Brain Stimulation of Elderly with Dementia Using Virtual Reality Home

Brain Stimulation of Elderly with Dementia Using Virtual Reality Home

Sung-jun Park*

Abstract

The virtual reality (VR) is an immerging technology used in the serious games industry to treat psychological disorders like dementia. We created a system named as Virtual Reality Home (VRH) for the elderly who lived with Alzheimer’s disease (or other form of dementia) and cognitive impairment using virtual reality technology. The purpose of our study is to measure the long-time immersion and retention of VRH on the moods and apathy, enhancement in physical and brain stimulation as well as a decision making with peoples of dementia and explore the experience of aged care home staff’s member. The VRH shows a positive impact on the elderly participants and staff members. During the VRH experience, excitement and a great level of alertness were observed among the participants but few of them were feeling anxiety. Furthermore, we observed the improvement in physical, memory and brain stimulation, but the participants have a low focus on decision making because they wanted to explore all interactable objects in the VRH. This study suggests that the VR may have the potential to improve the quality of life, and these results can assist to expand the future development in the enhancement of efficiency of people with dementia.

Keywords：Mixed Reality, Elderly Dementia, Brain Stimulation, Retention Methodologies, Serious Games, Health, Pseudo Weight

1)

Received：2019. 06. 11. Revised : 2019. 07. 04. Final Acceptance：2019. 08. 20.

※ This research was supported by the Academic Research fund of Hoseo University in 2017 (20170309).

* Associate Professor, Division of Computer and Information Engineering, Hoseo University, Hoseo-ro 79-gil 20, Baebang-eup, Asan-si,

Chungcheongnam-do, 31499, Republic of Korea, Tel：+82-41-540-5990, e-mail：sjpark@game.hoseo.edu

1. Introduction

There was a direct relationship between the elderly developing populace and the psy- chological disorders all through the world pre- dominantly by those affected by Alzheimer’s disease (Slimani et al., 2016) or Cognitive Impairments which leads to dementia, it has become a challenge for the medical services, social organizations and a serious problem for medical personals. Many efforts were done by different medical fields to solve this problem.

It’s a prediction that the elderly population is almost two billion worldwide in 2050 due to swift augmentation in the life expectancy graph [Hillis, 2017a; Miao, 2015], and the psy- chological disorders underneath dementia will be considered as an umbrella term which covers Alzheimer’s disease (Slimani et al., 2016) and Cognitive Impairment [Hillis, 2017b], are also continuously growing worldwide. Under these situations, the elderly unable to live auto- nomously and they need backing to stay alive [García-Betances et al., 2014].

<Figure 1> Dementia Rising Graph

<Figure 1> shows the elderly people suf- fered from dementia with respect to the year.

These are statistics collected by the World Health Organization (WHO) that 47.6 million

people in the world are suffering now and it will be increased to 131.5 million in 2050 [García-Betances et al., 2014; Hillis 2017a;

International, 2017]. According to [Associa- tion, 2016] someone in the USA develops AD (Alzheimer’s Disease) in every 66 sec and expected to be in 33 sec in 2050 and according to [International, 2017] someone in the world develops dementia every 3 seconds. Studies in the UK with dementia and cognitive de- cline show that Mild Cognitive Impairment (MCI) leads to dementia and its other forms.

This is the worst condition facing the elderly and has the functional memory impairment, such as names of people, places, numbers, misplacing things, keeping track of schedule of pledges, disremembering to carry out a planned activity and memorizing what was said or decided [Davidson, 2014]. Researchers are developing drugs that treat AD and or other types of dementia by removing amyloid plaques and allowing the brain to regenerate normally. However, the damage of the brain remains and cognitive functions are not auto- matically restored and a comprehensive train- ing is required to gradually reestablish the patient’s cognitive abilities [Buss, 2009].

Researchers are considering the VR as a

hope against dementia because the VR deli-

vers real-world assistance to dementia patients

by using real-time computer graphics, body

tracking devices, visual displays, and other

sensory devices to immerse a participant in

a computer-generated VR world [Rothbaum

and Hodges, 1999]. The fundamental purpose

of the VR in engagement, which is to define

as the perception of them being physically

present in the Virtual World. Such a feeling

reports self-engaging activity of the person

who is suffering from Alzheimer’s (or another

form of dementia) [Dementia, 2017; Rothbaum

and Hodges 1999]. Based on this immersion

virtual reality has been used as a therapy for the people who practice psychological disor- ders. It is analyzed that the people have low mental health issues or can resist against the AD and MCI who play brain games, as a result, serious games, especially through VR, are being worked to treat these psycho- logical disorders, distinctly using diverse ga- ming gears and devices [Buss, 2009; Locklear, 2017].

There are concerns that the cognitive chal- lenges associated with dementia may pre- vent participants from reaching the level of presence required to be in contact with these environments. Based on the virtual reality’s immersion concept, Virtual Home has been made for the elderly to observe the mood, apathy, retentions, physical and brain sti- mulation, memory and decision-making im- provement of dementia suffering people. The salient feature of this system is to train and restore the cognitive function of the elderly in a virtual environment and provide the long-time retention with a positive state of mood that fulfills the functional task of daily living activities. <Figure 2> shows an exam- ple of applying a virtual reality game to the elderly.

<Figure 2> Virtual Reality Home Gameplay Image

2. Related Works

Studies have shown that VR is more effec- tive and sensitive in dealing with functional capabilities such as cognition [Zygouris et al., 2014]. Correspondingly, the IT industry plays a very important and efficient role in treating these kinds of psychological disorders [García- Betances et al., 2014; Locklear, 2017].

The University of Sydney researched and made “Exert games” in VR to justified that through such games can treat dementia and expressed that VR games have potential to make exercise feel the fun, engaging, modera- tely easy and most essential change in demen- tia [Peterson-Ward, 2017]. Similarly, Alzheimer’s Australia made a Virtual Forest for treatment of dementia patient and found qualitative experience and overall positive impact on elderly with dementia [Dementia, 2017].

Abundant serious games are participating in the treatment of AD and struggling for improvement of cognitive functions for the dementia patients. These games are based on different user’s engagement strategies. Re- searchers made a system called “Executive Time Target Game” based on time which helps to make improvement in cognition [Tong et al., 2017]. On another hand, University of California San-Francisco researched for el- derly in cognitive issue and made a 3d game for brain fitness and, they found general im- provement in cognitive ability and multitas- king [Kurtzman, 2013].

It is equally important to say that the

work that Alzheimer ’s UK created a unique

VR experience that gives awareness of life

through dementia is “walking through demen-

tia” (UK 2016). Based on the results, one per-

son was suffering from dementia, and faced

other problems such as social interaction, poor

decisions, audible sounds, and blurred vision.

Design Layers Purpose Researched Distribution of methodology layers

Pedagogy Learning, Instruction, Intentions & Strategies 20%

Story Gameplay Immersing, Improve in learning outcome 9%

Game Play Game Mechanics, Requirement & Specification of game 22%

Game Structure Rules of play, Simulation, Challenges & Fun 17%

Game World Focuses on fictional content, Topology/Level design 17%

Technology Implementation & Game engine 4%

Assessment Debriefing Player Evaluation Strategy 6%

Assessment Design

Evaluation Analyzing the achieved Prototype &

Required Modification 2%

Social Component Relationship, Visualization, Dialogues 2%

<Table 1> Serious Game Design Methodology Used in Virtual Home

System Purpose Brain

Exercise Physical Exercise Decision

Making

Strategy

&

Puzzles Psycho-

logical Effect

Concent-

ration Time Naviga- tion &

VR Walk Environ-

ment Excite- ment User

Retention Exert

Game Cognitive ** *** *** * ** *** * - ** * *

VR

Forest Alzheimer’s - * - - **** *** - - **** *** **

Executive

Target Time Cognitive ** - * - - *** ** - * * *

3d Brain

Fitness Cognitive &

Multitasking *** - ** - * ** * ** * * *

Walk Through Dementia

Experiencing

Dementia * * ** * *** *** - *** * - **

Sea Hero

Quest Cognitive *** - ** ** * *** *** *** *** *** ***

<Table 2> Games, Purposes, and Features Involved

FEATURE PRESENCE RATING SCALE (- : NO, ^* POOR, ^** FAIR, ^*** GOOD).

Difficulties in recognition and adjustment, loss of sense of direction, change in behavior and atmosphere, loss of skills in daily life.

At the same time, Alzheimer’s Research UK has teamed up with Deutsche Telekom and scientists from University College London and the University of East Anglia to develop Sea Hero Quest [Fleming, 2017]. This game designed to help the researcher to better un- derstand the cognitive process behind the spa- tial Navigation and memorizing capacity.

<Table 1> shows the weight of the elements for constructing the game for the elderly.

2.1 Analysis of Relevant Systems

The analysis phase begins with the eva-

luation of relevant studies on the system

design guidelines and the researched factors

based on which these systems are designed

[Alcid et al., 2017]. The features are shown

in the <Table 2> are those features, which

have effects on human brain activities and

plays an important role in dementia. Related

systems are very well designed but some

limitations which are found after enactment

of these systems. As a matter of fact, some

<Figure 3> This is the Most Generalize Feedback from Elderly who Suffering from the Alzheimer’s of the important functions that effect on the

brain of the user in mental health recovery cannot be separated from the brain exercise.

But when you add these functions in the game, user do not give retention and recovery only can be improved if the user practices the sys- tem with its functionality. While the elderly take the system, not a game but treatment [Vasconcelos et al., 2016], and do not give retention and concentration [Miao, 2015].

We have explored and got feedback from the elderly who experienced the previously made systems [Miao, 2015]. <Figure 3>. is presented generic issues which found in the serious games and due to these issues elderly not partici- pated in such kind of treatment games.

3. Virtual Reality Home(VRH)

The research highlights the possibility of using VR applications in serious games for enhancement in mental health impairment (psychological disorders) [Bilal Ahmed, 2018;

Robert et al., 2014]. It’s significant to realize

that, for the treatment of Alzheimer’s (or other form of dementia) or cognitive impairment through VR applications, training usually needs a highly repetitive and daily exercise, for this game should be highly addictive but these kinds of games usually more complex in term of gameplay [Vallejo et al., 2017; Zucchella et al. 2014].

It is very challenging to stimulate the el- derly in the gameplay because the elderly do not give retention. The game should be reali- stic and activity-based to get retention and motivation in the game for the elderly [Carvalho et al., 2015]. In the activity-based scenario, the focus always on the engagement of the users because an activity describes their ac- tions, tools, goals, and impact on the user.

In the activity-based scenario, the serious

game will be designed according to serious

design methodology. The design methodology

consists of layers and each layer has distri-

buted according to predefined criteria for bet-

ter performance and consequences [Slimani et

al., 2016].

<Figure 4> The Visual Model of the Virtual Reality Home, its components and their Interactions Our system has been designed according to

this predefined methodology as shown in the

<Table 1> (Slimani et al., 2016] with the story keeping of VRH. The VRH uses video game technology, involving motion sensor and vir- tual devices to create an interactive and im- mersive environment. In the creation of VRH system, the concentration was on the feed- back which got from the already made sys- tems as shown in <Figure 3> and due to which elderly do not like to use serious games. We have tried to decrease all the possible pro- blems that could come after the previous experience.

The VRH includes animated environment like a water pond, interactable objects and colorful fishes and ducks, attractive garden with cutting and watering the plants, win- ding through trees and flowers, butterflies and season’s effects which is accompanied by a background soundtrack integrating peace- ful white clamor and faint garden sounds.

Furthermore, stimulation in VRH with the functions of light on/off, setting of your home, and interactions with animated objects, color selection of your choice and change your home’s color through leap motion sensor. Some inter- actions and manipulation are contingent upon the movement of your arms and hands. In addition, all the functions are based on very fair given time but for more time and fun

there are VRH Hand Wrist Exercise. <Figure 4> Shows the system diagram of VRH.

4. Design and Method

4.1. Study Design and Participants

The mixed-method study was conducted between 11 January and 4 May 2018 from three different aged care homes in the pro- vince of Chungcheongnam-do Republic of South Korea named as Hoseo Social Welfare Foun- dation HyoHouse located at Cheonan, Hong- Sung Aged Care House located in Hong-Sung and Seosan Old Nursing Home located at Seosan.

For this study, thirty elderly participants (Subjects/N = 30) and fifteen aged care homes staff members (n = 15) were recruited. El- derly subject’s participants had the average age of 70.4 years ranging from 59～83 years and the average age of the male elderly peo- ple was 69.18 years and females were 71.15 years. Majority of the participants (elderly

& staff) were female.

The average duration in ACH (Active Chro-

nic Hepatitis) of elderly participants was 44

months ranging from 25～60 months and staff

members were registered as nurses, were wor-

king at ACH average for 124.2 months ran-

ging from 60-180 months.

Elderly subjects had a mean of 11.3 years of formal education ranging from 0～20 years of formal education and all nursing staff had 12 years of formal education and in addition, n = 7 had some technical education.

The recruited elderly participants had a documented diagnosis of Alzheimer’s or other form dementia and declining with cognitive impairment, but they were looking good in health with the means weight of 62.8 kg.

Subjects’ level of cognitive functionality was depicted using a Psychogeriatric Assess- ment Scale score, also obtained from their medical files. A higher score represents a higher level of cognitive decline. Subjects (N

= 30) had a mean score of 14.25 of the brief cognitive assessment tools ranging from 8.1

～20.

Subjects participated in fifteen weeks of the training session and VRH experience duration of the session for each subject was 15 min maximum, 3 times a week. A trained staff were facilitated to Subjects in VRH ex- perience. Trained staff were the staff mem- bers (n = 15) of ACH and Game Media Rese- arch Lab’s ™ team trained the ACH staff members in the use of the technology.

4.2 Experiments and Data Collection

During the training sessions, elderly par- ticipants were asked to read the instructions as presented by the application. Afterward, the psychologist briefly explained, motivated and demonstrated the use of the Virtual Home.

Elderly participants were shown down how to select and interact with objects and gra- phical user interface, remember and navi- gate in the game and exercise for time incre- ment. In the practice session they were helped and guided by staff members for each move of the experience but during the test session

they were free to perform any activity in game and staff helped only when elderly partici- pants were confused/stopped.

The purpose of data collection was to mea- sure the following aspect : Psychological ob- servations, Physical Exercise Improvement, Memory Improvement, Decision Making Im- provement, Subject’s Retention in VRH expe- rience and this was then followed by an indi- vidual interview session with Staff members of ACH and Elderly Subjects. Under the con- sideration of these aspects, the data was col- lected in different ways. Ten-minute video recording was recorded at two times before and after VRH experience and 15 minutes during the intervention for every participant.

Quantitative analysis of recorded video was completed and made result which was fo- cused on the psychological effects the VRH experience had on mood states, apathy and engagement of the elderly subjects who were suffering the Alzheimer’s or another form of dementia.

The number of fists makes (VRH Hand Wrist exercise) was calculated for Subjects for a time of the 60s to observe the physical improvement.

Furthermore, the initial and final points were given through navigation followed by the given time of maximum 5 minutes in the gameplay, the time taken by subjects to reach the same destination every time was mea- sured for everyone. Based on time, subject’s (N = 30) memory was observed.

Additionally, the selection and interaction with objects and colors which were on the way of elderly subjects in the VRH expe- rience were observed by the psychologists.

Based on these selections and interactions

the score was defined and subjects were asked

to get a high score and based on these scores

their decision making was calculated. Finally,

the interviews were conducted individually for each staff member and elderly participants.

5. Results

5.1 Observed Emotion Rating Scale

Observed Emotion Rating Scale (OERS) [Lawton et al., 1999] is an observational tool for rating two positive and three negative emotions which are a pleasure and general alertness and anger, anxiety/fear and sad- ness respectively. The video was observed, and Subjects were rated in term of each of the five emotions by choosing one of the pre- defined time intervals (1 = never, 2 = <16 seconds, 3 = 16-59 seconds, 4= 1-5 minutes, 5 = > 5 minutes, and 7 = not in view). This indicates the amount of time the participant displayed each of the five emotions [Lawton et al., 1999). The OERS scores of the sub- jects during VRH experience were compared with the previously established for the people living with dementia in an activity context [Lawton et al. 1999]. The Higher scores show the longer duration of expression of that emo- tion. <Figure 5> shows the rating of observed emotions. Based on these values, we found significantly more pleasure and alertness du- ring the VRH experience. The pleasure and alertness had the values of (p = 0.0088) and (p < 0.0011) respectively than those previou- sly established for people living with demen- tia in research scenario. N = 12 displayed 2-6 minutes of pleasure, N = 25 displayed alert- ness for more than 5 minutes and N = 17 dis- played the greater level of anxiety/fear (p = 0.0166) during the experience. In case of an- xiety/fear N = 10 were observed to display 2-6.5 minutes and N = 7 were observed 22s -1.45 minute of anxiety/fear. There was no observed anger or sadness (p>0.05) during

the VRH experience. <Figure 5> also shows that during the VRH experience have higher average values of emotions than the before and after the VRH experience.

<Figure 5> Shows the Rating of the Observed Emotions for the Subjects at Three Stages, Before, After and During the VRH Experience

5.2 Person-Environment Apathy Rating

Person-Environment Apathy Rating (PEAR)

[Jao et al., 2016] was used to measure co-

existing apathy and environment stimula-

tion over the three types of stages of video

recordings. Apathy was measured by obser-

ving facial expressions, eye contact, physical

engagement, purposeful activity, verbal tone,

and verbal expression. Environmental stimu-

lation was measured by observing stimula-

tion clarity, stimulation strength, stimula-

tion specificity, interaction involvement, phy-

sical accessibility, and environmental feed-

back. Each subscale of PEAR consists of six

items evaluated on a 1-4 scale [Jao et al.,

2016]. A higher score on each subscale shows

a higher level of environmental stimulation

and apathy. Three points of a video recording

of VRH experience (Before, during and after)

of the N = 30 were measured to variance

<Figure 6> The Fist Made by the Subjects in 60 seconds between 15 Training Weeks

changes in environmental stimulus and apathy.

To determine the pairwise differences bet- ween three points post hoc comparison were conducted. The significant environmental sti- mulation effect for the time (Before during and after) was observed and the score was (p = 0.005). The environmental stimulation score was significantly higher during the VRH experience than before (p = 0.002) and after (p = 0.002). It states that the VRH experience had motivating qualities was physically ac- cessible and endorsed responses from N = 30 and environmental stimulation effect was not found before and after the VRH experience.

Furthermore, the noteworthy apathy effect in three-time points was observed (before, during and after). Apathy scores were sug- gestively lower during (p = 0.025) the VRH experience than before (p = 0.015) and after (p = 0.007). There was no significant diffe- rence was found between before and after the VRH experience in apathy. We found from these results shown in the <Table 3> that elderly participants were immersed in the experience of the VRH and resulting in re- duced apathy during the involvement but only when N = 30 were undergoing.

Scale

Before Experience

M (SD)

During Experience

M(SD)

After Experience

M(SD) Environmental

Stimulus 17.65

(6) 25.32

(0) 19.83

(5.79)

Apathy 20.89

(7.13) 14.73

(3.42) 20.13

(6.89)

<Table 3> The Person-Environment Apathy Rating (N = 30)

5.3 Virtual Reality Hand Wrist Exercise

<Figure 6> shows the fist made by the Sub- jects in 60 seconds between 15 training weeks.

During the 15 weeks of training, each subject

went through with this exercise 3 times a week. In VR hand Wrist exercise, subjects were asked to make a maximum number of fists in the 60 seconds. After every five fists, the subject found some amazing colorful particle effects on their hands in VRH which always increased the motivation of a Subject to do some more fists.

We conclude from these results that the

motivations and consistency of the Subjects

lead them to the physical improvement with

training weeks. This graph explained that

the training weeks and fist made by Subjects

shows a directly proportional relationship

with each other. The physical exercise plays

a very important role to improve the mental

and physical health, but the elderly do not

want to do exercise or do not want to engage

himself in physical activities. It was found

that the VRH plays an important role in

engaged elderly for physical exercise and

activities. The motivations for the elderly

were found to be a very important factor by

ACH staff members in this scenario. Due to

motivations, the Subjects didn’t take this as

a burden during VRH experience with fist

exercise.

(a) (b)

<Figure 7> Shows that an Inverse Proportional Relationship between the Time Taken by (a) Subjects and (b) ACH Staff Members to Reach at the Destination in 15 Training Weeks

5.4 Navigation System

The walking system has been made in VRH and introduced with two walking techniques.

The 1 ^st technique was cycling with your hands and 2 ^nd with your eyes. In 1st scenario, your walking speed depends upon your hand cy- cling speed in the 2 ^nd scenario the players will move in VRH, where they will see on the ground around them. The first and last points were determined with the help of the navi- gation system. The maximum five minutes time was given to walk for results. The arrows and signboards were telling the Subjects which direction they should go and in case of wrong direction social element were intro- duced to guide about the right path.

In the navigation scenario, both the Sub- jects and ACH staff members were asked to perform this experience every week. The staff was asked once in a week, but Subjects were asked thrice in a week <Figure 7>. Shows that the initially more time was required for both types of participants, but the improve- ment was found in the participant’s perfor- mance with practice time. In this research,

we found that the Subjects have gradual im- provement in their memory shown in <Figure 7(a)> and ACH staff members have sudden improvement in their memory with practice time shown in <Figure 7(b)>.

5.5 Decision Making

In the walking scenario of VRH different objects was placed with different scores. The psychologist was asked to Subject to interact with those objects which carry maximum score.

<Figure 8> shows the earned scores by the Subjects in 15 weeks. Based on these scores, the decision making of the Subjects was mea- sured. This graph shows a little enhancement in the earned scores after 3 weeks which means their decision-making power was increased.

We found some Subjects wanted to interact

with all the objects which were placed in their

ways and they did not focus on the score, this

is the reason the graph average value has not

any linear trend in the improvement in decision

making with respect to training weeks.

<Figure 8> Shows the Average Score Earned (out of 5) by the Subjects During the 15 Training Weeks

5.6 Interviews

The interview sessions were started after the completion of 15 weeks of training. First, we interviewed 30 Subject (N = 30) and then ACH staff members. The given results below are supported by some quotation and coded representation of Male (M), Female (F) elde- rly Subject (N), ACH Staff member (n) and numerical code.

5.6.1 Elderly Participants

The majority (N = 18) of participants re- ported a positive perception of VRH expe- rience. They talked about it being good and relishing of the opportunity (“It’s wonderful and fantastic to interact with the objects”

[NF4, NM2]). Some participants talked about the precise aspects of the VRH experience such as (the water pond outside of the house and the fishes with different animations and colors [NF2]), (“I can feel the air when leaves were falling down from the trees[NF2] and the beautiful butterflies were around me, I loved it” [NF1]), (“The music was very peace- ful” [NM1], I want to spend my whole time near water pond with this music[NM1]). Like- wise, the two participants said they wanted to have an umbrella when they left the house

and it rained [NM1, NF1]. Similarly (“All the time I have turned off the light when I left the home” [NF2, NM2]). Not all the Subjects (N = 12) found the VRH experience to be positive. Two participants reported that the experience was very boring (“It was tedious involvement, but I was free to do it” [NM1, NF1]). Comparatively some participants were very confused and stated that “Its new for me and have never experienced such thing before”

[NM1], “It’s strange and I don’t want to expe- rience it again” [NF2]. Three participants were very clear in what they did, unrealistic and have no effects on them [NM1, NF2].

One of the participants stated that he does not like the wires around them (“I don’t want to die in these wires and headset on my face, it was suffocation for me”). Furthermore, three participants stated that they are not chil- dren and this experience was very childish.

Participants had a different opinion to use the VRH. The time of use varied from mor- ning to evening. One subject stated that I don’t want to use it in case it became a habit and then I will not like the real world while N = 11 stated that they want to use it spor- adically. When Subjects were asked if they wanted to undertake the VRH experience with the ACH staff members, only 5 participants expressed they wanted an assistant during the experience, NF2 wanted to experience with their husbands and NM1 wanted to under- take with his wife. In the last week of the training session, Subjects were asked if they would like to change VRH suggestion were about making the experience more active (maybe next I want to stand up and walk in real and move forward rather than just sit- ting down and moving with hands [NM1]).

Similarly, (I want to go fishing in the pond

while I will be sitting on a chair and listening

to the music [NF1]).

5.6.2 ACH Staff Member

All the ACH staff members (n = 15) inter- viewed indicated the VRH had a positive impact on most of the Subjects (“The main- stream of the Subjects seems to categorically enjoy it. I see their expressions smiling, and they gave the impression quite relaxed with it” [nF2]). Some of them (n = 7) observed distinct differences in how Subjects predomi- nantly highlighted optimistic effects on their moods (“I think it would have been lifting them little bit up and for the time being they have in different world”[nM2]), Subjects were found (“the VRH was very stimulating and they could remember the VRH and discus- sing the walk, interactable and fishpond with each other and they seem to be excited” [nM1, nF2]). Two staff members stated about cogni- tion (“Their faces light up when they also realize that they are controlling the interac- table and motions” [nM1, nF1]). A sedative effect of the VRH was also observed as a helpful impact. Five staff members noted that some subjects enjoyed only sounds and wat- ching the environment without any interac- tion. Furthermore, one staff member observed that two subjects made their mind and de- clared in the beginning that it’s very difficult to do exercise so, they were appreciating only the music near the fishing pond and onetime look around with smiling appearance.

Most staff (n = 13) suggested that the stages of dementia and physical functioning were significant pointer whether Subjects would appreciate the VRH. ACH staff member ob- served about the Subjects performance were depending upon their stages of dementia. Cor- respondingly, the staff stated that the sub- jects have mild dementia used to say “I have done it and don’t want to do it again, it’s enough for me” [nF2, nM3]. Similarly, two staff

members stated that I have noticed, “it’s more motivating for people with more advanced dementia than possibly people who are in the early to moderate stage” [nF1, NM1]. Additio- nally, the Subjects who have early stages of dementia they were arguing “why am I doing this? Is it not childish?” [nF2]. Whereas staff (n = 8) specified that cognitive decline leads the Subjects to be confused and making in- volvement very difficult for the people in the advanced stages of dementia. ACH staff mem- ber (n = 4) reported that mid-stage of de- mentia are the right time to introduce the VRH experience for elderly, (Based on the experience, haven’t found any achievement in advance stage dementia, but middle stage people with dementia works well) [nM2, nF2].

In addition, the staff member (n = 6) re- ported that the age and Alzheimer’s related physical decline limited usage and enjoyment of the VRH (A lot of Subjects were exhausted by walking with the hand cycling and stood in the mid of the way and then moved with the look technique [nF3]. “They were talked about my body is tired and I need to stop”

[nF2]). The staff reported that 15 minutes

time is too long, but in VRH there were a lot

of objects which were interactable that’s why

most of the Subjects were not bored because

all the time Subjects could interact with new

things. Similarly, staff (n = 5) observed that

15 minutes of time were physical fatigue for

the elderly who were at the advanced level

of dementia. Furthermore, two staff members

asked about more time would be beneficial

for Subjects. It was noted that most of the

difficulties experienced were related to the

ACH’ staff member’s computers and included

hardware difficulties of installation. In addi-

tion, some staff members (n = 7) asked for

the troubleshooting guide through which step

by step on how to get it started. All the staff

members (n = 15) asked to get the train on the VRH system before training session will be started.

All the staff members (n = 15) indicated that environments, weather, and objects were designed very well and elderly participants have enjoyed and admired. Some of the Sub- jects liked the falling leaves from the trees and they were so immersed in it and wanted to feel the air in real. In addition, if the Sub- jects were exhausted with the same scene, then in the next movement unexpected envi- ronment effects changed and again Subjects were busy with new things. Two staff mem- bers stated that the one Subject was asking about the environment of his real hometown (I want to see the hometown and street of my area. Can I see? [nF1, nM1]). Similarly, 4 staff members suggested finding some easily hid- den objects for elderly to engage them more [nM2, nF2].

Majority of the staff member (n = 11) indi- cated that the elderly people need assistance all the time when they were experiencing the VRH (Motivations were very important when they were tired while having the hand fist exercise [nM1, nF3]). There was general agree- ment (n = 15) among participants that staff assistance and encouragement was required for most Subjects to VRH (But I don’t think that any of our Subject can sit there and manage by themselves [nF3]), and they also described that it was individual, (If you don’t have enough resources, people resources, then to devote so much time just on one Subject is really tough [nM2, nF7]).

All the staff member (n = 15) agreed the Virtual Home was visually appealing, but that some Subjects told the VR headset is heavy [nF1, nM1]. One of the staff members asked to add some beach scene in VRH for those who only liked the fishing pond with sound.

6. Discussion

The purpose of this study was to evaluate and describe the effectiveness of VRH on the psychological observation, engagement of the elderly people with dementia on the physical and brain exercises and with the help of brain stimulation through virtual world immersion, finding out the improvement in decision ma- king and reminiscence. Furthermore, based on interviews of elderly people with demen- tia and concierge of three aged care homes, concluded the weaknesses and improvement which will be done in VRH and which will be more beneficial for the Subjects.

This research was started to form the sys- tems which were already made in the domain of serious games technology to deal with the Alzheimer’s (or another form of dementia) or Mild Cognitive Impairment which leads the Subjects to dementia. Initially, the affecting features (undesirable and encouraging) were found for elderly in earlier created systems and concluded that due to some of the nega- tive aspects elderly didn’t get retention, self- confidence, enhancements in brain stimula- tion and took systems as a fatigue. Secondly, the activity-based design model was preme- ditated in which the focused-on retention of a player based on layers and each layer has a specific depth in the whole system. Game Media Research Lab designed a system based on activity design model with no negative aspects found in the systems that were by now created.

The system VRH applied in the three di-

fferent aged care homes in the Republic of

Korea. Although the VRH had an overall po-

sitive impact on the study participants and

the ACH staff members. In this research also

founds some limits because of the experimen-

tal nature of the study. The results of quan-

titative analyses indicate that during the VRH experience, Subjects practiced more pleasure and a great level of alertness as shown in

<Figure 5>. which was highly appreciated for the VRH. The result of OERS also indicates the more level of anxiety/fear. [Lawton et al., 1999]. The results of anxiety/fear indicated the more research about this domain.

Furthermore, PEAR results are shown in the <Table 3> supports for the positive per- ception and indicated that the VRH created a stimulating environment and this helped the Subjects in absorption while experien- cing which in turn reduced their apathy. A return to baseline quantity is not infrequent in any populace when an involvement is re- moved but this does raise the question of the length of time that a person with dementia needs to be immersed in the virtual experience to see sustained changes. Based on environ- ment stimulation for elderly immersion, it can be stated that VRH had a deep impact on Subjects. In the case of PEAR good re- sults, the motivations of the ACH staff mem- bers (talking with them) was very impor- tant. They assisted the Subjects to introduce a possible confounding effect, whereby play- ful apart and suggesting causation is proble- matic.

Similarly, the purpose of making the VRH Hand Wrist Exercise to engage the elderly for exercise and results are shown in the

<Figure 6>. Initially, it was tough to motivate to ask the Subjects for exercise but ACH staff members (talking with them) assisted them for exercise after fifteen weeks of training, Subjects were sustained on exercise and ma- jority of them were feeling good. It’s impor- tant to realize that one on one communica- tion is obligatory for the elderly to motivate for the exercise. We conclude from these results that the motivations and consistency of the

Subjects lead them to the physical improve- ment with training weeks. The motivations for the elderly were found to be a very impor- tant factor by ACH staff members in this sce- nario. Due to motivations, the Subjects didn’t take this as a burden during VRH experience with fist exercise

The navigation scenario was made in the VRH with the determination of the improve- ment in memory, and this scenario also expe- rimented on the ACH Staff member (healthy mind). <Figure 7> shows that an inverse pro- portional relationship between the time taken by (a) Subjects and (b) ACH staff members to reach the destination in 15 training weeks.

Based on the results we can say that we have improved in memory in the Subjects and ACH staff members with training weeks. According to a psychologist, the reduction in the time is not only due to more practice of the same route by navigation, but also due to the moti- vation factor and discussion about the navi- gation path with each other were also impor- tant. All these factors come together and made improvement in memory of Subjects.

There were strong indicators that impact of VRH was adapted and reliant on several variables such as level of Cognitive Impair- ment. Specifically, the scores were assigned to the interactable objects and asked the Sub- ject to interact with objects contained high scores. Accordingly, the rewards system was made with the maximum five scores. In the training session, Subjects didn’t focus on hi- gher scores and they want to interact with all the objects. According to the psychologist, elderly people focused on the enjoyment and this involvement kept them engage with VRH.

Based on the results given in the <Figure 8>

and psychologist observations, it was con-

cluded that the elderly become fatigued when

engaging in VRH through the need, limited

movement, and interaction but, cognitive im- provement observed in the navigation scenario, when most of the Subjects tired cycling with hands, at that time they have walked through another technique by a look at the location.

Initially, they forgot about another technique for walking but gradually it was becoming a part of their movement.

This study justifies the immersion of vir- tual reality and this justification strengthens the positive impact of VRH on the elderly li- ving with dementia. We have some limita- tions of virtual reality, but these boundaries are device based and are reduced by impro- vements in device technology. Further stu- dies might be exploring the cost and effec- tiveness of virtual reality products in compa- rison to ACH staff members interacting with the subject or another media technology wi- thin VRH. The strength of this research is the addition of the participants with demen- tia in the qualitative assessment of VRH.

The results and suggestions have helped us to understand the changes that could be mer- ged in VRH.

7. Implication

This study suggests the VRH stimulated the Subjects to develop immersed in the in- volvement and the experience was reported by the ACH staff members as presence most suitable for the people with dementia. For the treatment of peoples suffered from demen- tia, Virtual Reality technology was appreciated.

The following development will be made in this technology through virtual reality :

∙There will be a separate scene related to water such as beach/fishing pond with some colorful Aquatic animals and interactable objects

∙Specific environments will add such as ACH inside the building view and its surrounding

∙All elements that are interactable objects will be clear with scores and obvious in decision making

∙The social factor will increase because you will talk more inside a VRH with relatively external motivation. Hence the staff influ- ences will be reduced.

∙Reward system will improve, and Subject will get a reward for every achievement, this factor increases the motivation for more immersion.

∙In the future, we need to improve our VRH according to the consequences and recom- mendations of Subjects and ACH staff mem- bers.

8. Conclusion

The creation of VRH has been an exclusive modernization in the use of Virtual Reality technology to engross and improve the lives of those peoples living with dementia. In this study, initial suggestions would advocate that the VRH has a positive impact on the elderly.

It shows the improvement in excitement, alert-

ness, physical exercise and memory improve-

ment, and decision making for the Subjects

living with dementia. The unwanted results

around anxiety/fear indicated the further-

more study and suggested by a psychologist

that the reason can be technophobia. It was

observed that the VRH experience shows the

positive impact in all scenarios of our pre-

sented study. The evaluation of the technical

and more gamification improvement in VRH

was required to engage the users those are

living with dementia to improve their efficiency.

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저자소개

Sungjun Park

Sungjun Park is a Professor

of Department of Game En-

gineering at Hoseo Univer-

sity. His current research in-

terests Game, VR, HCI, Com-

puter Vision and Bioinfor-

matics. Professor Park received and MS and

Ph.D in Computer Engineering from Konkuk

University in 1999 and 2005 respectively, and

BS in Computer Engineering from Hoseo

University in 1997.