Usability and Acceptability of Virtual Reality-based Cognitive Stimulation by Healthy Participants
Phase: NA
Conditions: Virtual Reality
Sponsor: The Methodist Hospital Research Institute

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PROTOCOL TITLE: 
Usability and acceptability of virtual reality-based cognitive stimulation by healthy participants 
 
PRINCIPAL INVESTIGATOR  
Hina Faisal, MD/Department of Surgery 
 
CO-INVESTIGATORS/ COLLABORATORS: 
Eugene C. Lai, MD / Neurologist  
Jiaqiong Susan Xu/Statistician 
Antara Dattagupta, EnMED student  
 
SPONSOR / FUNDING AGENCY  
Houston Methodist Hospital  
Reliant Innovation grant 
 
VERSION NUMBER/DATE  
v.1: 05 JUN 2022  
REVISION HISTORY 
 
Revision # 
Version Date 
Summary of Changes 
Consent Change 
(Yes/No) 
 
 
 
 
 
 
 
 
1. Study Summary  
Virtual reality (VR) imitates reality by creating an artificial 3-D environment using computing 
technology or software. Using this software with a headset, a virtual environment is created, 
which cognitively stimulates the user's brain to think they are in an artificial world. Creating a 
virtual environment allows flexibility and measurement of different types of stimuli while 
recording the various responses provided by users in the controlled virtual environment. VR 
strengthens the brains' ability to focus, learn, and retain experience. VR for attention deficit 
disorders has been reported to have promising results. We plan to follow in similar footsteps 
using the gamification of exercises for cognitive stimulation in healthy volunteers to record 
outcomes and usability testing.1 These exercise "games" allow users to focus and pay attention 
to the game while helping reorient and cognitively stimulate the user's brain. The games are built 
with increasing difficulty and complexity of user demand and output. Our team developed a 

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novel, 3D simulated software platform prototype called  ReCognition VR to provide VR-based 
cognitive exercises to healthy participants for testing.   
Our premise is that  VR-based cognitive stimulation software will allow controlled delivery of 
structured cognitive exercises focusing on orientation, attention, memory, and executive 
functions. The system will allow customized frequency and duration of cognitive exercises based 
on the users' difficulty level in a delightfully relaxed- environment with music.  
Hypothesis: 
We will test the hypothesis that VR-based cognitive exercise will be feasible and acceptable by 
the test population.  
2. Purpose of the Study / Objectives  
The purpose of this study is to determine the feasibility, acceptability and usability, and to assess 
the safety of use of a VR-based software in health volunteers. Results from this study will be used 
to inform the design of a future study in hospitalized patients at risk for delirium. 
The question that drives this study is: 
In healthy volunteers, what is the feasibility of use of the ReCognition VR-based software and 
what is the acceptability and usability of the software? 
OBJECTIVES AND ENDPOINTS 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
Primary 
 
 
The primary objective of this 
study is to assess the feasibility 
of VR-based cognitive 
stimulation exercises in healthy 
volunteers.  
The primary endpoint is use of the 
ReCognition  VR-based software 
for 20 minutes by 70% of enrolled 
participants. 
It is important to 
know if participants 
can complete the 
exercise since an 
incomplete 
experience will 
prohibit assessment 
of the other variables 
to be measured. 
Secondary 
 
 
The secondary objectives are  
• to determine the 
acceptability and usability of 
VR-based cognitive 
stimulation exercises 
The secondary endpoints are: 
• Acceptability and usability: the 
proportion of participants with 
a System Usability Scale (SUS) 
score >35. 
Successful 
implementation 
depends on the 
acceptability of the 
intervention and is 
one of the main 
factors considered 
before adopting and 

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OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
• Proportion of participants who 
complete the game without 
any user errors  
• Number of attempts to 
complete the game.  
implementing 
computerized 
cognitive software. 
Tertiary/Exploratory  
 
 
Tertiary objectives are to report 
the safety of VR-based cognitive 
stimulation exercises in healthy 
volunteers. 
• Safety will be assessed using 
each of the following 
endpoints: 
1. Mean change from pre to 
10 minutes: 
a. Heart rate variability:  
b. Pulse oximetry oxygen 
saturation (SpO2) 
c. Respiratory rate 
d. Blood pressure 
2. Mean change from pre to 
end of VR session: 
a. Heart rate variability:  
b. Pulse oximetry oxygen 
saturation (SpO2) 
c. Respiratory rate 
d. Blood pressure 
Knowing the 
proportion of change 
in these biometric 
measures will assist 
in designing future  
investigation of 
patients at risk of 
delirium 
 
3. Background   
Attention is the most crucial cognitive domain required for the effective completion of mentally 
challenging tasks by healthy individuals. Many healthy people cannot complete high executive 
brain functioning tasks due to lack of focus or attention, leading to poor performance both at 
work and home. Generally, mild attention deficit is not identified, and daily life stresses are 
usually blamed. Computerized cognitive training programs have shown improved attention 
deficit disorder and mild cognitive impairment. Virtual Reality (VR) is an emerging technology 
and can improve brain functions, including attention. VR engages multiple learning systems, 
making it a more effective natural environment for cognitive training. Based on this idea, our 
team developed a 3D simulated software platform prototype called ReCognition VR with 
incorporated exercise in the forms of games that can improve attention and executive functions.  

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Recognition VR software (Figure 1) allows users to 
immerse themselves in a relaxing virtual 
environment; reorient the user to person, time, 
and location; and play mini-games to encourage 
attention, focus, and movement of limbs; and 
record user progress and scores in mini-games. 
Critical gaps exist in our knowledge of cognitive 
interventions and their application through VR. 
Data on interventions focused on early cognitive 
exercise using Virtual Reality Simulation, 
specifically using Oculus Quest 2 and Unity 
software, are limited. Moreover, many critical barriers to implementing cognitive exercise in 
clinical protocols exist. Cognitive stimulation through VR is a new and upcoming area in 
technology that is rapidly expanding but currently limited in the literature. A lack of 
understanding or appreciation for the evidence supporting cognitive stimulation through VR, 
specifically gamification, contributes to the barriers. The rapid increase and use of VR in other 
areas urges our team to seek this area for development.   
The major goals of this proposal are to assess the feasibility and usability of VR-based cognitive 
interventions in healthy volunteers using ReCognition VR software while providing easy delivery 
of cognitive stimulation exercises provided by VR. 
4. Study Design 
The study is a single-center, prospective assessment of the feasibility, acceptability and usability 
of ReCognition VR -based simulated cognitive stimulation to improve attention and focus in 
healthy participants.  
Sample size: We will enroll 30 participants: 15 participants who are >18 or up to 35 years of age 
and 15 participants who are >60 years of age. Results from each age group will be analyzed 
separately. 
Justification of sample size: The study is a feasibility study having the expectation that 70% of 
participants in each group (>18-35 years of age and >60 years of age) will complete 20 minutes 
of the ReCognition VR-based exercise and where each group will be evaluated separately. 
Descriptive statistics will be used to summarize the findings; 15 participants in each group will be 
recruited. The intent is that this study will provide information for a larger, subsequent clinical 
trial of patients >60 years old at risk for delirium. 
 
Data and measures to be taken: 
The endpoints for this feasibility study are: 
Primary – 70% of participants in each group will complete 20 minutes of use of the ReCognition 
VR-based software (a binary outcome). 
 
Figure 1: Describes the system architecture to the 
observer and healthy participants 

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Secondary – We will measure the acceptability and usability of the experience based on the 
proportion of participants with a System Usability Scale (SUS) score >35. 
We will report on the proportion of participants who complete the game without any user errors  
We will report on the number of attempts each participant uses to complete the game. 
We will examine measure that can inform on safety of the experience to be used in the 
subsequent clinical trial. The measures are: 
1. Mean change from pre to 10 minutes of the ReCognition VR-based exercise in: 
a. Heart rate variability:  
b. Pulse oximetry oxygen saturation (SpO2) 
c. Respiratory rate 
d. Blood pressure 
2. Mean change from pre to end of the ReCognition VR-based exercise in: 
a. Heart rate variability:  
b. Pulse oximetry oxygen saturation (SpO2) 
c. Respiratory rate 
d. Blood pressure 
We will report the demographic variables of age, sex, race and ethnicity for each group and the 
clinical characteristics whereby they meet ASA criteria (body mass index, self-reported history of 
hypertension with active management, drinking status, and smoking status; see Section 9). 
Accessing data from medical records: 
This feasibility study involves healthy volunteers. No medical records will be reviewed. Medical 
history will be self-reported. 
Data analysis plan: 
The results of this study will be reported using descriptive statistics. Continuous variables will be 
reported as means with standard deviation or medians and interquartile range contingent on 
normality of the distribution. Categorical variables will be reported using Chi-square or Fisher’s 
exact test, as appropriate. 
5. Study Intervention 
1. The healthy participants will be selected from a random population to use the 
Recognition VR – based cognitive exercise interventions. 
2. The study participants will receive a 3D- ReCognition VR-based simulated cognitive 
exercise program targeting attention, organizing thinking, motor activities, and executive 
brain functions. 
3. The study team will create an order set for the 3-D Recognition VR – based cognitive 
stimulation exercise sessions to be delivered to the healthy participants who will place 
virtual reality headsets on themselves. 
4. The detail of the software as follows:  
3-D Recognition Virtual Reality-Based Simulation Sessions Program: 

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Software Platform:  
Virtual reality platform  will consist of  
- 
The virtual reality headsets manufactured by the Oculus Quest 2 glasses (Facebook inc., 
USA) with stereoscopic vision and stereo sound will be used to show the virtual world to 
participants. 
- 
Motion Sensor   
- 
Flat Screen TV with Software  
The virtual reality headsets manufactured by the Oculus Quest 2 glasses (Facebook inc., USA) 
with stereoscopic vision and stereo sound will be used to show the virtual reality to study 
participants. After headset placement, the study participants will be able to follow instructions 
provided by virtual nurse AVATAR. The participants will receive low cognitive load exercises 
based on virtual reality techniques, including a relaxed environment, music therapy, time 
orientation, delivery instructions, and task completion motivation. The exercise task will focus on 
attention, organized thinking, motor activities, and executive brain functions.  
Dosing: 
The study participants will receive approximately 20 minutes of VR- based cognitive stimulation 
session and fill out a post-user survey.  
The session will provide neurocognitive stimulation, engagement through exercise. 
The physiological data of vital signs will be recorded before, during, and after sessions (see 
Schedule of Activities).  
Acceptability Survey: 
PI or a research team member will interview the healthy participants using the System Usability 
Scale survey.   
The estimated date to complete the study is one month after the last participant is enrolled.  
Schedule of activities 
Procedures 
Day 1,  
Time 1: 
pre 
Day 1,  
Time 2: 
10 
minutes 
Day 1,  
Time 3: 
post 
Day 1, 
Time 4: 
end of 
study 
Informed consent 
X 
 
 
 
Demographics 
X 
 
 
 
Medical history 
X 
 
 
 
Administer study intervention 
|--------------X---------------| 
 
Concomitant medication review 
X 
 
 
 
Physical exam (including height and 
weight) 
X 
 
 
 

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Procedures 
Day 1,  
Time 1: 
pre 
Day 1,  
Time 2: 
10 
minutes 
Day 1,  
Time 3: 
post 
Day 1, 
Time 4: 
end of 
study 
Frailty assessment 
X 
 
 
 
Heart rate variability 
X 
X 
X 
 
Pulse oximetry 
X 
X 
X 
 
Respiratory rate 
X 
X 
X 
 
Blood pressure 
X 
X 
X 
 
System User Survey 
 
 
 
X 
Adverse event review and evaluation 
 
 
 
X 
Complete Case Report Forms (CRFs) 
X 
 
 
X 
 
6. Drugs, Biologics, Devices  
Specifically, VR will be simulated using UNITY software and Oculus quest (two headsets) for this 
project.  
7. Collaborative / Multi-site Research 
N/A 
8. Data Privacy / Confidentiality  
Houston Methodist policies for Protected Health Information (PHI) will be followed, including all 
physical and electronic data security requirements, encrypted devices, and HM password-
protected servers. 
All data obtained for the study will be stored in a password-protected spreadsheet in a 
Methodist server and will only be accessible to IRB-approved investigators and research staff at 
Houston Methodist. Data will be completely de-identified at the time of collection and sent to 
the statistician via secure mail for analysis. Research materials will be stored in a password-
protected computer system database on a secure server on the Houston Methodist network. 
Data collected will be transferred and stored on RedCap, a secure web application for building 
and managing databases. Study personnel requiring access will have their own Login/Password. 
Access to clinical study information will be based on individuals' roles and responsibilities. All 
study data will be transmitted over an encrypted SSL (Secure Sockets Layer) connection that 
requires user authentication. This application is designed to be in full compliance with the 
International Conference on Harmonization and Good Clinical Practices (ICH-GCP), the FDA's 
Code of Federal Regulations (CFR) 21 Part 11 Electronic Record and Electronic Signatures, the 

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FDA's "Guidance: Computerized Systems Used in Clinical Trials," and the Privacy Rule of the 
Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
HMRI policy on record retention will be followed, and human subject research data will be kept a 
minimum of 6 years after completing the study.  Research written materials will be stored in the 
Department of Surgery Research Office (Skurlock 1150) and electronic materials on password-
protected computer systems on a secure server on the Houston Methodist network.   
A unique identification code will be assigned to each participant in this study, and the study team 
will maintain the linking log. The only individuals who can see un-coded personal health 
information include the Study Team and the Institutional Review Board at the hospital, 
employees of the sponsor who check that this study is being done correctly, and regulatory 
authorities where required by law.   
Data to be collected include: 
• Sex 
• Age 
• Race, ethnicity 
• Height, weight 
• Heart rate variability & heart rate variability analysis  (Time Frame: before, during, 
and after use of RecognitionVR software; see Schedule of Activities) 
• Pulse oximetry oxygen saturation (SpO2) (Time Frame: before, during, and after 
use of RecognitionVR software; see Schedule of Activities) 
• Respiratory rate (Time Frame: before, during and after use of RecognitionVR 
software; see Schedule of Activities) 
• Safety adverse events 
 
Identifier (or parts of)  
Recorded  Disclosed  Comment 
All elements of dates (except year) for dates 
directly related to an individual, including 
patient names, birth date, admission date, 
discharge date, date of death; and all ages 
over 89 and elements of dates (including 
year) indicative of such age 
Yes 
No 
Necessary for complete data 
analysis 
Phone numbers; Fax numbers 
Yes 
No 
Necessary to complete a 
questionnaire 
Medical record numbers 
Yes 
No 
Necessary to organize data 
collection 
Any other unique identifying number, 
characteristic, or code 
Yes 
No 
Virtual cognitive 
interventions frequency 
delieverd  

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9. Data and Specimen Banking  
No specimens will be obtained, stored, or banked in this study.   
10. Study Population  
This study will be a single-center study of healthy volunteers conducted at Houston Methodist 
Hospital. We will enroll 15 participants who are >18 and <35 years of age and 15 participants 
who are ≥60 years of age. The rationale for the age distribution is to obtain information from 
people who are considered healthy by ASA criteria 1 and people who meet ASA criteria 2. 
Partcipiants who are >18 to 35 years of age are a) more likely to have experienced VR software 
previously and b) more likely to meet ASA criteria 1. Participants who are >60 years of age are a) 
less likely to have experienced VR software previously and b) more likely to  meet ASA criteria 2 . 
These older participants are considered similar to the target population of a proposed 
subsequent inventional clinical trial; however, it is possible that participants in the younger age 
group (>18 to 35 years of age) may meet ASA crtieria 2.   
A total of 30 participants will be prospectively enrolled. All participants will be given post-use 
surveys to assess usability and efficacy outcomes. 
Inclusion Criteria: 
1. Healthy volunteers >18 years of age who meet one of the following criteria: 
a. ASA 1: A normal healthy patient. Example: Fit, nonobese (BMI under 30), a 
nonsmoking patient with good exercise tolerance. 
b. ASA 2: A patient with mild systemic disease. Example: Patient with no functional 
limitations and a well-controlled disease (eg, treated hypertension, obesity with 
BMI under 35, frequent social drinker, but is nonsmoking). 
2. Person without underlying cognitive disorder or associated phobias (eg. claustrophobia). 
Exclusion Criteria:  
1. Person with active psychiatry disorders, especially schizophrenia 
2. Person who is deaf or blind. 
11. Screening and Recruitment 
All participants will be screened by the principal investigator and clinical research staff, who have 
been trained in the clinical investigational plan, to determine if the potential participant is 
eligible for enrollment. Potential participants will be assigned a screening number which be 
recorded in an excel sheet; all participants who receive the study intervention during the will be 
noted. All participants must meet eligibility criteria (and if not, which eligibility criteria were not 
met will be recorded); reasons for not meeting enrollmente criteria or receiving study 
intervention will be recorded. No participants belonging to a vulnerable population will be 
enrolled.  
During the informed consent process, the investigator or designee, who has been trained on the 
protocol, will explain the nature and scope of the intervention, potential risks, and benefits of 

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participation and answer questions from the potential participants. All participants will sign and 
date the Institutional Review Board (IRB)/Ethics Committee (EC) approved informed consent 
form before any study-specific procedures are performed. In addition, the signed informed 
consent will be retained with the research records, and a copy will be given to the participant. 
Healthy Participants will be identified: 
1. Through public advertisement sent via flyers posted around Texas Medical Center and mass 
emails to public domain emailing lists for example, University of Houston and Rice University, 
available to the local Houston population. 
No medical records will be reviewed for this healthy volunteer study. Medical history obtained 
will be from participant self-report.  
12. Withdrawal of Subjects 
Participants will be withdrawn from the study if they do not receive any study interventions. At 
the moment of withdrawal, all data related to participant will be removed from the 
corresponding excel documents and waivers will be shredded.   
A participant may discontinue his or her participation without giving a reason at any time during 
the study. For example, the Principal Investigator may withdraw a participant due to failure to 
comply with pilot study intervention requirements, or the participant is uncooperative or refuses 
to continue in the study intervention.   
13. Provisions to Protect the Privacy Interests of Subjects  
Only the minimum amount of personal information needed to conduct this study will be 
collected regarding participants' privacy interests.  Study participants will be informed that the 
only individuals who can see un-coded personal health information include the following: the 
Study Doctor, other employees who work on this study (including the Institutional Review Board) 
at the hospital, employees of the sponsor who check that this study is being done correctly, and 
regulatory authorities where required by law. In addition, participants will be carefully informed 
about the Release of Health Information section in the ICF, which describes who will access their 
information and how it will be used.  We will emphasize that participation in this study is 
voluntary and that participants can choose at any time to cease participation and revoke 
authorization to use and disclose their information. 
14. Risks to Subjects 
The risks below are associated with the use of the Oculus Quest 2 Virtual Reality Headset Device.  
All adverse events (AEs) will be captured, and recorded at each time point. We will report AEs as 
a proportion of study participants who developed AEs. 
Specific AEs to be monitored will include: 
Neurological AEs: (defined as new-onset blurry vision, tingling, perioral numbness, seizures, 
or coma within 30 minutes after starting the study intervention) 

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Cardiovascular AEs:  (defined as new-onset hypotension [SBP <90 mmHg and DBP <60 
mmHg], bradycardia [HR < 50 bpm], tachycardia [HR  >130 bsspm], or any new hemodynamic 
instability requiring more than two vasopressors after starting the study interventions 
Pulmonary AEs: (defined as new-onset hypoxia [SpO2 < 88%] and/or hypercarbia [PCO2 > 60 
mmHg] on arterial blood gas within 30 minutes of starting study interventions 
Cardiac Adverse Events:  New-onset hypotension (SBP <90 mmHg and DBP <60 mmHg),  
Bradycardia (HR < 50), Tachycardia (HR> 100), and Arrhythmias (Supraventricular or 
ventricular ) with HR> 150 beats per minutes within 5 minutes after the starting of 3D 
Simulated VR sessions. Or changes >20% from baselines. 
Pulmonary Adverse Events: New-onset hypoxia: SpO2 < 88%, Respirator rate > 35 
breaths/minute within 5 minutes after the starting of 3D Simulated VR sessions.   
Others:Rash, nystagmus, muscular hypertonicity, clonus or myoclonic jerks, and allergic 
reactions  
If enrolled participants vital signs changes > 20% from baseline, the session will be stopped as 
it would be considered unsafe events 
The safety precautions to minimize the risk to participants are as follows: 
Vital signs BP, HR, RR, SPO2, and pain scores (using numeric pain rating scale tool) will be 
monitored before, during, and after using ReCognitionVR software. 
15. Potential Benefits  
No direct benefit to participants is anticipated. The data from this study is expected to inform on 
a subsequent clinical trial of the use of the ReCognition VR-based software in patients at risk for 
delirium. 
16. Financial and Economic Issues  
The participants in this study will not be compensated, and there is no additional cost to 
participants for taking part in this study. 
17. Data Safety Plan  
• The research team plans to periodically evaluate data collected regarding the benefits 
and harms of the study in order to evaluate the safety of the participants 
• Data reviewed periodically will be the following: 
o Accuracy of the game/outcome 
o Adverse effects occurred during study intervention (ex. Seizures, nystagmus etc.) 
o Adverse effects post-24 hours of study intervention 
o Number of software and device re-starts and re-sets.  
 
• Safety information will be collected during study visits and through telephone calls with 
participants 

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• Data collection will occur during the game. Specifically after the user plays the minigame 
in the ReCognitionVR Software. The software has been programmed to report the 
outcome to the research team once the user plays the minigame. Safety data collection 
will begin before the study intervention and also be collected 24 hours after study 
intervention.  
All study data will be transmitted over an encrypted SSL (Secure Sockets Layer) connection that 
requires user authentication. This application is designed to be in full compliance with the 
International Conference on Harmonization and Good Clinical Practices (ICH-GCP), the FDA's 
Code of Federal Regulations (CFR) 21 Part 11 Electronic Record and Electronic Signatures, the 
FDA's "Guidance: Computerized Systems Used in Clinical Trials," and the Privacy Rule of the 
Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
HMRI policy on record retention will be followed, and human subject research data will be kept a 
minimum of 6 years after the completion of the study.  Research materials will be stored in \ on 
password-protected computer systems on a secure server on the Houston Methodist network.   
The roles and responsibilities of the Investigators (a) assuring that the trial is conducted 
according to the Protocol and MOP; (b) identifying, recruiting, and enrolling participants; (c) 
obtaining informed consent from each participant and protecting their rights; (d) collecting and 
entering study data into REDCap, and following participants through study completion: (e) 
assuring regular IRB/REB review. 
18. Informed Consent Documentation and Process  
Informed consent will be obtained in written format using a consent document that is HMRI-
approved. The investigators involved in the consent process will all be credentialed at HMRI to 
participate in research at HMH.  System Policy and Procedure RE-12 will be followed. The PI and 
investigators will identify healthy participants through public and randomized advertisement. 
Potential participants may also consent on the same day of use of ReCognitionVR software. 
During the informed consent process, the investigator or designee, who has been trained on the 
protocol, will explain the nature and scope of the intervention, potential risks, and benefits of 
participation and answer questions from the potential participants. All participants must sign and 
date the Institutional Review Board (IRB) approved informed consent form. 
Additionally, the signed informed consent must be kept in the participant's medical records, and 
a copy must be given to the participant.  During the informed consent process, the investigator 
and designee, who has been trained on the protocol, will explain the nature and scope of the 
intervention, potential risks, and benefits of participation and answer questions from the 
potential participants. Participants will be informed that the study is investigational and that 
their participation in the study is voluntary. They will be informed that they may refuse to 
participate or may withdraw consent to participate at any time, and for any reason, without 
jeopardizing their future care at this institution. 
The PI and study team will ensure enough time to explain the ICF to the participants and answer 
all questions before signing the ICF. The study and the contents of the ICF will be explained in 

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detail, and ample time will be given to the study participant to read the consent and discuss it. 
Questions will be encouraged and will be answered to the participant's before the document is 
signed. The study team will not proceed if adequate time is not available to the participant to 
demonstrate an understanding of the study and indicate a desire to participate. 
19. Waiver of Informed Consent and /or Authorization 
No waiver of informed consent or authorization is requested. No medical records will be 
reviewed. Participants will self-report their medical history. No PHI will be recorded or stored if 
the participant does not fit study eligibility or inclusion criteria. The study team will only collect 
the minimum necessary information to verify eligibility per inclusion or exclusion criteria. If the 
participant is eligible based on the study's inclusion criteria and agrees to participate in the 
study, then the PI or study team will gain informed consent before collecting any PHI or 
conducting any study-related procedures.  
20. References 
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The virtual classroom: a virtual reality environment for the assessment and rehabilitation of attention 
deficits. Cyber Psychol. Behav. 3, 483–499. doi: 
10.1089/10949310050078940doi:10.1002/14651858.CD008349.pub4 
2. Lee E, Kim J. Cost-benefit analysis of a delirium prevention strategy in the intensive care unit [published 
online ahead of print, 2014 Oct 29]. Nurs Crit Care. 2014;10.1111/nicc.12124. doi:10.1111/nicc.12124. 
3. Turon M, Fernandez-Gonzalo S, Jodar M, et al. Feasibility and safety of virtual-reality-based early 
neurocognitive stimulation in critically ill patients. Ann Intensive Care. 2017;7(1):81. doi:10.1186/s13613-
017-0303-4. 
4. Kolenda, H., Gremmelt, A., Rading, S. et al. Ketamine for analgosedative therapy in intensive care 
treatment of head-injured patients. Acta neurochir 138, 1193–1199. 1996. 
5. Ostermann ME, Keenan SP, Seiferling RA, Sibbald WJ. Sedation in the Intensive Care Unit: A Systematic 
Review. JAMA. 2000;283(11):1451–1459. doi:10.1001/jama.283.11.1451 
6. Elamin et al., Is ketamine the right sedative for intensive care unit patients?: 12AP9-1.European journal 
of anaesthesiology,June 2007-volume 24-issue,p161