Ethics approval and consent to participate
The project was approved by the Institutional Review Board of A University (MC18QNSI0055). Before participation, researchers obtained written informed consent from each patient and from the patient’s legal guardian or representative. Participants were recruited by posting recruitment notices in facilities after obtaining approval from the managers of institution. Once identified, the manager who are the mental health expert spoke with patients to identify if the participants would agree to be contacted for possible study participation. Once agreed, we contacted the legal guardian or representative to recruit participants and obtain consent to participation. Informed consent was obtained from participants and their guardians. The participants were assured of the anonymity and confidentiality of all data collected. Informed consent was obtained from the participants and their guardians.
Again, there was an opportunity to ask questions and participants were informed of their right to withdraw at any stage from the study without giving a reason to overcome the short-term memory problems and variable capacity.
Phase 1: Psychological needs to relieve symptoms
This phase aimed to identify the psychological needs to relieve the symptoms of the patients by polling surveys and questionnaires. The source of the data was a large-scale research project focused on BPSD to develop an intervention program for improving quality of life. Details of the sampling process have been reported in Park et al. [42].
The following inclusion criteria were applied to select participants: having a confirmed diagnosis of dementia, aged over 60 years, experiencing behavioral and psychological symptoms, and reporting that activities provide relief. Data were collected from 325 participants, out of which 103 datasets were used in the analysis.
An open-ended question was asked of primary caregivers who had cared for at least 4 weeks for the patients with dementia participating in the study. The question addressed the activities that relieved BPSD in patients: “What activities relieve the BPSD of the patient for whom you are caring? [Additional file]” Answers were sorted and compiled into response categories and subcategories. In addition, qualitative data from the caregivers’ narratives were analyzed thematically based on the psychological needs of patients with dementia [43-45].
Based on the five psychological needs of dementia patients [43], activities were classified into the character-strengthening aspects of comfort (being free from distress and pain, experiencing reduced anxiety by receiving tenderness and friendliness, and feeling soothed), identity (having a sense of self, knowing details of life history, knowing who one is in relation to significant others, and having a sense of continuity with the past), attachment (feeling security and safety, and trust), occupation (having a purpose in life, being empowered to have an impact), and inclusion (a feeling of belonging, being encouraged to interact with the social environment physically and emotionally). Two independent reviewers (A and B) classified the relieving activities based on the psychological needs of patients with dementia. Any disagreements regarding activities were resolved through the judgment of a third reviewer.
Activities that relieve BPSD
Activities that relieved BPSD among patients were characterized and classified into five types of psychological needs. The need for “comfort” was rated highest in terms of providing relief from BPSD, with 36.9% out of a total of 103 patients making this assessment, followed by the need for “identity” (28.2 %), “inclusion” (24.3 %), “attachment” (10.7 %), and “occupation” (6.8 %). Activities related to the need for comfort included walking, eating snacks, physical contact such as hugging and holding hands, and creating a quiet environment. Activities related to the need for identity included religious activities, and visits from guardians and family. Activities related to the need for inclusion were conversation, and receiving positive support from others. Activities related to the need for attachment included checking objects (checking one’s clothes, placing a name sticker on personal closets). Activities related to the need for occupation included reading, solving puzzles, and playing Korean traditional card games (Hwatu; Table 1).
Phase 2: Development of VR intervention
The VR platform was developed considering the three elements elaborated below.
Reflecting psychological needs
The basis for the scenarios constructed was to fulfill the five psychological needs of comfort, identity, attachment, occupation, and inclusion of the patients with dementia, to strengthen the participants’ personality. The scenarios included to satisfy the comfort needs of the participants were physical touch (patting a friend on the shoulder), place of memory, forming a quiet environment, and walking. Identity need were met by visiting family and, viewing family pictures, while inclusion needs were reflected in the scenarios of conversation, being with someone, positive expression, and words/expressions of acknowledgment. The scenario of hanging out with friends and family was included to meet attachment needs, and occupation needs included scenarios such as selecting a destination that the patients wanted to visit, erasing graffiti, going grocery shopping, playing with dogs, and putting logs in the stove.
With the theme of “Train of memories,” this study implemented VR in 15 different places using four categories. The participant could choose the content via hand movements; the content was categorized into “Streets of memory,” “Nostalgic youth,” “Homely hometown,” and “Where I want to go.” In the “Train of memories,” the participant could choose their destination by handing a train ticket to the train station attendant and enjoy the scenery of the old train station. In the “Streets of memory,” the program depicted elementary schools of the past, neighborhood alleys, and old houses, and allowed the participants to experience games of slap-match in alleyways with friends, erasing graffiti on school blackboards, playing with puppies at home, and seeing family photos. “Nostalgic youth” was structured to include watching an old film at a theater, drinking tea in a traditional coffee house, and going home after shopping for groceries at a traditional market. “Homely hometown” allowed the participants to experience interactions such as playing in the waters of a valley, stroking reeds while walking in a breezy field, and placing kindling in a furnace in a rural home. In “Where I want to go,” the scenario did not include interactions, but included visual and auditory stimuli, with the major settings being those of orchards, Namiseom Island, the sea at night, observing crocks of condiments in the rain, and the Jungnogwon Bamboo Garden. There were no intellectual or functional demands in the user interaction with the virtual environment scenarios (Table 2).
Fully immersive and interactive VR
Virtual environment technology provides multimedia that may facilitate the storage and retrieval of memories. Accordingly, this intervention was structured to provide a fully immersive audio-visual experience of the different virtual environments. Sound, music, photos, and movies were added, in addition to anecdotes and verbal cues. To meet the psychological needs of the elderly with dementia, the scenario development consisted of environments, music, and sounds of nature suitable to foster the emotions of Korean persons.
The production method involved 360-degree video viewing, 360-degree camera recording, editing, and graphics production, which maximized the appearance reality and hence immersion. Interactions were implemented by attaching a leap motion to the Head Mounted Display, allowing for easy recognition of hand movements made by the participants.
The seasons and various animated objects could be manipulated through leap motion sensors (LM-010), allowing participants to interact with the scene through hand and arm movements. Particular movements triggered and moved animated objects such as train tickets, blackboard erasers, slap cards, puppies, teacups, radishes, valley water, reeds, and firewood. Participants did not need to use joysticks or keyboards.
Ease of use
Advanced, adaptable, and easy-to-use multisensory VR platform interfaces were considered that would permit implementation of strategies and procedures to facilitate patients’ interactions and navigation. The platform was built around the concept of untact, which allowed for easy solo use at home or with a little assistance, as well as overall ease of use, thereby ensuring the safety of the platform. Participants were seated next to their caregiver or a research assistant (RA) throughout the VR session; postural demands were reduced by the participants remaining in their chair during the VR exercises.
Phase 3: Feasibility test
Procedures
Participants were recruited by posting recruitment notices in residential and daycare facilities for older persons. This study selected participants based on their being a resident or daycare visitor with dementia, aged 65 years or above, with a Mini Mental Status Examination-Korean version (MMSE-K) score of 15 or higher, a Clinical Dementia Rating of 0.5 or higher, and who understood the research process and agreed to participate. Exclusion criteria consisted of motor dysfunction due to cerebral infarction, other mental disorders, neurological disorders, and metabolic disorders. A total of 10 participants were recruited.
The VR-based intervention programs were provided to the participants in the program rooms of the institutions in 1–2 sessions of 20–30 minutes each. The intervention times were customized for the participants; lunch hours, visiting hours, and napping hours were avoided.
Participants’ age, MMSE-K scores, and Activities of Daily Life (ADL) scores were obtained from medical records. The participants experienced VR-based intervention content after receiving guidance from trained researchers; two other researchers observed and posed questions to the participants, and recorded the real-time feedback from the patients through structured recording notes. The researchers asked the participants to respond to questions relating to immersion, preferences, and degree of interaction in their VR experiences on a 5-point Likert scale. Furthermore, the researchers recorded need for assistance, duration of VR experience, positive or negative experiences, and VR sickness to identify the participants’ tolerance for VR [Additional file].
Based on the need-driven, dementia-compromised behavior model [46], complaining, agitation, wandering, hitting, grabbing, pushing, throwing objects, biting, hurting self or others, tearing objects or destroying property, and making physical/verbal sexual advances were recorded as negative behavior. Remaining seated and still, being focused, sleeping better than usual during nighttime, being calm, smiling, and communicating verbally or non-verbally were recorded as positive behavior.