Kim et al.

BMC Geriatrics (2021) 21:167

https://doi.org/10.1186/s12877-021-02125-w

RESEARCH ARTICLE Open Access

Developing a virtual reality for people with

dementia in nursing homes based on their
psychological needs: a feasibility study
Jung-Hee Kim*, Seonmin Park and Hyeongji Lim

Abstract
Background: The purpose of this study was (1) to develop a virtual reality (VR) intervention program based on the
psychological needs of patients residing in nursing facilities in South Korea to alleviate their behavioral and
psychological symptoms and (2) to confirm the possibility of utilizing VR in patients with dementia.
Methods: In the first phase, patients with dementia residing in nursing homes and experiencing behavioral and
psychological symptoms were recruited. Surveys and questionnaires were used to identify activities that alleviated
the behavioral and psychological symptoms of dementia (BPSD) among the patients. These activities were classified
into five types of psychological needs. In the second phase, a fully immersive, interactive, easy-to-use VR platform
was developed that reflected these psychological needs. Patients with dementia experienced the VR content. The
researchers assessed the level of the participants’ immersion, preference, and interaction with the VR using a 5-
point Likert scale.
Results: In the feasibility test, 10 nursing home residents were recruited. The mean immersion score was 4.93 ± 0.16
points, the mean preference score was 4.35 ± 0.41 points, and the mean interaction score was 3.84 ± 0.43 points
using a 5-point Likert scale. Higher mean scores indicated a more positive outcome. Six of the 10 participants
required assistance while using the VR. The mean VR experience duration was 10.00 ± 3.46 min.
Conclusions: The VR-based intervention program that was developed to reduce BPSD was feasible for the
participants and provided them with a high degree of satisfaction and immersion. Furthermore, this study also
confirmed the convenience and safety of the program. These findings support the potential use of VR-based BPSD
intervention programs to treat patients with dementia.
Keywords: Dementia, Virtual reality, Virtual reality intervention, Cognitive dysfunction

Background of 2018, was 10.1%, and the number has continued to in-
The number of people with dementia is rapidly increas- crease [2].
ing due to the aging of the global population. According Patients with dementia experience cognitive dysfunc-
to Alzheimer’s Disease International, in 2018, there were tion and various behavioral and psychological symptoms,
50 million individuals with dementia globally, which rep- such as nervousness, depression, psychosis, yelling, and
resents a 6% increase from 2015 [1]. In South Korea, the violence [3, 4]. Due to their loss of social and communi-
prevalence of dementia in persons 65 years and older, as cation skills and limitations in their ability to undertake
physical activity, patients with dementia experience is-
* Correspondence: [email protected]
sues in their relationships with others. This can exacer-
College of Nursing, The Catholic University of Korea, 222 Banpo-daero bate negative emotions and behavioral and psychological
Seocho-gu, Seoul 06591, Korea

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Kim et al. BMC Geriatrics (2021) 21:167 Page 2 of 10

issues in older patients with dementia [5, 6]. The behav- obtained written informed consent from each patient
ioral and psychological symptoms of dementia (BPSD) and the patient’s legal guardian or representative. The
are one of the most significant reasons why those with participants were recruited by recruitment notices
dementia receive early admission into nursing facilities posted in facilities after obtaining approval from the in-
[7]. The early institutionalization into a nursing home stitution’s managers. Once identified, the mental health
leads to higher social costs and a lower quality of life for expert manager spoke with the patients to see whether
patients with dementia and their families [8]. they would agree to be contacted for participation in the
Interventions that decrease BPSD include non- study. Once agreed, we contacted the participants’ legal
pharmacological interventions that focus primarily on guardians or representatives to recruit the participants
reducing and removing the psychosocial or environmen- and obtain consent to participate. The participants were
tal risk factors associated with behavioral and psycho- assured of the anonymity and confidentiality of all data
logical symptoms [9] and therapeutic approaches, such collected and given an opportunity to ask questions. To
as recall therapy, horticultural therapy, music therapy, overcome the short-term memory problems and variable
art therapy, animal-assisted therapy, and physical exer- capacity, the participants were informed of their right to
cise [10–12]. However, it is difficult to apply existing withdraw at any stage from the study without giving a
non-pharmacological interventions to patients with de- reason.
mentia and decreased cognitive function. The applica-
tion of these interventions is restricted due to a lack of Phase 1: psychological needs to alleviate symptoms
trained professionals [13]. To overcome these restric- This phase identified the psychological needs that allevi-
tions, multisensory virtual reality (VR) platforms may be ate the symptoms of the patients using polling surveys
used to improve cognitive function and rehabilitation in and questionnaires. The data source was a large-scale re-
patients with dementia, as VR platforms are advanced, search project focused on BPSD to develop an interven-
adaptable, and easy-to-use [14–18]. VR refers to tech- tion program for improving quality of life. In this study,
nologies that allow people to experience realistic situa- the convenience sampling method was used, and details
tions or environments that are difficult to experience in of the sampling process have been previously reported
reality [19, 20]. In particular, immersive VR can be used in Park et al. [29]. Patients with dementia were recruited
to focus on certain sensory stimuli and has been re- from six nursing homes located in two cities. Partici-
ported to facilitate positive emotions and improvements pants’ preferred environment for intervention develop-
in their emotional state, interpersonal interactions, and ment was investigated. Their quality of life and
communication [21–23]. symptoms of psychological impairment were measured
The motivation to use VR may differ between individ- to verify the effect of the intervention program. In this
uals based on individual interests and preferences, aside study, the data selection process was as follows. Among
from maladjustment to VR [13]. The psychological needs the recruited 325 participants, participants who reported
of people with dementia include comfort, identity, at- behavioral and psychological symptoms were selected.
tachment, occupation, and inclusion [24]. While studies Of these participants, only those who answered the
on patient-centered dementia care have considered these questions addressing the activities that alleviated their
needs [25–28], very few studies have developed activities BPSD were included. Based on this, 103 participants
or interventions for dementia patients that consider their were included in the study, and 222 participants were
psychological needs. excluded from the study.
This study involved three phases. The objective of the A survey question addressed the activities that allevi-
first phase was to confirm the activities that alleviate ated BPSD in patients: “When you feel agitation, aggres-
BPSD and classify these activities based on the patients’ sion, psychosis, depression, and apathy, what activities
psychological needs. The objective of the second phase make you feel better or alleviate your BPSD?” If the par-
was to develop VR platform environments based on the ticipant could not answer the question, the question was
patients’ psychological needs and test whether it allevi- completed by asking the care staff who had been caring
ates BPSD. The objective of the final phase was to evalu- for the participant for at least 4 weeks (Additional file 1).
ate the participants’ VR immersion, preferences and The care staff responded with their observations on be-
interactions with VR, and tolerance for VR. half of the patients. The answers were sorted and com-
piled into response categories and subcategories.
Methods Additionally, qualitative data from the participants’ nar-
Ethics approval and consent to participate ratives were analyzed thematically based on the psycho-
The project was approved by the Institutional Review logical needs of patients with dementia [30–32].
Board of the Catholic University of Korea Based on the five psychological needs of dementia pa-
(MC18QNSI0055). Before participation, the researchers tients [30], the activities were classified into the
Kim et al. BMC Geriatrics (2021) 21:167 Page 3 of 10

character-strengthening aspects of comfort (being free 1. The VR project was then implemented through col-
from distress and pain, experiencing reduced anxiety by laboration with an external company that had the re-
receiving tenderness and friendliness, and feeling sources, experience, and time to meet the study
soothed), identity (having a sense of self, knowing details requirements.
of their life history, knowing who one is in relation to sig-
nificant others, and having a sense of continuity with the Design of VR and participants’ actions
past), attachment (feeling security and safety, and trust), The VR content was developed to fulfill the five psycho-
occupation (having a purpose in life and being empowered logical needs (comfort, identity, attachment, occupation,
to have an impact), and inclusion (a feeling of belonging, and inclusion) of the patients with dementia to
being encouraged to interact with the social environment strengthen the participants’ personality. The following
physically and emotionally). Two independent researchers sections detail the content and interactive factors of the
(A and B) classified the alleviating activities based on the VR experience (Table 1).
psychological needs of patients with dementia. The VR was designed to meet the comfort needs of
the participants, including physical touch (patting a
Phase 2: development of a VR intervention friend on the shoulder), place of memory, forming a
The VR was designed using the analysis of psychological quiet environment, and walking. Identity needs were
needs that alleviate BPSD, which was explored in Phase met by visiting family and viewing family pictures, while

Table 1 Summary of intervention program of virtual reality that addresses psychological needs
Title Places Psychological Contents Multimedia Interactive factors Session
needs length
(min)
Train of Train station Occupation Admiring the scenery at the train Sound of the train Giving train tickets to 1
memories Inclusion station station attendant
Boarding the train and choosing a
destination
Street of Elementary Identity Looking around the playgrounds and Sound of puppies barking Erasing graffiti on the 4
memories school Inclusion classrooms of elementary schools Family photo classroom blackboard
Alleyway Occupation Playing with friends in the Playing slap-match
My homely Attachment neighborhood alley Playing with puppies
house Coming home and playing with Receiving family gifts
(City) puppies
Receiving gifts and looking at family
photos
Nostalgic Theater Identity Admiring the surroundings and The bell rang at dawn Video selection 6.5
youth Coffee house Inclusion entering the theater (1972) Drinking black herbal
Market Attachment Watching an old film (Korea news) New invention (1981) tea
My homely Drinking tea in a coffee house Olympic closing Buying radish
house Visiting the market ceremony (1988) Playing with puppies
(City) Coming home and playing with The sound of water Receiving family gifts
puppies boiling in kettle
Receiving gifts and looking at family Market noise
photos Sound of puppies barking
Family photo
Homely Valley Identity Flowing water in the valley The sound of flowing Dipping one’s hand in 3.5
hometown Field of reed Comfort Walking in a field of reed valleys the valley water
My homely Attachment Returning to the country home and Water splashing Stroking the reeds
house lighting a fire in the furnace The sound of the wind Putting a kindling in
(Countryside) Coming back to the room and passing through the the furnace
viewing family photos reeds Receiving family
Crackling sound of fire photos
Family photo
Where I Orchards Comfort Walking through the orchards Sound of cicadas 10
want to Namiseom Taking a walk in the Namiseom Sound of the wind
go Island Island Sound of the waves
The sea at Watching lighthouses, waves, and Sound of the rain
night stars in the night sea Sound of the wind,
Crocks of Looking at the rain falling on crocks Korean traditional music
condiments Walking through the bamboo forest
Juknokwon while listening to Daegeum playing
Bamboo
Garden
Kim et al. BMC Geriatrics (2021) 21:167 Page 4 of 10

the inclusion needs were reflected in conversation, being participants’ hand movements. The seasons and various
with someone, positive expression, and words/expres- animated objects could be manipulated through leap
sions of acknowledgment. Attachment needs included motion sensors (LM-010), allowing the participants to
hanging out with friends and family, and the occupation interact with the scene through hand and arm move-
needs included selecting a destination that the patients ments. Particular movements moved animated objects,
wanted to visit, erasing graffiti, going grocery shopping, such as train tickets, blackboard erasers, slap cards, pup-
playing with dogs, and putting logs into a fireplace. pies, teacups, radishes, valley water, reeds, and firewood.
With the theme of “Train of memories,” this study im- The participants did not need to use joysticks or key-
plemented VR in 15 different places using four categor- boards (Fig. 1).
ies. The participant could choose the content via hand The platform allowed for overall easy solo use at home
movements, and the content was categorized into or with some assistance, thereby ensuring the platform’s
“Streets of memory,” “Nostalgic youth,” “Homely home- safety. The participants were seated next to their care-
town,” and “Where I want to go.” In the “Train of mem- giver or a research assistant throughout the VR session;
ories,” the participant could choose their destination by postural demands were reduced by the participants
handing a train ticket to the train station attendant and remaining in their chair during the VR exercises.
could 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, Phase 3: feasibility test
and the participants experienced slap-match games in al- Procedures
leyways with friends, erasing graffiti on school black- In Phase 3, the participants were also recruited through
boards, playing with puppies at home, and seeing family recruitment notices in residential and daycare facilities
photos. “Nostalgic youth” included watching an old film for older people. The participants were selected based
at a theater, drinking tea in a traditional coffee house, on the following criteria: (1) they were a resident or day-
and going home after shopping for groceries at a trad- care visitor with dementia, (2) they were aged 65 years
itional market. “Homely hometown” allowed the partici- or above, (3) they had a Mini Mental Status
pants to experience interactions such as playing in a Examination-Korean version (MMSE-K) score of 15 or
river, stroking reed grass while walking in a breezy field, higher, (4) they had a Clinical Dementia Rating of 0.5 or
and placing kindling in a fireplace in a rural home. higher, and (5) they understood the research process
“Where I want to go” included visual and auditory stim- and agreed to participate. The exclusion criteria con-
uli, such as orchards, Namiseom Island, the sea at night, sisted of motor dysfunction due to cerebral infarction,
observing the rain, and the Jungnogwon Bamboo Gar- other mental disorders, neurological disorders, and
den. There were no intellectual or functional demands metabolic disorders. A total of 10 participants were
required during interactions with the virtual recruited.
environment. The VR-based intervention programs were provided to
the participants in the program rooms of the institutions
Multimedia technological design and implementation in 1–2 sessions for 20–30 min each. The intervention
Through collaboration with the external company, we times were customized for the participants; lunch hours,
created an interactive VR program for relieving BPSD. visiting hours, and napping hours were avoided.
This intervention provided a fully immersive audio- The participants’ age, MMSE-K scores, and Activities
visual experience of the different virtual environments. of Daily Life (ADL) scores were obtained from their
Sound, music, photos, and movies were added, in medical records. The MMSE-K scores ranged from 0 to
addition to anecdotes and verbal cues. To meet the psy- 30, with higher scores indicating better cognition and a
chological needs of older people with dementia, the con- score below 24 indicating cognitive impairment [33].
tent consisted of different environments, music, and The participants used the VR at their own pace after
natural sounds suitable for fostering the positive emo- receiving guidance from the trained researchers. They
tions of South Koreans. were guided to specific places they wanted to visit and
The VR program was implemented using 360-degree experienced two to three VR places. To assess the
video viewing, a 360-degree camera recording of the nat- immersion, preference, and interaction during the VR
ural environment, editing, and graphics production, experience, the researchers asked the participants to re-
which maximized the reality and immersion. The inter- spond to three questions relating to immersion, prefer-
actions were implemented by attaching a leap motion to ences, and degree of interaction in their VR experiences
the Head Mounted Display (HMD; Samsung HMD on a 5-point Likert scale (1 = “Very poor,” 2 = “Poor,”
Odyssey Windows Mixed Reality Headset plus Wireless 3 = “Fair,” 4 = “Good,” 5 = “Excellent”) in every place they
controller), allowing for easy recognition of the chose. Higher mean scores indicated a more positive
Kim et al. BMC Geriatrics (2021) 21:167 Page 5 of 10

Fig. 1 Some screenshots from virtual reality interactions in this study: a) in “Train of memories,” a participant handing a train ticket to the train
station attendant, b) in “Streets of memory,” a participant playing with puppies while playing bowls at home, c) in “Nostalgic youth,” a participant
shopping for groceries at a traditional market, d) in “Homely hometown,” a participant placing kindling in a fireplace in a rural home

experience, and the answers to these questions were ob- followed by the need for “identity” (28.2%), “inclusion”
tained through the structured questionnaire. (24.3%), “attachment” (10.7%), and “occupation” (6.8%).
To identify the participants’ tolerance for VR, the re- Activities related to the need for comfort included walk-
searchers recorded the need for assistance, duration of ing, eating snacks, physical contact (such as hugging and
the VR experience, positive or negative experiences, and holding hands), and creating a quiet environment. Activ-
VR sickness (Additional file 2). Positive or negative expe- ities related to the need for identity included religious
riences were measured by their visual alertness and ver- activities and visits from guardians and family members.
bal engagement. The following negative behaviors were Activities related to the need for inclusion involved re-
recorded: complaining, agitation, wandering, hitting, ceiving positive support from others. Activities related to
grabbing, pushing, throwing objects, biting, hurting self the need for attachment included checking objects
or others, tearing objects or destroying property, and (checking their clothes and placing a name sticker on
making physical/verbal sexual advances. The following personal closets). Activities related to the need for occu-
positive behaviors were recorded: remaining seated and pation included reading, solving puzzles, and playing
still, being focused, being calm, smiling, and communi- traditional South Korean card games (Table 2).
cating verbally or non-verbally. Two researchers ob-
served and recorded the participants’ responses, and Immersion, preference, and interaction during VR
disagreements between their ratings were resolved by experience
discussion and reaching a consensus. For the statistical All participants were female. The mean age of the par-
analyses of the data, SPSS Statistics 27.0 was used, and ticipants was 85.80 ± 3.26 years (Min 82 ~ Max 90, Me-
these included frequency and descriptive analyses, in dian [IQR] 85.5 [84.25–88.75]). The participants had a
which the means, standard deviations, medians, and mean MMSE-K score of 21.44 ± 4.59 points (Median
interquartile ranges (IQR) were analyzed. [IQR] 22 [18.00–24.00]) and a mean ADL score of
4.33 ± 2.88 points out of 30 points (Median [IQR] 5
Results [1.75–6.00]).
Activities that alleviate BPSD As the participants engaged with the VR program, the
Activities that alleviated BPSD among the patients were researchers observed the level of the participants’
characterized and classified into five types of psycho- immersion, preference, and interaction with the VR on a
logical needs. The need for “comfort” was rated highest 5-point Likert scale. The mean immersion score was
in terms of providing relief from BPSD, with 36.9% out 4.93 ± 0.16 points (Median [IQR] 5.00 [4.87–5.00]), the
of a total of 103 patients making this assessment, mean preference score was 4.35 ± 0.41 points (Median
Kim et al. BMC Geriatrics (2021) 21:167 Page 6 of 10

Table 2 Classification of psychological needs based on relieving activities for BPSD (N = 103)
Psychological Relieving activities for BPSD N (%)
needs
Comfort ▪ Taking a walk, moving (from own room to living room), reading magazines (picture books) 38
▪ Taking medicine, receiving nutritional shots, getting one’s prescription filled, sensory stimuli (listening to music, (36.9)
applying liquid painkiller), coffee, snack
▪ Creating a quiet environment, shutting the door, staying in one’s room and coming out to the living room to exercise
when no one is there, sitting in the toilet, taking a bath for more than an hour
▪ Doing what one wants when immediate request is granted
▪ Hugging, holding hands, physical contact, looking at the visitor log and confirming family’s visit, listening to what
others are saying, being told warmly that they need to leave tomorrow
Identity ▪ Reading the bible, hymnbook, listening to pastor’s sermons, worshipping, thinking of God, always having prayer beads 29
by the bedside (28.2)
▪ Calling home, visit by caregiver, visit by younger sibling, visit by sons, visit by daughters, visit by grandchildren, photos
with the family, visit by family, chatting with a daughter, receiving attention, told by son that he would call, told that
their children are coming
▪ Isolated from daughter-in-law, refraining from visiting children
Attachment ▪ Checking for one’s own belongings, checking for clothes, wearing familiar clothes, placing name tags in individual 11
closets, touching individual belongings with permission from elderly with dementia, receiving what one wants, bags, (10.7)
radio (Far East Broadcasting)
▪ Going to the bathroom, toilet paper rolls, touching one’s genital area (washing one’s entire body thoroughly), asking
for nighttime diaper care after touching one’s genitals, putting on feces, less abnormal behavior when a woman takes
interest and treats them, being cared for by the opposite sex
Occupation ▪ Walking exercise 7 (6.8)
▪ Hwatu (Korean traditional card game), puzzles, reading books, reading magazines (picture books), thinking of times
when they spend money
Inclusion ▪ Conversation, talking, emotional support, taking their side to support, holding hands in conversation, warm 25
conversation, face to face conversation, listening to what they want and appeasing them, staying with them, being a (24.3)
conversation partner while having their favorite snack, talking with them while meeting eyes, friendly and gentle
approach, others answering well to the same questions, listening to complaints quietly
▪ Listening to positive expressions about own behavior, words or expressions of acknowledgment, emotional care (using
cyclical language), attention from those that care for them and adaptation to the environment
BPSD behavioral and psychological symptoms of dementia

Table 3 Level of immersion, preference, interaction and tolerance of VR (N = 10)

No Assistance Immersion Preference Interaction Tolerance for VR
device
M ± SD Min- M ± SD Min- M ± SD Min- Need Length of Participants VR
max max max assistance experience (min) reaction sickness
1 Cane 5.00 ± 0.00 5 5.00 ± 0.00 5 4.63 ± 0.35 4–5 No 15 Positive –
2 Cane 4.85 ± 0.38 4–5 4.85 ± 0.38 4 ~ 5 4.38 ± 0.45 4–5 No 15 Positive –
3 – 5.00 ± 0.00 5 4.92 ± 0.29 4 ~ 5 4.64 ± 0.75 3–5 No 10 Positive –
4 Walker 4.65 ± 0.24 4.5–5 3.55 ± 0.37 3 ~ 4 2.80 ± 0.76 2–3.5 Yes 10 Positive/ +
negative
5 Wheel chair 5.00 ± 0.00 5 2.88 ± 1.44 2 ~ 5 3.00 ± 1.47 1.5–5 Yes 5 Positive/ –
negative
6 Walker 4.94 ± 0.18 4.5–5 4.50 ± 0.71 3.5 ~ 5 3.56 ± 1.43 1–5 Yes 8 Positive –
7 Wheel chair 5.00 ± 0.00 5 5.00 ± 0.00 5 3.63 ± 0.48 3–4 Yes 10 Positive +
8 Walker 5.00 ± 0.00 5 3.70 ± 0.67 2.5–4 3.70 ± 0.67 3–4.5 Yes 5 Positive –
9 Cane 5.00 ± 0.00 5 4.28 ± 0.51 3–4.5 4.00 ± 1.41 2–5 No 10 Positive/ –
negative
10 Wheel chair 4.83 ± 0.39 4–5 4.79 ± 0.40 4–5 4.07 ± 0.73 3–5 Yes 12 Positive –
Mean ± 4.93 ± 0.16 4.35 ± 0.41 3.84 ± 0.43 10.00 ± 3.46
SD
Min-Max 4.65–5.00 2.88–5.00 2.80–4.64
Median 5.00 (4.87–5.00) 4.65 (3.84–4.90) 3.85 (3.58–4.30)
(IQR)
VR virtual reality, IQR interquartile range
Kim et al. BMC Geriatrics (2021) 21:167 Page 7 of 10

[IQR] 4.65 [3.84–4.90]), and the mean interaction score preference, interaction, and tolerance for VR. The partic-
was 3.84 ± 0.43 points (Median [IQR] 3.85 [3.58–4.30]) ipants’ feedback was consistent with previous results
in each of the virtual places. demonstrating that patients with dementia participated
more keenly in activities that reflected their individual
Tolerance for VR experience preferences [35] and activities that they could recall and
There were multiple indicators of VR tolerance. First, six reminisce about [40–43]. A high degree of preference
out of the 10 participants required assistance, such as and immersion were confirmed among the participants,
help with wearing the HMD, focusing their visual acuity demonstrating the usability of the VR intervention pro-
on the HMD glasses, and capturing their hand move- gram. This indicates that it is important for VR plat-
ments via leap motion. The mean VR experience dur- forms to present a familiar environment, given the
ation was 10.00 ± 3.46 min. The participants’ reactions historical and cultural backgrounds of patients with de-
throughout the VR were classified into positive or nega- mentia. Furthermore, intervention programs that reflect
tive outcomes. Seven participants had positive responses familiarity and various emotional stimuli can increase
to VR, while the remaining three had both positive and immersion and contribute to active interactions by help-
negative responses. The positive reactions included ing the participants reminisce and recall the past [44].
pleasure, such as focusing on the program for a set Manera et al. [15, 45] reported that older individuals
period, laughing, and communicating verbally and non- with mild cognitive disorders or Alzheimer’s disease had
verbally in a stable state. Negative emotions were re- higher levels of satisfaction and reported less anxiety,
corded as the occurrence of complaining (Table 3). discomfort, and fatigue with image-based VR exercises
compared to paper and pencil exercises. The results of
Discussion these studies indicate that well-developed VR content
The purpose of this study was (1) to develop a VR inter- can be effectively applied to patients with dementia and
vention program based on the psychological needs of pa- mild cognitive impairment and can result in positive
tients residing in South Korean nursing facilities, (2) to outcomes [46].
test whether this VR intervention alleviates BPSD, and Despite these promising results, the usability problems
(3) to confirm the utilization of VR in patients with de- of the VR system developed in this study need to be
mentia. This program aims to improve the patients’ solved. In terms of the experience length, this varied
quality of life and provide effective care models for from 5 to 15 min. This was because the participants
health professionals. chose different themes, and their interaction pace varied.
The VR program was designed to meet the partici- The theme “street of memories” was selected the most,
pants’ psychological needs by securing their emotional which included an elementary school, an alleyway, and a
immersion and engagement in accordance with the pref- homely house. The theater and coffee house were se-
erences and emotions of South Koreans. Comfort needs lected the least. Considering that the participants’ mean
were most frequently suggested as a way to alleviate the age was 85.80 years, watching movies in the theater and
patients’ behavioral and psychological symptoms. Pa- drinking coffee in a café might not be preferred activities
tients with dementia maintain their identity through love for these participants. Therefore, historical and cultural
and comfort, which provides them with a greater sense characteristics should be considered to develop immer-
of well-being [34, 35]. Patients with dementia obtain sive VR programs [47].
happiness and enjoyment by engaging in meaningful ac- In this feasibility study, there were issues related to the
tivities, such as various leisure activities, social participa- assistance required to use the VR: the weight of the
tion, and work-related activities, which improve the HMD (Samsung HMD Odyssey Windows Mixed Reality
individual’s sense of autonomy and identity [36, 37]. Headset and Wireless controllers 630 g), controlling the
When their psychological needs were satisfied, their anx- visual acuity, and capturing the participants’ hand move-
iety and behavioral psychological symptoms decreased ments via leap motion. The participants displayed diffi-
[38, 39], and such reductions have been effective in re- culties operating the VR with hand movements mostly
ducing the need for neuroleptics [16]. Additionally, this likely because of the decreased hand movement and cog-
VR environment provides a multimedia platform that nitive functions of the older patients [48]. The patients
can facilitate the storage and retrieval of memories and complained of limited vision while wearing the HMD as
simulate multisensory experiences. This could be used they are cut off from the outside world; they also com-
to create a therapeutic environment for alleviating plained about the heavy weight of the displays [20]. The
BPSD. weight of the HMD is 590 g, which is relatively lighter
The VR content developed in this study was applied to than other HMDs; even lighter HMDs for older patients
patients with dementia, and the evaluations were subse- will be released in the future (e.g., HP Reverb G2). The
quently obtained from the participants’ immersion, VR environment requires active movement and the use
Kim et al. BMC Geriatrics (2021) 21:167 Page 8 of 10

of visual and auditory senses. This may be limited in Limitations and implications of the study
older people with dementia since they typically experi- This study was a feasibility test with a limited sample.
ence reduced visual and auditory capacity, resulting in Future studies should recruit a large sample of partici-
decreased accuracy and attention [5]. The results of this pants and consider factors such as age, gender, personal-
study indicate that the participants experienced some ity type, and severity of dementia. Additionally, we used
difficulties due to their diminished sensory capacity. This the trained researchers’ observations to screen the nega-
should inform the design, implementation, and evalu- tive and positive responses during VR experience among
ation of similar technologies or interventions. For in- the participants. The participants’ minor discomfort
stance, physical functions, such as visual acuity and hand could not be reported because we did not use a standard
power, and the weight of the HMD should be considered measure. Researchers should continue to explore the
for the use of VR technology with dementia patients. potential discomfort of VR or sickness related to VR
In the current study, VR sickness varied with two par- among the participants with cognitive decline using vari-
ticipants complaining about dizziness or nausea during ous measures such as self-reported questionnaires and
the VR immersion. The VR intervention program test standardized observations. In this study, there may have
was implemented while the participants were seated, been some response bias since the researchers and asses-
which decreased the effort required to maintain their sors were the same. After completing the intervention,
posture. Clearer images and accurate motion tracking collecting immediate feedback from participants with
can reduce VR sickness [49, 50], and content requiring moderate-to-severe dementia can be challenging since
less movement [51] is less likely to lead to VR sickness. they struggle to respond to these types of questions. A
Although these symptoms are temporary [52], re- mixed-methods approach involving semi-structured in-
searchers and developers need to pay attention to this terviews and observational data should be used to assess
issue. their responses in future studies.
This feasibility study aimed to uncover the strengths However, the VR-based intervention program devel-
and weaknesses of VR interventions. The findings dem- oped in this study to reduce BPSD was feasible for the
onstrate that it is feasible to use VR with patients with participants and provided them with a relatively high de-
dementia but did not demonstrate the efficacy of VR to gree of satisfaction and immersion. Furthermore, this
reduce BPSD. Further research should be conducted study also confirmed the convenience and safety of the
based on rigorous experimental design to build more program. These findings build evidence for the potential
evidence for VR intervention programs. High-quality utility of VR programs to alleviate BPSD.
methodological and experimental studies are required to
demonstrate the effectiveness of randomized controlled Abbreviations
BPSD: Behavioral and psychological symptoms of dementia; VR: Virtual reality;
trials and should be designed to include a control group MMSE-K: Mini mental status examination-korean version; ADL: Activities of
of dementia patients as a long-term intervention pro- daily life; HMD: Head mounted display
gram in a nursing home.
Typically, VR platforms have been underutilized in Supplementary Information
healthcare services for groups such as patients with The online version contains supplementary material available at https://doi.
org/10.1186/s12877-021-02125-w.
chronic diseases or people with disabilities [53]. This is
the first study to develop VR interventions for dementia
Additional file 1. Open-ended questions for primary caregivers; Obser-
patients by considering their psychological needs. Over- vation and records for patients with MCI or Dementia.
all, this study has demonstrated that VR could increase Additional file 2. Observation and records for patients with MCI or
immersion, preference, interaction, and tolerance, but Dementia.
such effects vary with the nature of the task. Moreover,
unlike previous studies, this study demonstrated that a Acknowledgments
low demand VR environment that facilitates the storage Not applicable.
and retrieval of preferred memories could permit the
Authors’ contributions
implementation of strategies to facilitate patients’ inter- JH contributed to the study’s conception, conducted the statistical analysis
actions. While VR-based programs have issues, such as and interpretation of the data, and drafted the manuscript. SM and HJ
high costs, difficulty in operating the system, space interpreted the data and drafted the manuscript. All authors read and
approved the final manuscript.
constraints, and low portability [54, 55], the VR pro-
gram employed in this study increased the conveni- Funding
ence and safety of use by using simple interactive This work was supported by a Korea Research Foundation grant funded by
motions, such as pointing one’s hand in the desired the South Korean Government (MOEHRD, Basic Research Promotion Fund;
NRF-2017R1E1A1A01075188). The funder had no role in the study design,
direction and avoiding the need for large and complex data collection, data analysis, interpretation of data, presentation of results,
hardware. or decision to submit for publication.
Kim et al. BMC Geriatrics (2021) 21:167 Page 9 of 10

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The dataset used and analyzed during the current study is available from the Karagiannidis C, Tzovaras D, Tsolaki M. A preliminary study on the feasibility
corresponding author on reasonable request. of using a virtual reality cognitive training application for remote detection
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Information Soc Dev Ins. 2016;28(7):1–23.
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