewarding effect of increasing the sense of flow, motivation, and presence. This would translate into training adherence and learning outcomes, besides generating engagement and a positive attitude toward VR applications, especially in elders [26, 27].

So, if immersiveness is an essential aspect to consider when implementing VR technologies, which factors would support immersion?

Immersion is strictly related to the technology used as the interface between the device and the user. Thus, a good field of view, high quality in the display resolution, realism of lightning, frame rate, and refresh rate are parameters that should be tuned and optimized to guarantee a proper VR setting and a maximum sense of immersion. Indeed, more realistic VR setups demonstrated to better support the execution of real-life movements, higher sense of presence, and physiological responses (e.g., galvanic skin response, heart rate), as well as, the evocation of behavioral responses transferable to real-life situations [28, 29]. In addition, VR offers the possibility to reply and freeze the simulation to improve and reinforce learning on a variety of functions (e.g., focused attention, dual-task, spatial searching, interference control, task-switching) [30].

Promises and limits

Despite the availability of research investigating the effect of technologies on supporting instrumental activities of daily living (IADLs) in older adults, fewer studies focused on evaluating this effect on enhanced activities of daily living (EADLs). EADLs are activities to promote physical, and emotional health and well-being while reducing stress. Therefore, understanding how advanced technologies, such as VR, may support these activities among elders would shed light on its potential for improving motor and cognitive functioning.

A recent study published in Frontiers in Virtual Reality (2021) [31] explored and compared how older and younger adults experience VR environments concerning the sense of presence, workload effects, and cybersickness. In the experiment, older adults were engaged in different environments that represented a variety of EADL activities (e.g., household leisure and outdoor activities, meditation for well-being, and videogames), from passive viewing experiences to more active games. Independently of the VR setting and despite less proficiency with technological management, older adults reported a great sense of presence that was not associated with higher levels of cybersickness or workload when compared to younger adults. Accordingly, due to easiness of use, and the minimal effect of cybersickness (e.g. compared to driving simulator scenarios) characterized by a minimal mismatch between visual and vestibular information, the study highlighted a positive attitude toward VR adoption by older adults and the usefulness of this technology. Nevertheless, although this study provides initial data on age-related differences while experiencing VR technology and potential obstacles toward its adoption, the effect of novelty might have influenced and biased the greater sense of presence in elders who experienced the VR environment as unique. Besides, the long-term effects of VR applications should also be investigated to gain better insight into the feasibility of this technology as a potential tool to enhance EADL activities [31].

While augmented reality (AR) represents new ways to interact with the environment, VR allows users to experiment and interact with new environments. Hence, VR and AR hold the promise that through a gaming environment and digital social interactions, a healthy lifestyle can be promoted to enhance health, and well-being, besides rehabilitation purposes [32]. However, a digital divide frequently observed between younger and older generations might prevent older individuals from approaching digital technologies and benefiting from them. Despite the democratization of digital devices (e.gsmartphone) and access to the internet, older adults invest less time in using technologies compared to younger adults, and this fact might even affect socialization, particularly during the Covid-19 pandemic in which a lower level of digital literacy prevented elders to connect with friends and relatives, consequently affecting their psychosocial well-being [33,34]. A recent survey conducted in Switzerland and 16 European Union countries showed that only 53% of individuals 50+ years old used the internet and that this event was influenced by several demographic, socio-economic factors, health, and level of experience in using technologies [35]. In addition, this age-related discrepancy might be even more affected by the progressive vulnerability of older adults that would affect learning while approaching new technologies [36].

Digital divide: how to overcome it?

Awareness of which factors led to the digital divide between young and old adults is the key when implementing AR/VR in everyday life to support the performance of even simple tasks.

Covid-19 already anticipated the importance of integrating digital technologies to socially connect, gaming activities and virtual workouts, but also to visit doctors remotely [33,37]. Therefore, VR and AR have a great potential in supporting our daily life, particularly when targeting the aging population [32]. Indeed, the integration of these technologies would empower users with better navigation skills while enhancing orientation and transferability in real-world environments. This is particularly relevant in the context of early dementia and mild cognitive impairments in which the capability of navigating in unfamiliar environments declines progressively. Furthermore, immersion in VR or AR has the effect of modifying learning speed patterns while enhancing intergenerational educational experiences in late-life learning. The inclusion of gamification features is also a plus when learning through VR-based lessons [38] Besides providing entertainment, engagement, and joyful experiences. Fitness and cognitive programs can also be fostered through AR/VR to improve health by establishing psychotherapy and rehabilitation type of interventions supporting memory, balance, and motor skills [32, 33]. Lastly, social interaction through AR/VR may mitigate age-related mobility limitations that typically prevent older adults from socially connecting and participating in recreational activities (can it be the effect of being Baby Boomers?)[33].  

Tips from the gerontology

Investing in gerontology becomes necessary when VR/AR research involves the aging population. This would overcome those limits brought by current approaches such as classical methods that do not incorporate digital technologies when investigating everyday activities, generalization in technological usage (without considering the specific user’ need and skills) and VR/AR settings, and lack of personalized training programs (that do not account for the single individual cognitive and motor abilities), and cybersickness [33]. Overall, more time and resources should be redirected toward educating future care professionals in implementing such technologies in their healthcare facilities while educating older generations to integrate digital technologies into their daily life.
To know more about gerontology recommendations for further developments, read here.

Going mainstream: therapy vs gaming

In response to the global crisis associated with the incapability to provide adequate care for the aging population, the European Innovation Partnership on Active and Healthy Aging was initially proposed in 2011 by the European Commission to promote active and healthy aging while embracing the rapid process of digital transformation through innovation [2, 39].

A potential way to cope with the increasing aging population and limited support by health professionals would be through the progressive use of digital technologies, allowing elders to access medical services from remote. Surprisingly and in contrast to the stereotype that seniors struggle with new technologies, recent surveys prove the contrary. Indeed, a June 2019 Pew Research Center survey showed that individuals 60+ years old spend daily a long time in front of screens and this fact matches with a significant increase in the use of digital technologies by older Americans. In 2000 only 14% of elders were found to use the Internet. But nowadays, 73% of elders declare to use smartphones and other devices [2]. In addition, a recent American Association of Retired Persons survey predicts that in about 10 years, more than $84 billion per year will be spent on technology by individuals over 50 years old..

Nevertheless, technologies already implemented in healthcare are still based on 20th-century models and thus unable to support and meet the needs of the growing aging population. Therefore, to generate healthcare innovation while fostering a proactive and participatory approach toward health by engaging the patients in their health journey, closer attention to advanced technologies must be considered. The 21st century suggests digital and telehealth as innovative approaches to care delivery and care access. As mentioned previously, it is interesting to see how VR/AR are potential candidates to promote physical health and psychological well-being in elders [2].

What does the market say?

Industry experts predict that today’s $6.1 billion VR market will be worth $21 billion by 2025 if individuals 65+ years old would start embracing technologies. VR companies such as MyndVR, Viarama, and Rendever are confident enough that this is going to happen.

Covid-19 and the global pandemic, forcing many seniors to isolate themselves at home, had a dramatic effect on their health and thus affected their psychosocial well-being. This lead to a cause of cognitive decline and other age-related healthcare issues.

Can VR cope with these problems? “Any activity that promotes curiosity, critical thinking, and meaningful social engagement is good for the brain’s health and fitness. Virtual reality’s ability to give users a sense of presence by stimulating the visual, auditory, and vestibular systems allows them to experience new and remembered—or forgotten—experiences like never before,” “Whether or not VR takes root in the mainstream remains to be seen, but recent advances in therapeutic and clinical use cases are certainly here to stay” says Aaron Tate, director of emerging technology at the University of Texas at Dallas’s Center for BrainHealth. Coming into a time in which VR starts to be incorporated into digital health, MyndVR has already hundreds of clients across the USA, Canada, and Australia. Clients are mostly seniors who live in communities and pay around $600/year to rent headsets while engaging in VR programs, with the end goal to offer a possibility for caregivers and health professionals to remotely support seniors in their VR experiences.

Besides cognitive training and rehabilitation, reminiscence therapy aims to enhance the sense of touch, smell, sight, sound, and taste to help patients affected by dementia recall memories, people, and familiar places. Therefore, VR could be implemented with this scope in mind, although scientific evidence that VR can be a treatment for memory loss is still lacking. However, recent studies from Australia and Taiwan, explored the effect of reminiscence therapy in seniors while showing the potential of VR in ameliorating psychological health. “It may not slow down cognitive decline, but you could imagine its impact on patients’ quality of life and their families' quality of life,” said Nicole Fowler, associate director of the Indiana University Center for Aging Research. Furthermore, if apathy, depression, and dementia can be treated, Fowler continued “I think that’s where the potential is.”

Among innovative solutions, Senopi, a startup from Switzerland, was born with the mission to improve the physical and cognitive health of seniors. Hence, VR headsets and designed 360-degree videos from natural environments are implemented to activate or calm users while engaging in joyful experiences. Besides, Senopi platform would allow caregivers (or any health professionals) to prepare and control VR activities simply by using a tablet. Lastly, in the context of digital health and by collaborating with clinicians and researchers, Senopi is actively developing and testing VR therapies to promote digital therapeutics while ensuring the best VR product for seniors across the world.

The incredible thing about the technology is that you feel like you’re actually present in another place with other people. People who try it say it’s different from anything they’ve ever experienced in their lives.” (Mark Zuckerberg)

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