Virtual Reality for Veteran Relaxation: Can VR Therapy Help Veterans Living With Dementia Who Exhibit Responsive Behaviors?
Authors: Appel Lora , Appel Eva , Kisonas Erika , Lewis Samantha , Sheng Lacey Qing 
Published: February 2022

Background: Due to the high prevalence of post-traumatic stress disorder (PTSD) among veterans, as this population ages, they are more likely to develop dementia and exhibit behavioral and psychological symptoms of dementia (BPSD), including responsive behaviors. BPSDs are linked to adverse clinical outcomes, hospitalization, and earlier mortality and are directly related to increased cost and burden of care. In long-term care institutions, residents' behaviors such as physical (striking out, biting, grabbing, etc.) and/or verbal (cursing, screaming, etc.) reactions are associated with higher staff burnout levels which contribute to absenteeism, high turnover, low engagement, and elevated risk of patient abuse or neglect. Despite their limited effectiveness and association with hastening of cognitive and physical decline, medications (neuroleptic/sedating drugs) are commonly used for people with dementia who exhibit responsive behaviors. In long-term care settings, more than 30% of veterans with high-care needs and 20% of those with low-care needs are prescribed drugs to manage their symptoms and behaviors. There is growing pressure from the medical community to engage in non-pharmacological strategies as the first-line of treatment to reduce BPSDs. Virtual reality (VR) presents a unique opportunity to transport people away from environmental factors that amplify feelings of loneliness, boredom, and discomfort, which are known to trigger responsive behaviors, into natural calming settings (such as a peaceful lake, or a colorful forest). Using immersive VR as a non-pharmacological therapy has been piloted with frail older adults in both community and acute-care settings with promising results. However, to date, there have been no rigorous longitudinal studies of VR therapy in long-term care, in particular, studies that evaluate its potential to reduce responsive behaviors related to triggering events. The current study provided novel opportunities for Perley and Rideau Veterans' Health Centre (Perley Health), which has prioritized reducing resident responsive behaviors and maintaining a healthy workforce.

Objective: The purpose of this study was to evaluate the feasibility and potential benefits of introducing VR therapy in a veterans' long-term care health center, with the main goal of reducing responsive behaviors for veterans living with dementia, including responsive behaviors related to experiencing physical and emotional pain. This includes evaluating VR therapy with respect to acceptability, comfort, enjoyment, relaxation, and its ability to promote reminiscence. Of special interest was the impact of VR therapy in cases where responsive behaviors were triggered by a predictable environmental event (e.g., bathing, toileting, etc.).

Methods: This was a prospective, longitudinal, non-randomized interventional study that employed convenience sampling. Veterans residing in this long-term care setting who exhibited responsive behaviors were recruited and grouped into two categories according to how they usually exhibited responsive behaviors: Group T—responsive behaviors were triggered by known activities or events in a relatively predictable way (e.g., sundowning, wound care), and Group S—initiation of responsive behaviors did not follow specific predictable patterns. Residents in both groups received the VR therapy intervention, which consisted of watching 360° VR video footage of natural and social scenes using an Oculus Go head-mounted-display. Group T received “targeted” VR therapy sessions occurring just before or during events that could trigger responsive behaviors (e.g., before bathing). Group S received “scheduled” VR therapy sessions akin to other recreational activities (e.g., at a mutually convenient time during the day). Intended data collection consisted of baseline scores from validated tools including the Pain Assessment for Advanced Dementia (PAINAD), Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS), and Palliative Performance Scale and daily clinical progress notes extracted from patients' electronic records during the study period, as well as intervention data-collection tool comprising a quantitative survey (for residents' feedback when possible) and qualitative structured observations during the intervention by recreational therapists (RTs). Also described are the changes implemented to data collection and analyses as a number of methodological challenges arose during the study.

Results: Thirty-three veterans (mean age 91.6 years, SD 5.9) with varying degrees of cognitive impairment: 3% (1/33) borderline intact, 15% (5/33) mild impairment, 61% (20/33) moderate impairment, 12% (4/33) moderately severe impairment, and 6% (2/33) severe impairment participated in the study. The number of sessions per participant ranged from 2 to 6, with an average of 3.3 (SD = 1) sessions per participant. A total of 111 VR therapy sessions took place, 98 of which were scheduled (88%) and 13 were targeted (12%). The RTs reported that targeted sessions were particularly difficult to conduct due to staffing/resource constraints. In 61% (68/111) of all sessions, no responsive behaviors were observed during, or soon after, the VR therapy, and no pro re nata (PRN) medications had to be administered during the sessions. In 46% (6/13) of targeted sessions, participants did not exhibit responsive behaviors usually triggered by a specific environmental event. The majority (63%, 70/111) of participants found the technology comfortable, and in 47% (52/111) of sessions, the RTs reported that VR therapy made the resident feel good or better than they felt before the session. In 33% (37/111) of all sessions, residents reminisced about the past and in 67% (74/111) of sessions residents reported wanting to try VR again.

Conclusion: Findings indicate that VR therapy is overall acceptable and enjoyable for veterans living with dementia with varying degrees of cognitive and physical impairments. Staff at the veterans' center continued to use scheduled VR therapy as a recreational tool beyond the study period. Notwithstanding the difficulties in administering targeted sessions, there was observational evidence of the potential to reduce environmentally triggered responsive behaviors; this warrants further exploration of approaches to improve protocol feasibility in support of studying treatment effectiveness. Finally, manufacturers and providers of VR therapy should consider ways in which content, equipment, and administration can be customized and optimized for this particularly frail and diverse population.