Virtual reality to manage anxiety in older adults: the FBK study highlights promising results

23 Povo’s “Margherita Grazioli” nursing home residents involved.

Exposure of people with cognitive and physical impairment to realistic and natural immersive virtual reality scenarios via a viewer is safe and has an impact on promoting the state of relaxation and positive emotions. This
is the general picture that emerged from the survey conducted by researcher Susanna Pardini, from the University of Padua and a doctoral student at the Digital Health and Wellbeing Center at Fondazione Bruno Kessler, titled “Use of Personalized Virtual Environments in People with Cognitive Impairment.” The study, conducted between January and February of this year, involved 23 seniors (of whom 19 women), with an average age of 86.6 years, residing in the “Margherita Grazioli” nursing home at Povo – Trento.

“Our seniors are a precious resource that should not be neglected and we must take more and more care of them. The Covid pandemic period has taught us that technology helps us do this, and it can be supportive of families and our healthcare professionals. These research initiatives need to be supported and accompanied with confidence so that our province becomes, thanks also to TrentinoSalute4.0, a laboratory for experimenting with innovative solutions that allow us to anticipate the challenges of aging that we will have to face in the coming years.”This is the comment by the provincial councilor for health, social policies, disability and family, Stefania Segnana.

“We wanted to investigate,” Pardini explained, “whether making older people try virtual reality could cause adverse effects associated with the use of the viewer. But not only that: we wanted to see if this experimental procedure could merit further, more rigorous investigations, in terms of assessing clinical and statistical efficacy. ”

Experts say that being in nature contexts increases the perception of positive emotions and has an influence on reducing fear, anxiety, anger and sadness. But residents in nursing homes often do not have the opportunity to live recreational and pleasant experiences in the open air. Old age, with its physical and cognitive impairment resulting in a reduction in motor skills, and the fear of falling or getting hurt moving in the environment, prevents seniors from being transported outside the health facilities where they are cared for and protected.

There is a way, however – and this was the object of the study just concluded at the Povo nursing home – to give these people the chance to immerse themselves in a “natural” environment, without having to go out. It is virtual reality which, according to scholars, thanks to the immersive power that characterizes it, seems to have a positive and relaxing effect.

To find out whether the virtual solution was a good idea for anxiety management and what the degree of involvement of the seniors was during the exposure, researchers at FBK laboratories developed, using PCs with powerful graphics cards and a dedicated software platform, relaxing and customizable 3D virtual environments embellished with sounds and graphic details.Elderly people, carefully selected by operators, were able to choose how and where to live their 3D experience: in a mountain, country, or seaside setting; customize the colors of river water or a lake; whether to see the sunset, sunrise, add clouds, rain, snow, or meadow with animals, flowers, plants, and trees to the landscape; observe streams, or waterfalls; or whether to listen to a classical melody or pop music and add the sound of rain, wind, birdsong.

“Our study,” Pardini said , “has given satisfactory results, and confirms what has been highlighted by previous research. The experience with VR was generally well tolerated by participants, who did not experience or report moderate or severe side effects related to wearing the headset (such as nausea, dizziness, or confusion) related to wearing the headset. In addition, participants expressed verbally, or manifested with non-verbal behavior, a general state of interest, awareness, engagement, and enjoyment during the virtual exposure, showing that they appreciated the experience. ”

What emerged from the feedback provided by participants was that exposure to a realistic, natural and, above all, personalized virtual environment tailored to the users’ preferences and needs elicited reactions such as reminiscence of melancholy memories, aesthetic appreciation of what they were seeing, and a sense of safety and security in an appreciated context. “It was interesting to note” Pardini said , “that participants also experienced feelings of self-realization and a desire to ‘be useful’ by providing opinions and suggestions to experimenters on how to improve virtual scenarios. In summary, we found that the relaxation state of seniors increased, and anxiety and worry decreased after the use of virtual reality. These results support the hypothesis that  VR can serve as a useful experience to manage or reduce the state of stress and represent a promising way to reduce isolation and increase involvement in recreational activities and useful for well-being aimed at different types of population.

“This type of intervention – said Oscar Mayora, head of FBK‘s Digital Health Research Unit (dHRes), within which the study was carried out – “could become a digital therapy in the future.At FBK, we are exploring the potential of virtual reality in healthcare, and also in other contexts, to support various conditions, such as pain therapies, autism, where we have already started some specific projects. ”

“It has been an exciting experience that has involved us a lot both as a company, but also on the family front and the operators of the structure. We took this opportunity with great favor because it allowed us to participate in such an important innovative research process. We thank FBK and TS4.0 for trusting our organization and supporting us on this strategic program. We hope to continue the collaboration in the next feasibility studies and to be able to involve a larger number of people in more familiar VR contexts ” – said Patty Rigatti, director of “Margherita Grazioli”.

The article reporting the full results of this study was recently submitted to Nature journal’s Scientific Report and, pending feedback, the research group is structuring investigation protocols to further explore the use of virtual reality with people with cognitive impairment.

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The seniors who took part in the experiment, carefully selected with the involvement of family members and the Povo nursing home staff based on strict criteria, were equipped with a 3D viewer that allowed them to make an interactive (audio and video) experience, under the watchful eye of the assistants and researchers who supervised the trial.

Results

On average, participants spent 9.91 minutes exposed to the VR scenario (SD = 4.78; minimum = 1 minute; maximum = 17 minutes). None of the users reported experiencing a general condition of discomfort, drowsiness, headache, sweating, claustrophobia or disorientation and nausea during the experience. 13.1% of participants experienced mild tiredness, 4.3% boredom, 43.5% reported feeling mild eye discomfort, and 13% reported having mild difficulty concentrating. Ten participants reported a state of mild discomfort related to wearing Oculus, but not to such a degree that they decided to discontinue the experience.

The virtual environments in which participants were “immersed” were developed by FBK researchers who, to meet their preferences, created three contexts (marine, mountain and country) embellishing them with sound details, such as the sounds of birds, rain, wind, and graphic details, such as sunset, sunrise, the presence of animals, flowers, plants, trees, watercourses, waterfalls.The virtual environments have been designed to be customizable by the user and build a pleasant and relaxing scenario that facilitates the state of relaxation.

The research project entitled  “Use of virtual personalized environments for the management of anxiety in patients with cognitive impairment: proof-of-concept and feasibility investigation” stemmed from the collaboration between the Digital Health & Well-being Center (DHWB) at Fondazione Bruno Kessler (Trento), directed by Stefano Forti, the “Margherita Grazioli” public nursing home (Povo, Trento), directed by Patty Rigatti, and the Department of General Psychology of the University of Padua (Caterina Novara – associate professor, and Susanna Pardini – psychotherapist and doctoral student of the Brain, Mind & Computer Science course).
Silvia Gabrielli (researcher – Fondazione Bruno Kessler), Marco Dianti (technologist and developer of virtual contexts – Fondazione Bruno Kessler), Lorenzo Gios (project manager – TrentinoSalute4.0), Oscar Mayora-Ibarra (head of the Digital Health Research unit – dHRes- at Fondazione Bruno Kessler), Emanuela Trentini, Lucia Leonardelli and Michela Bernardi (APSP “Margherita Grazioli”, Povo) also took part in the design and implementation phase of the study.

Study purpose The study was designed following up on the usefulness, highlighted by scientific studies, of the activation of psychosocial interventions, aimed at the rehabilitation of cognitive skills with the use of new technologies.
In particular, Virtual Reality (VR) is a technology that allows the introduction of new activities in institutions and residences for elderly people with or without impairment of cognitive functioning, also with the aim of improving a number of useful skills in daily life.

Participants 
23 users were recruited by the “Margherita Grazioli” public nursing home.
Regarding the level of cognitive impairment, based on the Mini-Mental State Examination (MMSE) tool, 11 people (47.8%) had “mild” cognitive impairment, 9 people (39.2%) “moderate”, and 3 (13%) “severe”.
Twenty participants (87%) were able to move their heads without difficulty, five (34.8%) were able to move independently in the environment but under the supervision of an operator. Eleven participants were in wheelchairs during the virtual reality experience (47.8%), and twelve (52.2%) used the virtual experience chair that had been prepared.

Table 2. Socio-demographic characteristics of the sample.

One of the tolerability indicators was the frequency of time spent in the context of virtual reality.ResultsOn average, participants spent 9.91 minutes exposed to the VR scenario (SD = 4.78; minimum = 1 minute; maximum = 17 minutes). None of the users reported experiencing a general condition of discomfort, drowsiness, headache, sweating, claustrophobia or disorientation and nausea during the experience. 13.1% of participants experienced mild tiredness, 4.3% boredom, 43.5% reported feeling mild eye discomfort, and 13% reported having mild difficulty concentrating. Ten participants reported a state of mild discomfort related to wearing Oculus, but not to such a degree that they decided to discontinue the experience. One participant completed only the T0 assessment but decided not to try VR because he was concerned about wearing the HMD.
From what was verbally reported by the participants, seven main topics were extrapolated: (1) reminiscence of past events (47.8%); (2) aesthetic appreciation of the elements observed in the virtual context (34.7%); (3) realism and similarity of the virtual elements with elements of reality (26.1%); (4) perception of security and protection associated with being within the virtual context (17.4%); (5) suggestions provided to improve the virtual scenarios (8.4%); (6) lack of interest (8.4%); (7) appreciation regarding the experience in the virtual context (4.3%).

• Intervista a Susanna Pardini
• Intervista a Oscar Mayora
• Intervista a Patty Rigatti