The Influence of Virtual Reality on Dementia (PDF)

Int. J. Human–Computer Studies 196 (2025) 103413 Contents lists available at ScienceDirect International Journal of Human - Computer Studies...

Int. J. Human–Computer Studies 196 (2025) 103413 Contents lists available at ScienceDirect International Journal of Human - Computer Studies journal homepage: www.elsevier.com/locate/ijhcs “Transported to a better place”: The influence of virtual reality on the behavioural and psychological symptoms of dementia Maria Matsangidou a,*, Theodoros Solomou b , Fotos Frangoudes a , Ersi Papayianni c, Natalie Kkeli c , Constantinos S. Pattichi a,b a CYENS Centre of Excellence, Nicosia, Cyprus b Department of Computer Science, University of Cyprus, Nicosia, Cyprus c Archangelos Michael Elderly People Nursing Home/Rehabilitation Centre for Patients with Alzheimer, Nicosia, Cyprus A R T I C L E I N F O A B S T R A C T Keywords: Emerging research supports that institutionalisation may contribute to the development of the behavioural and Virtual reality psychological symptoms of dementia. Many studies have documented that Virtual Reality can enhance symptom Dementia management in people diagnosed with dementia. We design a Virtual Reality system to improve the symptom Patient-centered design management of people diagnosed with dementia residing in long-term care services. Twenty people with de­ Psychophysiological responses mentia were enrolled in the study to evaluate the developed solution. Following semi-structured interviews and Behavioural and psychological symptoms of dementia observations, a thematic analysis was conducted to analyse the results of the system. Heart Rate and Eye-tracking data were recorded to enhance the reliability of the findings. Our findings indicate that Virtual Reality might be able to improve the quality of life of people diagnosed with dementia, as it is highly effective in reducing behavioral and psychological symptoms associated with dementia, including aggression, agitation, anxiety, apathy, and depression. Additionally, Virtual Reality was found to be a possible solution for pain management, reminiscence therapy, and dementia diagnosis. 1. Introduction 2022). In 2021, the World Health Organization (WHO) estimated that the Dementia is an umbrella term for conditions leading to cognitive and total number of People with Dementia (PwD) around the world exceeds social functioning deterioration. It affects the afflicted person’s memory, fifty-five million people, and more importantly, the number of PwD is thinking, orientation, comprehension, calculation, learning capacity, expected to rise to one hundred thirty-nine million by 2050 (World language, and judgment. Dementia is commonly accompanied by Health Organization (WHO), 2021). As dementia is the seventh most behavioural and psychological symptoms of dementia (BPSD), which common cause of death worldwide and the leading cause of disability include challenging behaviours such as mood disturbances and lack of and dependency for older people (World Health Organization (WHO), emotional control (World Health Organization (WHO), 2021). These 2021), a Global Action Plan has been developed and released with a symptoms significantly impact the quality of life (HRQoL) of both Peo­ major priority to improve the Health-Related Quality of Life (HRQoL) ple with Dementia (PwD) and their caregivers (Appel et al., 2016; Kales for PwD (Verbeek et al., 2010; World Health Organization (WHO), et al., 2015; Sampson et al., 2014; White et al., 2017). The symptoms of 2017). BPSD can range from aggressive physical or verbal behaviour towards According to previous research, most interventions for PwD that aim self and others (e.g., hitting, grabbing, picking/scratching their skin, to improve their HRQoL and decrease the BPSD are mostly based on making loud noises, shouting angrily, cursing, screaming), to restless­ overprescribed and ineffective neuroleptic or sedating medications and ness, irritability, and agitated behaviours (e.g., pacing nervously, mov­ physical barriers (such as alarms and locks), which were found to ing excessively), or even to depression, apathy, and diminished accelerate the cognitive and physical decline of the PwD (Banerjee, motivation (Alzheimer’s Society of Canada, 2019; Pelletier and Land­ 2009; Banerjee et al., 2011; Appel et al.; 2020). Specifically, the use of reville, 2007; Savva et al., 2009; World Health Organization (WHO), neuroleptic or sedating medication has been associated with the * Corresponding author. E-mail address: [email protected] (M. Matsangidou). https://doi.org/10.1016/j.ijhcs.2024.103413 Received 15 November 2023; Received in revised form 27 November 2024; Accepted 27 November 2024 Available online 30 November 2024 1071-5819/© 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 condition worsening (e.g., faster cognitive decline), cardiovascular dis­ technology-based non-pharmaceutical interventions for dementia, orders, infections, drowsiness, nausea, fatigue, weight gain, headaches, chatbots and cognitive games are widely used to enhance patient and increases in anxiety, distress, and aggressiveness (Banerjee et al., engagement and provide therapeutic support. For example, AI-driven 2011; Appel et al., 2016; White et al.; 2017). Thus, and in line with the chatbots like Replika, 2024 offer personalized conversational in­ Global Action Plan (World Health Organization (WHO), 2017), it was teractions that help alleviate loneliness and stimulate cognitive recommended that best practices reflect the use of pharmacological in­ engagement (Ta et al., 2020). Similarly, games like Sea Hero Quest are terventions and physical restraints only as a last resort to treat complex designed to test and support spatial navigation, a critical cognitive skill cases where non-pharmacological interventions have proven often impaired in dementia (Alzheimer’s Research, 2024). Other pro­ unsuccessful. jects, like Lumosity, use gamified exercises to improve cognitive func­ Non-pharmacological interventions, which include sensory stimula­ tions and mood (McCallum and Boletsis, 2013; Hardy and Scanlon, tion (e.g., aromatherapy, thermal bath, calming music, hand massage), 2009). These tools promote cognitive health and mood improvement social engagement, exposure to interests and activities, alternative en­ and offer scalable, patient-centered care alternatives accessible to users vironments, and therapies based on behavior, reminiscence, music, and worldwide, making them an essential part of modern dementia care art, are now the preferred approach for treating BPSD. A growing body strategies. of evidence supports the effectiveness of these interventions. For In recent years, VR has become one of the most accessible and low- instance, reminiscence therapy has been associated with reduced chal­ cost solutions in the healthcare domain and it has been used in a vari­ lenging behaviors (Kasl-Godley and Gatz, 2000), as well as improved ety of medical applications, including but not limited, to areas of cognition and mood (Woods et al., 2018). Similarly, participation in art delivering treatment to people with mental health disorders (e.g., anx­ and music therapies has been shown to decrease agitation, anxiety, and iety and depression (Fodor et al., 2018; Zeng et al., 2018), eating dis­ depression (Gómez-Romero et al., 2017; Kishita et al., 2020; Livingston orders (Clus et al., 2018; Matsangidou et al., 2022), phobias (Botella et al., 2014; Zhang et al., 2017). Overall, a special emphasis is placed on et al., 2017; Parsons and Rizzo, 2008), psychosis (Rus-Calafell et al., the patient-centric philosophy of care (Kitwood and Kitwood, 1997), 2018), paranoid ideations (Valmaggia et al., 2007), schizophrenia (Park and the implementation of individualised formulation-led interventions. et al., 2011)). To date, computer technology, and especially Virtual Reality (VR), Current research suggests that VR can be a reliable, feasible, and has provided significant opportunities to support and enhance non- acceptable solution, promoting engagement and providing an enjoyable pharmacological interventions due to its ability to immerse users in experience for PwD (Rose et al., 2018; Appel et al., 2021), since it offers diverse environments and situations. VR is particularly valuable for PwD the user multisensory interactions and feedback (e.g., visual, auditory, because it can transcend physical boundaries, offering the experience of tactile, and/or olfactory). Within the context of the Human-Computer being in an entirely different setting—such as a forest or a beach—while Interaction (HCI) research field, the elements a VR system should they are physically confined to a room. This capability is especially incorporate for PwD have been examined, with the main conclusion that important for PwD, who often face isolation and environmental con­ special effort should be placed on creating personalised experiences that straints due to limited mobility or the need for constant supervision. By take into consideration the preferences and skill level of each user simulating rich, calming, and familiar environments, VR can alleviate (Hodge et al., 2018; Matsangidou et al., 2022; Siriaraya and Ang, 2014; the sense of confinement and isolation that many PwD experience. Tabbaa et al., 2019). More generally, most of the research on VR for PwD Moreover, VR can stimulate emotional responses and trigger positive, has focused on the improvement of the capabilities that deteriorate over responsive behaviors, which are often difficult to achieve in a controlled, time due to the progression of the disease. These capabilities typically physical environment. For example, exposure to soothing natural set­ relate to cognition (Sayma et al., 2020; Zhu et al., 2021), memory tings or exploring familiar landmarks can evoke and amplify responsive (Optale et al., 2010), spatial navigation (Cushman et al., 2008; Zakzanis behaviors and emotional reactions. This immersive experience has the et al., 2009), executive functions such as planning activities (Manera potential to provide therapeutic benefits without the need for physical et al., 2015) and attention (Doniger et al., 2018; Manera et al., 2016), movement or travel, which may be impossible for many PwD. In terms of and motor control (Matsangidou et al., 2022; 2022; 2020). feasibility, recent studies have shown promising results in using VR with To date, recent studies have reported successful deployments of VR PwD. Research suggests that PwD respond positively to VR environ­ for PwD. However, further evaluation is still needed due to inconclusive ments, finding the experience enjoyable and stimulating. These results results at this early stage (Appel et al., 2016; Huang and Yang, 2022; highlight VR’s potential as a powerful tool to engage patients, reduce Saredakis et al., 2021; 2020; Walden and Feliciano, 2022). Our study feelings of isolation, and enhance cognitive and emotional stimulation, explores the potential benefits of VR for PwD with BPSD. Our goal is to making it an innovative, non-invasive solution for improving the quality create virtually enhanced experiences for PwD living in locked hospital of life for this population (D’Cunha et al., 2019; Rose et al., 2018). units for care. Our approach is to use PwD reflections to draw implica­ The goal, therefore, remains to deliver non-pharmacological in­ tions and recommendations for delivering human-centric experiences. novations enhanced by the development of proper information systems This will ultimately improve the HRQoL of PwD residing in long-term for dementia, which can support HRQoL. This paper presents a VR non- care, enabling them to engage with the world beyond physical re­ pharmacological intervention for PwD designed to improve the HRQoL strictions in a mindful, joyful, and sustainable way. In this paper, we and the emotional well-being of the demented person, including any begin by mapping the important aspects of the relationship between associated BPSD. PwD and VR interactions. We then correlate PwD’s subjective claims with physiological responses (Heart Rate and eye-tracking). By doing so, 1.1. VR interventions to improve the HRQoL and reduce BPSD we identify key design principles that can improve the VR experience for PwD. Having the above in mind, we propose the following research Non-pharmacological approaches, such as digital therapeutics (DTx), questions: provide emerging, technology-driven methods for delivering personal­ RQ1: What therapeutic benefits does VR provide in managing BPSD ized care. DTx enables remote delivery, scalability, and online moni­ and improving the overall HRQoL for PwD? toring, enhancing individualized care’s effectiveness (Garg and Saluja, RQ2: How can VR systems be designed to incorporate personaliza­ 2023; Dang et al., 2020; Schneider et al., 2024). With the global DTx tion, social interaction, and accessibility to enhance acceptance and market projected to reach approximately 10.09 billion USD by 2029, effectiveness in dementia care? there is increasing emphasis on mental and behavioral health manage­ RQ3: What insights do physiological responses, such as heart rate ment, highlighting the growing significance of these interventions in the and eye-tracking data, offer about the emotional and behavioral impacts healthcare sector (Statista, 2024; Fortune Business, 2024). Among the of VR interventions on PwD? 2 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 RQ4: How can VR applications in dementia care address diagnostic 2.4. Study design and procedure challenges, mitigate loneliness, and facilitate reminiscence therapy through innovative and immersive experiences? The study was conducted in a hospital setting, in a room familiar to PwD. Initially, a researcher with a background in psychology and 2. Methods human-computer interaction (HCI), as well as experience in working with PwD, explained the study procedures to the PwD and ensured they 2.1. Ethics were comfortable with the equipment and familiarized with the process. This was particularly important as PwD may have challenging behav­ People diagnosed with dementia were recruited from a National iors, and introducing a new modality to this patient group requires some Health Alzheimer’s and Dementia’s Disease hospital. This study was time for familiarization. Subsequently, the PwD were escorted by the approved by the National Bioethics Committee (the reference is hidden researcher and offered an A3 paper “Menu” of the available Virtual for blind review). A consent form was signed by all participants before Environments (see Fig. 2 for a selection of environments). The HCI the study. researcher, possessing a background in psychology, verbally described each environment while simultaneously indicating the corresponding images. In instances where the PwD did not promptly choose a specific environment, the researcher initiated a second descriptive cycle, 2.2. Participants employing alternative and simpler language to enhance understanding. In cases where PwD were struggling to engage and select an environ­ Twenty people with mild to severe dementia, participated in this ment, this process continued until they showed an interest in an envi­ study. The diagnosis was confirmed using the Mini-Mental State Ex­ ronment. Each PwD could select up to three virtual environments from a amination (MMSE) (Anthony et al., 1982), ranging between 3 and 24. list of 10 available options. Table 1 displays detailed demographic information. Participants had no To prevent adverse effects such as dizziness associated with using the prior experience using VR. All participants had a normal or corrected system, a maximum duration of 15 min was recommended for visiting vision and no history of severe motion sickness. the environments. Transitions between environments occurred at the participant’s request; however, if necessary, the researcher would notify the PwD when the allocated time (i.e., 5 min per environment) in a 2.3. Materials particular environment had ended and ask whether they wished to stay longer or proceed to the next environment. Despite the recommended Heart rate (HR). Research has shown that HR provides a valid and time limit of 15 min, some participants were so deeply engaged in the reliable measure of emotional arousal (Anttonen and Surakka, experience that they expressed reluctance to remove their headsets once 2005). Therefore, we measure the participant’s HR every second to the allotted exposure time had ended. This phenomenon was particu­ identify emotional arousal to the visual elements. larly notable among patients suffering from depression, as the VR Eye-tracking data (EYE). The technology allowed the analysis of the experience frequently elicited feelings of pleasure (refer to Sections behaviour of PwD, thus providing the opportunity to gain a better 3.1.1.1 and 3.1.3.1). In such instances, participants were granted the understanding of what they were looking and experiencing. opportunity to extend their engagement by an additional five minutes. Observations were recorded during the sessions by two researchers The researcher offered prompts to facilitate the process of concluding to identify and record the interaction between the people diagnosed the experience. with dementia and the VR system, as well as the presence or absence A software engineer researcher was also present to manage the of BPSD traits and physical interactions between the PwD and the VR equipment throughout the VR session. Both researchers kept observa­ system. tional notes during the VR session and monitored the eye tracking and Semi-structured interviews were conducted by two researchers. We HR activity to proactively react. Then a semi-structured interview with examined the ’technology acceptance’ of VR using semi-structured the PwD where both researchers were once again present to make sure interview questions related to the usability, practicality, and that insights from psychology, HCI, and technical perspectives were immersiveness of the system. For example, people diagnosed with recorded. Each session lasted approximately 40 min. dementia were asked whether they felt immersed in the experience; whether they forgot about the physical boundaries of the room; as 2.5. Apparatus well as whether the VR headset was comfortable to wear. Questions were also asked regarding the emotional effects of VR and related to The system design built upon a systematic review that explored the observations made during the VR exposure. feasibility of using VR for people with neurological disorders and de­ mentia (Schiza et al., 2019). The entire design process has been docu­ Table 1 mented and published for transparency (Matsangidou et al., 2022). We Participants demographics. first identified the requirements for the VR system, using reflections Demographics Value N M SD from 51 healthcare professionals (HCPs) and 24 PwD and created an Sex Male 7 ​ ​ initial prototype. We then assessed the system’s usability and sense of ​ Female 13 ​ ​ presence with 16 HCPs, who used the system as both users and admin­ Mean Age ​ 73.15 16.17 ​ istrators. Based on the feedback from the HCPs, we refined the system MMSE Mild 6 22.17 1.52 and conducted a pilot study with 20 older adults suffering from Mild ​ Moderate 8 15.25 1.67 ​ Severe 6 7.83 3.82 Cognitive Impairment (MCI) to guide the system’s design (Matsangidou ​ Total ​ 15.10 6.16 et al., 2023). After refining the system again based on the feedback from Primary Diagnosis Dementia 20 ​ ​ the MCI older adults, we evaluated it once more with the 16 HCPs. Secondary Diagnoses Major depressive disorder 6 ​ ​ Finally, we evaluated, using quantitative measures, the usability and ​ Anxiety disorders 6 ​ ​ Additional Diagnoses Bipolar disorder 2 ​ ​ effectiveness of the system with PwD (Matsangidou et al., 2023). In this ​ Epileptic seizures 2 ​ ​ study, we present a thorough evaluation of the final product with PwD. ​ Psychosis 2 ​ ​ ​ Schizophrenia 1 ​ ​ ​ Delusional disorder 1 ​ ​ 3 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 Fig. 1. The depicted visualisation showcases an individual with dementia who is experiencing a virtual environment and reminiscing about a memory of a car accident that resulted in them being bound to a wheelchair for life. Notably, the graph indicates a significant increase in heart rate when the individual is looking at the car racing, which is followed by a sudden decline upon shifting their attention back to the sea. Fig. 2. The display portrays some of the virtual environments given at the PwD and some of our participants (PwD) during the VR exposure. The VR system for the study was developed by the authors using the 3. Findings and discussion Unity1 game engine. The 3D models for the virtual environments were retrieved from the Unity Asset Store and repurposed to run on a VIVE When assessing the potential of VR for PwD, it is essential to un­ Pro Eye VR system2. While a PwD was wearing the VR headset, the derstand the unique aspects, advantages, and limitations VR has to offer. displayed content was mirrored on a laptop screen in real-time. The For this purpose, we conducted a thematic analysis, which involves PwD’s gaze was tracked through the HMD’s embedded eye tracker and identifying, interpreting, and reporting patterns within datasets (Braun visualized on the laptop screen using a ray. The visualized ray was based and Clarke, 2006). The findings from interviews and observations in the on the head position and orientation, and the direction of the PwD’s study emphasize these key aspects. The outcomes are also reinforced and gaze, and reflected where they were looking at within the environment. explained through the quantitative data recorded in the study (i.e., the Through the same ray, the exact object they were looking at was also HR and eye tracking data). The interviews and the observation notes identified by detecting its overlap with pre-defined points of interest were coded by two researchers. The two researchers identified patterns within the environment. Finally, a Samsung Galaxy Active 23 smart­ in the data, which were then coded and refined into themes. To further watch was worn by the participants to track their HR. For this purpose, a refine and verify the themes, the researchers discussed them with smartwatch-based app was used called HeartRateOBS, which streamed medical experts and caregivers who were quietly present throughout the via Bluetooth the HR data every second. The data were then received by data collection process to intervene and assist the PwD if necessary. The a Desktop application, developed using Python, that stored the data thematic analysis revealed three core themes and nine subthemes. The locally on the phone. three core themes that emerged from the data were: “Therapeutic ben­ efits”, “Blending the real with the un-real”, and “Material properties and interactivity”. Table 2 presents the summary of the thematic analysis. For the 1 www.unity.com. presentation of the data, we used the following coding: PwD = person 2 www.vive.com/eu/product/vive-pro-eye. with dementia, R = Researcher, source: observation notes or interview 3 https://www.samsung.com/global/galaxy/galaxy-watch-active2/#g transcript. alaxy-watch-active2. 4 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 Table 2 the lower their HR responses were. A noticeable change in HR was Thematic scheme summary for people diagnosed with dementia. observed during the transition between the three virtual environments. Therapeutic benefits Blending the real with Material properties and In particular, during the transition between the three virtual environ­ the unreal interactivity ments, the PwD’s HR increased, and anxious behaviours were observed. Affective responses and Stuck in a loop Feasibility and acceptability Similarly, it was observed that the longer the PwD was immersed in a VR reduced BPSD of technology environment, the less agitation and aggression they displayed. Pain alleviation Transitioning between Material properties Before VR exposure, the researcher explains the experiment to the the two worlds PwD: Reminiscence therapy The role of caregivers in Augmentation of self: neural the multiverse impulses and interactions “PwD: [The PwD looks at R very angrily.] Do whatever you want. I don’t care; I am leaving this place [referring to the nursing home], I am here only for a while, and I will soon go home. 3.1. Therapeutic benefits R: Do you miss your home? During the study, we observed various therapeutic benefits for the PwD: [She raises her voice and angrily points at the researcher]. Listen to PwD. Here, we present three sub-themes arising from our analysis: (a) me! You! Listen to me; I am leaving my daughter will come to take me Affective responses and reduced BPSD; (b) Pain alleviation; and (c) home.” Reminiscence therapy, which overly improved the HRQoL of the PwD. After VR exposure: 3.1.1. Affective responses and reduced BPSD “R: How do you feel? Based on the collected data, 14/20 PwD presented severe BPSD, with either aggressive, anxious and/or depressive responses. Apathy and lack PwD: [The PwD looks at R calmy with a smile] I am happy. of motivation were diagnosed at higher levels, accounting for 17/20 R: And what makes you happy? PwD. People who have been diagnosed with dementia and have a his­ tory of BPSD have a high likelihood, up to 75 %, of exhibiting aggressive PwD: [The PwD looks at R with eyes wide open and seems impressed. and disruptive behaviour (Sampson et al., 2014; White et al., 2017). Then the PwD uses plural language, implying that R, who was pre­ Such behaviours in PwD are defined as intentional, overt, harmful acts sent in the physical room during the virtual reality exposure, was toward another person, object, or oneself (Sultana et al., 2020). Six PwD also present in the virtual environment] We saw so many nice things, presented verbal and physical aggression toward themselves before the we saw the birds, the grass, the sky; we saw the trees, the flowers, VR exposure. Caregivers reported that one PwD also exhibited aggres­ beautiful flowers, and the breeze, oh that breeze which made the sive behaviour towards other PwD and caregivers, though this was not flowers to move… I will keep everything in here! [PwD points to­ observed in our presence. ward their head]” [PwD2, Interview] Based on our research, it appears that VR can help alleviate BPSD in Based on previous research, a possible cause of agitation and individuals with dementia. Specifically, we observed a decrease in aggression in PwD is the sense of loneliness and the monotony of aggression and agitation during and after the VR session, which was everyday living (Lyketsos et al., 2011). Based on our findings PwD who corroborated by the reduced HR of the individuals and previous studies reside in long-term care are constantly experiencing loneliness and that also reported a reduction in agitation and HR after exposure to monotony (Lyketsos et al., 2011; Shen et al., 2022; Wood et al., 2009). virtual nature (Reynolds et al., 2018). Contrary to the pre-exposure data Many people diagnosed with dementia have expressed a desire to have and in line with recent pilot studies (Appel et al., 2016; Walden and their families around, as they have been missing them greatly. Addi­ Feliciano, 2022; Sultana et al., 2021), all of the PwD displayed a tionally, a majority of these people diagnosed with dementia have re­ reduction in aggressive or agitated behaviours during the VR session. It ported feeling bored and fatigued due to the repetitive nature of their is worth mentioning that the decrease in aggressive or agitated behav­ daily routine. iours persisted after the end of the session. It is even more interesting During VR exposure - Once the PwD wears the VR shouts: that the caregivers, who observed the PwD after they returned to the usual care validated the persistence of the reduced aggressive behav­ “PwD: Thank you! Thank you! Thank you! Thank you! Thank you! iours for a couple of hours after the VR exposure. Thank you! Thank you! You have given me back my life - it’s a miracle! Fig. 3 schematically illustrates the changes in HR over time as the You’ve brought God back into my life.” [PwD7, Observation] PwD is exposed to three different virtual environments. The HR data After VR exposure: indicated that the longer the PwD was immersed in a VR environment, Fig. 3. The graph depicts a significant drop in HR during VR exposure in three distinct virtual environments (indicated by white backgrounds), followed by a sharp increase during the transition phase (indicated by orange backgrounds). 5 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 “R: What made you so happy? “R: How are you feeling? Did you enjoy it? PwD: [The PwD look at R with gratitude] Thank you! Thank you! Thank PwD: Oh yes. Can we do it again? you! I wish you all the happiness in the world for the good you have done R: Maybe another day. What exactly did you like? for me. I can give you my soul if you wish, just promise that you won’t take this away from me. PwD: The silence! No one was talking to me, and no one was screaming around me. I was alone. I was in peace, so quiet. Can we R: What is it that you don’t want to lose? do it again? PwD: The Lord! My life! My eyes! Don’t cut down all the flowers. Don’t R: Will do. Another day. This is a promise. lock me back in here! PwD: Hmm. I will leave now, but you did make a promise. [He points R: Don’t you like being here? at R and smiles before leaving the room with the nursing staff]” PwD: I do, but… I miss life. Every day is the same here. Always the same! [PwD15, Interview] [The PwD seems sad] Even though all PwD enjoyed being exposed to the VR and their R: But you do so many activities, don’t you? There is a music session, and BPSD symptoms were reduced during and after the VR exposure, it is art, and sports classes… worth mentioning that as for depressive reactions, an interesting observation was made. During the VR exposure, all PwD reacted plea­ PwD: Yes, but there is no God! No flowers. No birds. No animals. No… surably, and it was documented that their feelings of sadness was No… [PwD tries to find the word “river” she moves her fingers like waves] reduced. However, some of the PwD reported feeling melancholic once R: Water? the VR session ended. A couple of them asked when they will be able to use the system again. PwD: Water! [PwD giggles and smiles].” [PwD7, Interview] “PwD: What you did for me today gave me courage. Thank you. Another factor contributing to agitation and aggression in PwD is their physical environment and lack of privacy. Previous research R: Courage? recognized that being locked into a hospital environment can negatively PwD: Living here is exhausting. Don’t get me wrong, all the staff and affect the levels of aggression the PwD are experiencing. To reduce the admin are doing their best, without them I am not able to survive; agitated behaviours, among others, spacious rooms, out-reach experi­ but still, I am not able to walk, I must wait for them to shower me, or ences enhanced by nature, and low-stimulus environments have been to take me to the yard. Here it was quiet, I enjoyed being alone, next suggested (Canatsey and Roper, 1997; Chou et al., 2002; Waller and to the beach, looking around. Now, that I am not wearing the glasses, Masterson, 2015). In line with a recent study (Tabbaa et al., 2019), our I feel so sad [He starts to cry and then anxiously continues in tears] findings suggest that VR could be used to create an isolated, private Please come again, will you come again?” [PwD18, Interview] space for the PwD. In particular, our findings support the reduction of aggregated behaviours during and after VR exposure. Our research “PwD: I have a question for you. Can I ask you a question? emphasizes the significance of experiencing pleasant environments in R: Sure! private settings and confirms the findings of a previous study (Tabbaa et al., 2019), while it also addresses the limitations of previous research, PwD: Why are you doing this? which lacked data on aggressive behaviours and had a small sample size R: Our goal is to help you feel nice. of only 8 PwD (Tabbaa et al., 2019). Before VR exposure the PwD speaks and acts angrily, making loud PwD: Oh, I felt wonderful, not just nice, but what’s in it for you? noises and picking his hands. He chooses to be exposed to the VR R: If you felt good then that is my gain. bedroom environment, where he sits quietly for a couple of minutes. During the VR session, he starts to smile and sing: PwD: [PwD got upset and start to yell at R] NO! NO! NO! That can’t be it. I felt so good, but if you are not getting something out of it then “PwD: aa.. olt… uuu… I am alone in life but the old radio on the table why should you come again? And I need you to come again, I need [He looks at an old virtual radio] playing music, reminding me of the this, do you understand, I need this, so tell me what you want from days to come, reminding me that life is beautiful [He started to move me so that I can give it to you so that I know you will come back his feet as if he was dancing while being seated], reminding me that I [PwD looks sad, almost ready to cry].” [PwD20, Interview] will smile again [He smiles], do not worry, don’t be sorry, don’t be sorry… [As he keeps singing, the lyrics convey a similar message as Apathy is associated with poor HRQoL for PwD residing in long-term stated above]. care and it is one of the most frequently underrecognized and over­ looked neurological disorder symptoms (Selbæk et al., 2013; Zuidema R: Our session is about to be over; shall we remove the glasses? et al., 2007; Ballard et al., 2001). Similarly, in our study, apathy was one PwD: No. [With a tone of sadness]. of the core diagnoses for our participants. As one can easily observe apathy demonstrated the greatest cognitive improvement during and R: Okay, you can stay a bit longer, but then we need to take off the after VR exposure. Almost all PwD entered the room highly apathetic glasses, alright? and unmotivated but once they were exposed to the VR environment PwD: [Remains in silence for a while and then starts to sing again] they turn to be happily alerted. The old radio… Before VR exposure the PwD looks dull and apathetic. He has a limited interest in things, and he is not even responding to R. PwD does R: Our session is over; shall we remove the glasses? not keep eye contact with R or any elements in the physical space. PwD: No. “R: Where are we now? R: Would it be alright if we waited two more minutes before PwD: [Looking at the floor, saying nothing and moving his shoulders removing them? up and down] PwD: Hmm ok.” [PwD15, Observations] R: We are in a room. Aren’t we? After VR: 6 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 PwD: [Looking at the floor, saying nothing] Maxwell et al., 2008; Shega et al., 2004; van t’Hof et al., 2011). Studies have described under-treatment of pain in dementia care (Morrison and R: [R asks the PwD multiple times and in different ways the same Siu, 2000; Teno et al., 2001), which in the end is a causal factor of BPSD, question until the PwD shows some form of agreement] and especially causative for agitation, aggression, and psychosis PwD: mmm [shows agreement] (Maxwell et al., 2008; Achterberg et al., 2013; Corbett et al., 2012; Hall-Lord et al., 2003; Husebo et al., 2014). In light of the above, we R: Mr X. Would you like to visit a forest? verify that most of our participants reported being in pain and some of PwD: [Looking at the floor, saying nothing] the participants refused to participate in the study because at that moment they were dealing with severe pain. However, in line with R: A river? studies which suggest that VR can provide an alternative and advanced PwD: [Looking at the floor, saying nothing] form of analgesia (Matsangidou et al., 2017), we found a negative cor­ relation between the administration of VR and pain in PwD. This is R: [R asks the PwD of several virtual environments until the PwD because research on the neurobiological mechanisms has shown that VR shows some form of interest] What about some cows? can alter the perception of pain with the help of actions that are PwD: [Looked at R] perceived by the subject in pain as withdrawing its attention from the painful sensory signal (Gold et al., 2007). This is because the in­ R: Ohhh! So cows? Do you like cows? dividual’s attentional resources are limited; thus, the use of distraction PwD: I… I… used to have. (via VR) decreases the cognitive capacity the individual has to process painful incomes (McCaul and Malott, 1984). VR technology offers R: So cows it is! [PwD19, Observations] multi-sensory information that helps the person become fully immersed During VR exposure (see Fig. 4 for the appropriate setting): in the simulated world and thus distracted from the sensory signal of pain. Previous research has also suggested that HR is a reliable measure­ “PwD: oh! Look-look! [He points with his finger – he moves his ment to indicate pain (Forte et al., 2022; Matsangidou et al., 2020) since finger] Where is my finger I can’t see it? people in pain are usually having an elevated HR as well. Our data support these findings. Fig. 5 depicts the HR changes over time of a PwD R: I can. It is ok, look at the cows! who initially reported high levels of pain (and therefore a high HR was PwD: ohhhh! There is one and two, and oh look at the goats, and detected), but as the session progressed the PwD forgot about the pain hahaha [laughs happily] there is a donkey! A donkey! He whistles at (and so a HR reduction occurred accordingly). the donkey and then he shouts “Hey you with the big ears” hahaha. Before VR exposure: So, listen to me, do you see the cows? [points with his finger] “PwD: I don’t want to do or try anything. I am in so much pain. R: Of course, I do. R: Why? What happened? PwD: This kind of cows are the cows for producing milk not for PwD: I fell over my wheelchair. digging the fields, and the donkey is for carrying the harvest, and the flowers, the flowers are pink and white, and they are called, called, R: I have something that might help you feel a bit better. called… I cannot remember but they were always pink and white… PwD: mmm [looks upset and unsure] [PwD moves around, turned even back from his sit, points at stuff, laughs and acts happily] [PwD19, Observations] R: Shall we at least try? After VR: PwD: Do whatever you want. I am just waiting for my death to come.” [PwD11, Interview] “R: How are you feeling? Did you enjoy it? During VR exposure (see Fig. 6 for the appropriate setting): PwD: How nice, how nice, how nice, very nice, very nice. The flowers and the sky and the animals. How nice, how nice, how nice, very “PwD: oh! Look at the beach, there is a passing boat, there are sailors nice, very nice.” [PwD19, Interview] on the boat, oh here is a small island far – far away, is it Ithaca? A boat that is going to Ithaca. Look at the wooden deck and the flowers around me and [He starts to sing a rhythmic song about the sea] sea – 3.1.1.1. Pain alleviation. Research has shown that pain is one of the sea and salty waves […] what a blessing, oh what a blessing you have most common symptoms among PwD, with up to 80 % of PwD suffering given to me. Oh, my heart is young again!” [PwD11, Observations] from pain regularly (Department of Health 2014; Lobbezoo et al., 2011; During the VR exposure, PwD referred to Ithaca which is a Greek island well known in Odyssey mythology as the island home of the hero Odysseus. Ithaca has an important meaning due to its symbolic value within the Odyssey mythology as it represents Odysseus’ love for his home, family, and an end to his long and arduous journey. We believe that the PwD reference to Ithaca was not arbitrary, but instead, he liked something from his inner desires. After VR: “R: So how are you feeling? PwD: What have you done to me… You made my heart young again. You gave me a reason to live up to. R: And what about the pain? Fig. 4. The image depicts the virtual environment that the PwD observed PwD: Which pain [giggles]. I forgot that I was in pain. and discussed. 7 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 Fig. 5. The figure presents the elevated HR of the PwD while being in pain (areas with an orange background) and the sharp decrease in HR once the PwD got distracted from the virtual scenery (areas with white background). to meet the PwD interests and memories. In line with previous research (Siriaraya and Ang, 2014; Tabbaa et al., 2019; Rose et al., 2021) we found that PwD are reminded of a memory from their past once similar elements to that memory appears. For example, the presence of the lake, along with some vehicles racing around, reminded a PwD of his accident which confined him to a wheelchair. It is worth mentioning that, during the moment that mem­ ory occurred, the PwD’s HR raised at least 20 beats per minute (bpm), but once the PwD turned his attention toward the water his HR reduced back to normal. According to studies (Cohen et al., 2000; Harvey et al., 2012), when PwD recall their trauma, their heart rate tends to increase due to stressful reimagining, while other studies (Baillon et al., 2004; Cotelli et al., 2012) indicated that HR can decrease when reminiscence therapy is applied. It appears that our findings support this statement Fig. 6. The image depicts the virtual environment that the PwD observed since we observed that both positive (i.e., swimming in the sea) and and discussed. negative (i.e., car accident) aspects of PwD’s past integrated during the exposure resulted in a meaningful life story. Fig. 7 schematically pre­ R: Do you now feel any pain? sents the HR changes over time based on where the PwD was looking as recorded using the eye-tracking system. PwD: [giggles] Not really. During VR exposure (see Fig. 1 for the appropriate setting): R: And which island did you see in those glasses? “PwD: The birds flying around, bringing messages and greetings. The trees PwD: Ithaca! [his tone is confident and happy] Did I visit Ithaca? are green and there is sand [bends down to touch the sand] right under my feet! Ohh what a blessing, it is so beautiful! And look far-far way, there is R: What do you think? a car, with four wheels, and another car with four wheels, all the cars got PwD: I think it was Ithaca. four wheels, I don’t like four-wheeled cars, I used to have a two-wheeled [≈ motorbike]. [Heart rate starting to raise] I had a beautiful two- R: Why Ithaca? wheeled car and I was riding free and then I fall off and broke my legs PwD: I think it was Ithaca. and now I got 12 screws in each leg, and I can barely walk, I am stuck in this chair [His voice is breaking, and his heart rate has raised close to R: Whose island was Ithaca? 100bpm, then he looks at the beach and his heart rate drops back to PwD: [laughs] The great Odysseus” [PwD11, Interview] normal]. I think I am going to start crying, I am stuck in this chair far away from my beloved sea, but at least with these glasses, I can see the sea. Can I keep the glasses? Please let me keep the glasses so each time I 3.1.1.2. Reminiscence therapy. When treating dementia, it is recom­ miss the sea I can visit it…” [PwD11, Observations] mended to consider reminiscence therapy as a strength-based, person- centred approach (Saredakis et al., 2021). Reminiscence therapy in­ volves recalling memories through experiencing and discussing past 3.1.2. Blending the real with the unreal events and using familiar objects to aid in the process (Woods et al., Throughout our study, we noted a range of reactions from PwD. 2018). Through this therapy, the goal is to integrate both positive and Based on our analysis, we have identified three sub-themes that can be negative aspects of one’s past into a meaningful life story and ultimately used to inform the design of VR applications intended for PwD: (a) Stuck redefine negative interpretations of PwD’s past (World Health Organi­ in a loop; )b) Transitioning between the two worlds; and c) the role of zation (WHO), 2021). The recall of memories (either positive or nega­ caregivers in the multiverse. tive) may cause some sort of distress for the PwD (Wong and Watt, 1991; Cappeliez et al., 2008); however, to the best of our knowledge, up to 3.1.2.1. Stuck in a loop. Looping is very common for PwD and it in­ date no harm has been reported by the reminiscence therapy (Woods volves the repeating of stories or fixations. Looping is often described in et al., 2018). In line with the above, we found that during and after the association with BPSD, and especially agitation, as repetitiveness is one VR exposure, PwD reminisced about their hometowns and villages, of the core symptoms (Hwang et al., 2000; Tractenberg et al., 2002). places they visited, or even more intimate stuff like their backyard, etc. Based on previous literature, looping is measured by the repetition of Even though the system was not fully personalized, we managed words, the frequency of repeated words or similarity between sentences through the thorough VE selection process (see Matsangidou et al. 2022) as well as the repeating topics (Fraser et al., 2016; Cook et al., 2009). 8 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 Fig. 7. The HR of a PwD while they experience a VE and recall a memory of a car accident in their youth. The figure presents the sharp increase in the HR once the PwD looked at a car racing (areas with orange background) and then the sharp decrease once the PwD looked back at the water (areas with blue background). During our experiment, PwD were constantly looping by fixating on who will be in the room with the PwD during the VR session). We objects in view. It is worth mentioning that in all cases PwD were suggest that the deployment have a caregiver able to assist the tran­ fixating on objects which were associated with positive emotions. sitioning from the physical to the virtual world and back. Also, we During VR exposure: observed that most of the PwD interacted with the researchers in the physical room during exposure. “PwD: Oh, look at the sky, it is clear and blue, the flowers are red and During VR exposure: white, the donkey is rolling on the grass… [A couple of seconds later] Oh, look at the sky, the flowers are red and white… [A couple of “PwD: Look! Look! The car is passing through! [PwD laughs], and I seconds later] Ohhh, the flowers are red and white… [A couple of can also hear the birds! Where are the birds? [R didn’t respond, PwD seconds later] Oh, look at the flowers are red and white… [A couple repeated in agony, indicating that a response is required] Where are of seconds later] Oh look at the flowers are red and white” [PwD2, the birds? Observations] R: They are flying up to the sky. Look up! Previous literature suggests that looping in dementia, based on re­ PwD: [PwD turns her head up to the sky and bursts into laughter] Oh, petitive phenomena and fixed patterns, is considered to be an early sign here they are!” [PwD10, Observations] or a valid predictor of dementia (Baumgarten et al., 1990; Teri et al., 1992; Gauthier et al., 1997; Tariot et al., 1995; Hwang et al., 1997). “PwD: Is this the [named a specific] lake? Excuse me, do you hear Even though VR is still a relatively new and understudied solution, it is me? actively used in diagnostics of several neurological diseases (Słyk et al., R: Yes, we do. 2019). The exaggerated looping patterns of the PwD during the VR exposure suggest that VR may be useful for dementia diagnosis in the PwD: Which lake is it? Is it the [Name] lake? future. R: Yes, it is. 3.1.2.2. Transitioning between the two worlds. In general, PwD might PwD: I grew up close to that lake. Are you here? Do you listen to me?” experience disorientation in place and time, and previous literature has [PwD4, Observations] documented that VR exposure can increase the sense of disorientation in Despite the common preconception that VR is an isolating experience space (Tabbaa et al., 2019; Matsangidou et al., 2020). Our study ob­ (Pringle, 2017) and in line with a study that examined the appropriate servations align with the previous finding, as some PwD could not types of VR for PwD (Hodge et al., 2018), we believe that VR can be a distinguish between the virtual and the physical space. space to facilitate social interactions. Additionally, studies suggested During VR exposure: that VR can help patients open up and communicate their feelings “R: Where are you? (Matsangidou et al., 2022; Blythe et al., 2010). Based on our observa­ tions, we trust that the feeling of togetherness enhances VR’s therapeutic PwD: At the mountains [with specific tone]” [PwD6, Observations] role and VR is a critical intervention which can enhance the establish­ After the VR exposure: ment of the therapeutic alliance (Gorini et al., 2007; 2008). It is important to note that positive therapeutic outcomes are correlated with “PwD: Where are we? the therapeutic alliance or relationship between the therapist and the R: Where do you think? patient (Flückiger et al., 2018) and as for PwD, previous research has shown that social support and a sense of belongingness can help PwD to PwD: [PwD looks around, thinks a bit, then looks out of the window, improve their resilience coping mechanisms, thereby reducing BPSD and spots a tree] at the mountains [her tone is unsure]” [PwD6, especially anxiety and depression (Kelley, 1997; Lee et al., 2017; Campo Interview] and Chaudhury, 2012). We believe that the deployment of VR in dementia care must incorporate a smooth transitioning process between the physical and the 3.1.3. Material properties and interactivity virtual space. It is worth examining the use of the passthrough feature of Our analysis, identified the key aspects and functions necessary for modern VR headsets to ease the transition from the virtual space and to the successful VR system design. These can be summarized into the sensitively re-direct the PwD back to “reality”. following sub-themes: (a) Feasibility and acceptability of technology; (b) Material properties; and (c) Augmentation of self: neural impulses 3.1.2.3. The role of caregivers in the multiverse. In line with the previous and interactions. findings (see theme: transitioning between the two words), we also observed the vital role of the caregiver (or even the presence of a person 3.1.3.1. Feasibility and acceptability of technology. Even though a couple 9 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 of years ago, it was not clear whether VR can be a feasible solution for HMD with their hands) are preferred by people with mild dementia PwD, several studies documented the feasibility and acceptability of VR (Hodge et al., 2018; Tabbaa et al., 2019). However, the physical capacity when deployed into healthcare units with plenty of positive results (Rose of some of the PwD (e.g., those suffering from Parkinson’s disease or et al., 2018; Matsangidou et al., 2022; Siriaraya and Ang, 2014; Tabbaa osteoarthritis), makes such a solution impractical. In line with a recent et al., 2019; Matsangidou et al., 2022; 2020). In line with the above study on VR physical rehabilitation and dementia (Matsangidou et al., findings, we can confidently advise that VR is a feasible and 2020), an exoskeleton could be a feasible and practical solution which well-tolerated technology by PwD. However, in most cases, it requires a can increase PwDs’ tolerance and acceptance of VR. significant amount of time from the nursing staff to deploy the system into the healthcare setting. Therefore, choosing a technology that is 3.1.3.3. Augmentation of self: neural impulses and interactions. In the portable and easy to set up in hospital environments is essential. Espe­ past, some studies explored the use of embodied interactions by cially when working with PwD who are facing BPSD and can easily be providing PwD with interactive virtual avatars. Their findings suggested upset, a speedy and easy setup is a crucial factor to avoid PwD experi­ that for people with mild dementia embodied interactions resulted in a encing any type of discomfort. greater sense of engagement (Manera et al., 2015; Zuidema et al., 2007). Familiarization with the equipment is also a vital factor when Based on our observations, most of the PwD, including people with mild, dealing with PwD. As PwD are facing BPSD and usually are dealing with moderate and severe dementia, tried to physically interact with the high levels of anxiety and fear. Previous studies suggested a reluctance system. For example, some PwD tried to put their feet into the water, to wear the VR headset due to the fear of the unknown (Matsangidou others tried to cut a flower and touch the grass, while a PwD subject to et al., 2020). Even though our participants were exposed for the first paranoid schizophrenia tried to pet the cat which was in the virtual time to VR and therefore, the unfamiliarity of this technology could have space (see Fig. 8 for the appropriate settings). made the PwD sceptical, however, such reactions were not observed as During VR exposure: we spend a significant amount of time familiarizing the PwD with the “PwD: Hey kitty – kitty come, come… [PwD lean forward trying to equipment and the intervention. We believe that familiarizing them­ pet the kitten] Kitty – kitty come, come… kitty – kitty come, come… selves with the equipment made the PwD less anxious and more willing kitty – kitty come, come… kitty – kitty come, come…” [PwD12, to try the technology. Observations] Lastly, personalization is a key factor when dealing with older adults. In line with past studies, a special focus should be placed on creating “PwD: OHHH! OHHH! [PwD shouted in excitement and pushed the personalized experiences that consider the preferences and capabilities chair back to look towards the back-right and then the back-left side] of each PwD (Rose et al., 2018; Appel et al., 2016; Woods et al., 2018; OH! OHHH! Grr, Grr, […] Grass! [PwD tried to touch the grass with Manera et al., 2015). For example, some PwD were unable to listen to her foot] [PwD16, Observations] the system’s sounds and/or view objects far in proximity. Therefore, After VR exposure: during the VR exposure researchers had to adjust the audio-visual con­ tent based on the PwD capabilities and needs. “R: What did you like? During VR exposure: PwD: Let me tell you something. Life is a collection of images and “PwD: Why the birds aren’t singing? memories, and you, my lady, have given me so many. You, my lady, have given me life […] I am saving the images we saw today, so I can R: Can’t you hear them tweeting? save life […] I was miserable today and this gave me joy […] I was PwD: What have you done to the birds why they are not singing? [We miserable today, but now I am not […] I wish I could have this every noticed that the PwD seems to be upset, so we decided to raise the single day. volume] OH now I can hear them, […] nice birdies, happy birdies!” R: So, you liked it. Is there anything else that needs to be done, to [PwD8, Observations] make it better? PwD: I would love to be able to touch the flowers. Will you let me 3.1.3.2. Material properties. In contrast to other kinds of technologies, touch the flowers?” [PwD3, Interviews] such as flat-screen interfaces, the fully-immersive VR systems envelop the users’ view completely. Therefore, and due to the material aspects of Apart from the need for interactivity, PwD also reflected the need for the system (i.e., worn on the head) two out of twenty PwD (all women), multi-user / metaverse experiences. Metaverse is considered a post- reported being uncomfortable with the system. reality universe where social interactions can be held by merging During VR exposure: physical and virtual reality. Based on a previous study, PwD are suffering from loneliness which can be a predictor of the condition “PwD: These glasses are too heavy and are making it hard for me to worsening (Sutin et al., 2020), as well as a factor for increasing BPSD breathe. (Lyketsos et al., 2011). Most of our participants suggested that they R: Shall we remove the glasses? would enjoy the presence of their family, as they reported intensely missing them. PwD: No. After VR exposure: R: [A bit later] How are you feeling? Shall we remove the glasses? “R: What did you like? PwD: No, I am happy in here. PwD: In there [point to the VR headset] I was feeling happy, but now R: But is it heavy? I feel a bit sad again. PwD: Yes, and it is difficult to breathe. R: Is there anything we can do to make you feel better? R: Shall we remove them then? PwD: [PwD was immersed into the living room] Can you bring my son? I would like to be with him in the living room, I would like to PwD: No.” [PwD1, Observations] have him by my side while listening to that nice music. Observations of such responses among PwD are not uncommon. R: Would that be enough? Just having him in there? [R pointed to the According to previous research, handheld systems (i.e., holding the VR headset] 10 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 Fig. 8. The image depicts the virtual environment that the PwD observed and discussed. On the left the virtual environment where a PwD and paranoid schizo­ phrenia tried to pet the cat, while on the right the virtual environment where some PwD tried touch the grass. PwD: More than enough, that will be the absolute happiness” [PwD1, research recognizing that being locked into a hospital environment can Interviews] negatively affect the levels of BPSD the PwD are experiencing. To reduce BPSD and improve the HRQoL, exposure to out-reach and low-stimulus An experience in the metaverse is characterized by a sense of pres­ experiences have been suggested from the general literature (Canatsey ence, which combines the illusion of non-mediation, which means that and Roper, 1997; Chou et al., 2002; Waller and Masterson, 2015). the user can perceive the self in a space without being aware of the When considering the VR content design, we suggest taking into mediator technology that is responsible for its creation. We believe that consideration the medical history of the PwD, paying particular atten­ PwD were experiencing in some sense the metaverse and so they tion to the BPSD symptoms each PwD experiences. For example, for PwD requested for their relatives to join them in the virtual space without who are experiencing agitation, aggression, and/or depression, we being able to distinguish between the real and the virtual. suggest enhance the VR with content that is able to reduce the sense of loneliness. On this note our findings highlight the importance of social 4. Implications and recommendations presence. An often request was the ability to experience the virtual en­ vironments along with family members or friends. PwD living at long- The findings of this study demonstrate several important advance­ care homes are often isolated and miss connections from their past. ments in the use of VR as a DTx tool for PwD, particularly in addressing This can be detrimental to their well-being causing depression or an BPSD. By leveraging immersive virtual environments, we observed sig­ increase in agitated behaviours (Azevedo et al., 2021). Multi-user ex­ nificant reductions in symptoms such as aggression, agitation, anxiety, periences, and the connection with loved ones, can alleviate feelings of and depression. Moreover, the integration of real-time physiological loneliness and reduce BPSD improving the HRQoL of PwD (Appel et al., monitoring through HR and eye-tracking data provided objective evi­ 2021). dence that supports the emotional and behavioral benefits observed Furthermore, social presence plays a pivotal role in enhancing the during VR sessions. VR experiences further amplified these positive acceptance and effectiveness of digital interventions, particularly for outcomes, as PwD were able to engage with environments that evoked older adults who may be hesitant to adopt new technologies (Biocca personal memories, enhancing both emotional well-being and cognitive et al., 2003). To encourage the use of VR in this population, it is essential stimulation. Additionally, the study opens new avenues for future ap­ to design human-centered applications that emphasize social presence plications of VR in dementia diagnosis, based on behavioral patterns (Kim and Song, 2024). This can be achieved through group-based ac­ such as looping. Finally, the potential for multi-user VR environments, tivities or by incorporating avatars that closely mimic real human be­ where PwD could interact with family members, presents a novel pos­ haviors and communication. Research has shown that social presence in sibility to mitigate loneliness and improve HRQoL. We believe that these VR has a positive effect on PwD, and future developments should focus findings offer valuable insights into the growing role of VR in both on improving these experiences with features such as lifelike avatars, therapeutic and diagnostic contexts for dementia care, warranting synchronized lip movements, and natural body motions (Kothgassner further exploration and development in future studies. Below, we et al., 2018; McGlynn and Rogers, 2017; Latoschik et al., 2017; Mat­ discuss in detail the implications and recommendations that emerge sangidou et al., 2019). from our findings, which have facilitated the successful design of VR On a similar note, many of the participants in our study claimed to be systems for PwD. feeling homesick and so addressing this issue by implementing specific The study verified prior research that VR can be a feasible solution interventions is of major importance. This is in line with a previous study for supporting PwD. Even beyond that, however, it has shown the pos­ which suggested that PwD might be interested in visiting their own itive effects it may have on the emotional well-being of the population. homes (Allen and Tulich, 2015). We feel that VR may overcome the The data collected through qualitative methods confirms that the use of limitations of hospital boundaries and offer the PwD such a possibility. VR may improve BPSD for PwD. The positive effects were also validated Therefore, as part of future designs, we suggest including home-related through quantitative measures. As shown in Section 3.1.1 the recording environments to meet these needs. and analysis of physiological data allows for a better understanding of Research has also indicated that PwD may exhibit agitation and the emotional state of PwD during VR exposure. Analysis of these data aggression because of their surroundings and lack of privacy. Hospital revealed a significant decrease in HR while participants were exposed to settings have been shown to increase the likelihood of such behaviors. VR, supporting the observation that exposure to VR may effectively To create a more serene environment, it has been recommended to offer reduce pain and BPSD such as agitation, aggression, depression, and ample space, access to natural elements, and low-stimulation sur­ apathy in PwD. roundings (Canatsey and Roper, 1997; Chou et al., 2002; Waller and Pain and BPSD symptoms are a major cause of distress for PwD and Masterson, 2015). In line with a recent study (Tabbaa et al., 2019), our their caregivers, and are also linked to poor HRQoL (Selbæk et al., 2013; findings suggest that VR can be utilized to create a private and isolated Zuidema et al., 2007; Ballard et al., 2001). Hence, the positive effects of space for PwD. In particular, our findings support the reduction of VR on BPSD are crucial, as they may contribute to an improved HRQoL aggregated behaviours during and after VR exposure. Our research also for PwD. These findings could be explained by referencing previous 11 M. Matsangidou et al. International Journal of Human - Computer Studies 196 (2025) 103413 confirms the benefits of experiencing pleasant environments in private in-depth analysis of eye tracking data and gaze patterns (Tominari et al., settings for PwD. 2021; Liu et al., 2021). Research in these areas has only recently started, At the same time, it has been shown that VR has the potential to especially in relation to VR, and requires further exploration in the reduce anxiety and depression, especially when there is a greater sense future. To rigorously assess the long-term sustainability of these positive of presence (Wang et al., 2022). For example, during our study, it has outcomes, a longitudinal study with quantitative data and a control been observed that PwD often attempted to touch virtual objects in their group is essential. Additionally, further research is needed to evaluate environment, such as grass. To enrich their experience, incorporating the potential benefits of VR for older adults with general cognitive physical interactions and reactions into the design can be quite benefi­ impairment or those experiencing social isolation. Furthermore, areas cial. For instance, when an individual touches water, it could cause for future research include incorporating embodied interaction, utilizing ripples, or when someone pets an animal, there can be a corresponding multi-user experiences to increase social presence, and integrating reaction. Such actions can create a highly immersive experience, physiological and biometric data to better personalize VR content for resulting in better outcomes for BPSD. PwD. Ultimately, we hope that our study sheds light on how VR tech­ Similarly, and by addressing the suggestion of out-reach experiences nology can be designed, deployed, and used in the realm of dementia enhanced by nature, our findings also advise the design to add nature- care and advocate for its utilization as a therapeutic tool. related environments. Based on previous research, nature viewing can enhance emotional well-being and aid recovery from stress (Chalfont,