With increasing age, people can experience a reduction in physical, psychological and social health (Singh and Misra, 2009; de Mendonça Lima and Ivbijaro, 2013; Kemperman et al, 2019). This decline in health can affect all aspects of an individual's life, with a reduction in mobility (Rantakokko et al, 2013; Rantanen, 2013), ability to complete activities of daily living (Royall et al, 2005), social networking (Kemperman et al, 2019), increased risk of falls (Mahagna et al, 2019), hospitalisation (Nunes et al, 2017) and multimorbidity (Barnett et al, 2012). There is growing concern that these common complications in older adults could be amplified by the current climate, with lockdowns, curfews and social distancing being used as a response to the COVID-19 pandemic (Armitage and Nellums, 2020; Plagg et al, 2020).
It has been suggested that virtual reality (VR) may provide an alternative method for rehabilitation and support during the COVID-19 pandemic (Gao et al, 2020; Singh et al, 2020; Smits et al, 2020). The use of VR may provide some advantages over more traditional rehabilitation methods, such as enhanced patient-reported satisfaction, instant feedback allowing dynamic adjustment of intensity of the intervention (Mantovani et al, 2020) and opportunity for greater standardisation of rehabilitation (Rothbaum, 2009). A recent systematic review by Dermody et al (2020) examined the effectiveness of VR apps using immersive headsets for this population of older adults living in the community (Dermody et al, 2020).
Aims of the commentary
The present commentary aims to appraise the methods used in the systematic review by Dermody et al (2020) and to expand on their findings in the context of the COVID-19 pandemic.
Methods
Dermody et al (2020)'s systematic review was registered with Prospero prior to the commencing of data extraction. A robust multi-database search was undertaken from 1997 to June 2019. Alongside this primary search strategy, hand searching and screening of the included studies' citation lists were undertaken. Both experimental and quasi-experimental studies that included community-dwelling adults aged 60 years or older and examined the effectiveness of VR were included in the review. Studies that did not use VR apps delivered via immersive headsets were excluded. Screening, data extraction and assessment of bias (Joanna Briggs Institute Critical Appraisal Tools) were carried out by two independent reviewers, with arbitration by a third reviewer. A classification of certainty was undertaken by two independent reviewers using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Due to limited evidence, the included studies were synthesised using a narrative approach.
Findings
The primary research identified 416 references, with an additional 74 references being identified through screening of systematic review reference lists. After title, abstract and full-text screening, only six studies were included in the review, with three focused on falls prevention, one on pain management, one on memory and one on cognitive ability in those with dementia. Only one study explicitly assessed visual acuity, and four studies excluded participants if they reported uncorrected vision or serious/significant sensory impairment. No studies undertook a hearing assessment. All included studies used an immersive virtual environment intervention with a varying range of hardware, software and exposure time. The number of sessions ranged from a single session to three times a week for 7 weeks. Of the six small studies, three were randomised controlled trials (RCTs), one was quasi-experimental, one was a mixed-methods exploratory study and one was a case study.
For this commentary, the findings from the quasi-experimental study are not reported. This study did not examine the effectiveness of an intervention, but aimed to compare compensatory postural adjustments of adults with Alzheimer's disease with and without a history of falling, compared with the control group (Gago et al, 2016). Consequently, the results from this study should not have been included in Dermody et al (2020)'s review, as they did not directly examine the effectiveness of VR.
For the two studies that examined the use of VR in falls, one RCT demonstrated a statistically significant reduction in two outcomes measuring slip distance when comparing a single session of VR with treadmill compared to treadmill training alone. The second RCT demonstrated a statistically significant reduction in the fear of falling score when comparing the VR exposure therapy with the waiting list control.
For the three studies that measured depression outcomes (two RCTs and one mixed-methods exploratory study), there was no strong evidence of benefit between groups or from the baseline to the end of the study. One RCT found that there was a clinical and statistically significant reduction in anxiety when comparing VR exposure therapy with the waiting-list control.
One RCT demonstrated multiple statistically significant improvements in general cognitive abilities and verbal memory with varying comparisons of pre- and post-test, post-test and end of the booster phase (additional training for 3 months) and between the intervention and control groups. When comparing auditory stimulation and VR experiences with music therapy, one mixed-methods exploratory study demonstrated a clinical and statistically significant reduction in pain scores between baseline to the end of the study, using an immersive VR intervention for pain management.
One mixed-methods exploratory study found no strong evidence of benefit for overall health, physical health, social life and psychological health comparing the baseline to the end of the study using an immersive VR intervention for pain management. Similarly, one RCT found no strong evidence of benefit to social and family life scores when using VR exposure therapy for fear of falling. Lastly, one RCT found no strong evidence of benefit for both instrumental activities of daily living, activities of daily living and spatial/visuospatial abilities when using VR for memory training.
Commentary
Using the Joanna Briggs Institute Critical Appraisal Tools for systematic reviews (Aromataris et al, 2015), nine of the 11 criteria were judged to be satisfactory for this review. The two criteria that were not achieved were assessment of publication bias, which was not carried out due to the limited number of studies, and unsupported recommendations for practice. The recommendations for practice are deemed to be unsupported due to the unclear and inconsistent application of the GRADE criteria. Justification for grading of ‘moderate’ was only given based on the assessment of bias, with no indication of imprecision, inconsistency, indirectness and publication biases being considered. Despite these inconsistencies, it was deemed that this systematic review provided an accurate and comprehensive synthesis of the available studies that addressed the question of interest.
Based on the findings of the review, there is evidence that VR may be effective in improving fall reactions and reducing fear of falling. These findings of potential benefit are partly supported by previous reviews, with VR being found to be effective in improving balance in those with Parkinson's disease (Dockx et al, 2016) and balance performance, as well as improving functional mobility outcomes for community-dwelling adults (Donath et al, 2016). It is important to note that these two reviews used a broader definition of VR compared with the review by Dermody et al (2020), making these findings less applicable to Dermody et al's review; nevertheless, they do support the use of virtually built environments to aid rehabilitation. Similarly, there was some evidence that VR may be effective in improving cognitive abilities, verbal memory, pain scores and anxiety, with previous reviews demonstrating possible potential benefits for memory in patients with stroke (Wiley et al, 2020), pain management in adults (Mallari et al, 2019) and anxiety in individuals with anxiety disorders (Carl et al, 2019). Therefore, although the evidence is not strong enough to make recommendations to practice, there is clear potential for further research in the application of VR for falls prevention and cognitive outcomes for community-dwelling older adults.
As highlighted previously, the use of national lockdowns, curfews and social distancing restrictions during the COVID-19 pandemic have the potential to exacerbate common complications in older adults (Armitage and Nellums, 2020; Plagg et al, 2020), and VR has the potential to counteract some of the impacts of these restrictions (Dermody et al, 2020). However, as reported in this review and the reviews identified above, there is a substantial lack of high-quality evidence examining the effectiveness of VR in healthcare. Therefore, future use of VR in response to COVID-19 restrictions in community-dwelling older adults should be, wherever possible, a part of further research in this area.
A multidisciplinary, international working group made up of established authors in the use of VR in healthcare has recommended that future VR trials should try to develop their research through a three-tier system (Birckhead et al, 2019). The first tier should focus on content development; the second tier, on feasibility, acceptability, tolerability and initial clinical efficacy; and third-tier studies, on evaluating effectiveness through RCTs. Based on this tiered approach, future research on VR use in community-based older adults should be carried out at tiers 2 and 3. Second-tier studies should focus on the feasibility, acceptability and tolerability of more complex community-based adult populations, such as those who are visually or hearing impaired, as these were exclusion criteria in the studies included in Dermody et al's (2020) review and require further examination. Future tier 3 research should be an adequately robust and powered RCT focusing on impactful patient outcomes for community-dwelling older adults.
KEY POINTS
- The use of virtual reality (VR) interventions demonstrates potential improvements for slip distance in falls prevention and cognitive outcomes for community dwelling older adults
- Wherever possible, clinical application of VR as a response to COVID-19 restrictions should be part of a clinical trial for community dwelling older adults
- Further research should focus on the feasibility, acceptability and tolerability for the auditory and visually impaired within the community dwelling older adult population
- Further high-quality randomised controlled trials are required to assess the effectiveness of VR in community dwelling adults
CPD REFLECTIVE QUESTIONS
- From the evidence presented in this review, what aspects of older adult care might benefit from virtual reality (VR) technology?
- Do you think that interventions using VR technology would be of benefit to patients in your own service?
- What are the potential barriers to the use of this type of technology with older adults in the community?