Analysis of a Cognitive Training based on Virtual Reality Contents for the Elderly

Ⅰ. Introduction

Based on Statistics Korea, it was in the year 2000 when Korea has reached the aging society where the population of people aged over 65 reached 7.2% [1][2]. In the year 2010, it has reached 10.7% and 14.42% in 2018 according to the World Bank collection of development indicators [3]. Most of the elderly were not involved in leisurely activities and were suffering from anxiety disorders and cognitive impairments. Moreover, most elderly were also suffering from chronic diseases such as diabetes, osteoporosis, Alzheimer’s disease and dementia, arthritis, asthma, cancer, and more [4].

South Korea has been aging at a great speed and the society must prepare programs for the huge elderly population. Various programs and efforts to support the elderly are essentially important so that they can be productive and become active members of the society. In this regard, the idea of leveraging the advantages of the virtual reality technology can be effective in training cognitive functions of the elderly that includes perceptual attention, mental rotation, working memory, visualization, visual field of view, and visual processing speed [5][6].

VR-based brain training games were becoming popular to improve one’s cognitive skills such as perceptual attention, spatial cognition, or executive function [7][8]. It includes gamified elements into cognitive tasks for the players to perform in order to improve their cognition components. Most notable brain training games were Lumosity, Dakim, Clevermind, Brain Fitness, Brain Trainer, and Brain Age. The main idea of using brain training games was to enhance the cognitive skills and improve skills in performing daily life activities.

This paper deals with the analysis of the utilization of VR technology and VR-based brain training games in diagnosing cognitive impairments with the elderly. It aims to analyze the utilization of VR technology and incorporation of gamified tasks in brain training games to enhance the individual’s cognitive skills such as perceptual attention, mental rotation, working memory, reasoning, visualization, visual field of view, and visual processing speed. Significant studies pertaining to the utilization of VR technologies in cognitive impairment diagnosis and treatment were identified and its results were analyzed. Moreover, popular VR-based brain training games were also identified and analyzed based on their target cognitive training and results.

The rest of this paper is organized as follows: Section 2 provides an overview of cognitive impairment in the elderly; the utilization of VR technology in cognitive programs and training is outlined in Section 3; the analysis of utilizing VR technology and VR-based brain training games on cognitive program and training is outlined in Section 4; Section 5 provides the discussion on the analysis of results; and the concluding remarks in Section 5.

Ⅱ. Cognitive Impairment in the Elderly

Cognition generally refers to “the process of mentally acquiring knowledge and understanding through the combinations of thought, experience, and the senses” [9]. It include many facets such as attention, knowledge formation, memory, judgment, reasoning, problem solving, decision making, comprehension, and language production as indicated in [Fig. 1].

Fig. 1.

Facets of cognition

Cognitive processes uses existing knowledge and new knowledge are generated to allow individuals to interact with complex environments. It is a complicated process which includes attention, memory, emotion, language, etc. Cognitive processes can be performed smoothly when the brain is in the normal state, however, the process may be stalled if the brain contains lesions that could result to attention deficiency, memory impairment, and learning disabilities [10].

Cognitive impairment specifically for the elderly can be caused by various factors such as medication side effects, delirium, depression, dementia, and aging as the most common. In addition, the progressive decline in cognitive functions may lead to neuropsychological disorders such as Alzheimer’s disease [11]. The elderly suffering from cognitive impairments may be incapable of living independently as they may have memory loss, inability to roam around spaces, and unable to communicate and socialize with others. Moreover, they may not be capable of performing simple daily activities such as cooking, driving, preparing coffees, gardening, and so on which makes them dependent with their family members. Thus, cognitive impairment may cause a heavy load to the family requiring the services of professional caregivers. Futhermore, the growing number of the elderly with cognitive impairments results to more serious social problems.

Most serious cognitive impairments were irreversible, but, early diagnosis can lead to a better cognitive training program which can make the patients gradually recover. In this regard, an effective method of cognitive program and training is essentially necessary to enable gradual recovery of our elders with cognitive impairments. In this paper, the advantages of VR technology have been analyzed and exploited in order to explore an effective cognitive program and training in order to counter cognitive aging and enable our elderly to perform normally their daily life activities that they may be able to live independently [12].

Ⅲ. Utilizing VR Technology in Cognitive Programs and Training

The evolution of Virtual Reality (VR) technology has been rapidly growing and the diversity of its applications is continuously expanding. VR technology utilizes interactive devices such as head mounted displays (HMDs), handles, and gloves to virtually create an environment that replicates the real world. It allows one or more people to interact or embed with the computer-generated virtual environment and its 3D entities [13]. The virtual environment in VR technology encompasses the following key properties [14][15]: 3D-representation and perception, spatial interaction in real-time, and sense of presence and immersion.

VR technologies has been employed in various applications including the treatment of some neuropsychological diseases such as anxiety, fear, and even cognitive impairments. VR technologies are capable of providing an immersive virtual environment that is almost the same as the real environment, thus, it can be used by doctors in surgical training to gain more experiences. In addition, VR technologies can also be used for post-stroke intervention and treatment for fast recovery of patients. Immersion with VR environments allows the person’s sensory perceptions to perform several tasks that involves touch, vision, hearing, and kinematics.

VR environment provides responses to the actions and movements of the person in real-time to create an immersive interaction between them. Thus, it creates a realistic simulation on the tasks provided by the VR environment. The utilization of VR technology in cognitive programs and training enables a fully controlled virtual environment in order to observe and analyze the patient’s perception, attention, emotion, memory, movements, and other aspects in real-time [16]-[19]. The more realistic the VR environment provided to the patients, the more immersive the simulation will become, that is, higher levels of immersion requires more realistic VR environments.

Ⅳ. Cognitive Training with VR-based Game Contents

This section provides an analysis of the utilization of VR-based technologies and VR-based games in cognitive programs and training to effectively treat cognitive impairments. First, some significant and recent studies on VR-based cognitive diagnosis, programs, training, and treatment were briefly classified and analyzed based on their objectives. Second, popular VR-based brain training games that were utilized for cognitive impairment diagnosis and treatment were also identified and analyzed based on their target cognitive training.

Various VR techniques were experimented and studied to provide an efficient and effective cognitive training for the elderly particularly those suffering from cognitive impairments. The main research methods and expected results of these studies were summarized in Table 1.

Table 1.

Significant and recent studies on the use of VR technologies for cognitive impairment diagnosis and training

In the experimental study by Weniger et al. [20], VR technology was used to study and analyze self-centered and heteroego-centered memory in individuals suffering from amnesic mild cognitive impairment (aMCI). A virtual maze of self-centered memories and a virtual park with heteroego-centered memories were setup to study and analyze spatial memory deficits in individuals suffering from aMCI. The study was conducted on 29 patients with aMCI and 29 healthy matched controls. It has demonstrated the feasibility of the utilization of VR-based techniques in studying spatial memory deficits on aMCI patients.

In the work of Mathews et al. [21], a virtual environment was used to test prospective memory recovery in stroke patients. The VR environment was designed using a constraint-based modeling (CBM) in tracking user actions as well as to provide individual feedback. The study was conducted on 15 stroke patients and results revealed that they have shown significant improvements through VR-based cognitive training.

VR-based training approach was used in the study of Serino et al. [22] to enhance the psycho-frame synchronization of patients suffering from Alzheimer diseases which results in an improved patient’s spatial memory. Psychological frame synchronization which also refers to the mental frame syncing is the specific cognitive transition process between egocentric and heteroego-centric memory. The study was conducted on 20 patients suffering from Alzheimer’s disease and 8 elderly but healthy individuals.

The 8 healthy elderly individuals were tasked to participate in VR-based training to provide a different comparison group while the 20 Alzheimer’s disease patients were randomly assigned to perform VR-based training or assigned as controls. The results of the study indicated that VR-based training provided significant improvements in long-term spatial memory for Alzheimer’s disease patients as well as on the executive functioning for healthy elderly individuals.

In 2018, Doniger et al. [23] conducted a study to evaluate the utilization of VR-based cognitive motor training aiming to improve cognition and cerebral blood flow for middle-aged high-risk Alzheimer’s disease individuals. The study involves 125 middle-aged individuals with family history of Alzheimer’s disease which were randomly divided into four groups including 20 individuals for passive controls and 35 individuals on each other groups. The first experimental group will perform cognitive stimulation on a treadmill with VR-based tasks aiming to provide sustained and selective attention, working memory, covert rule deduction, and planning. The second group performs the same VR-based tasks without the treadmill, the third group will be performing nonspecific cognitive stimulation such as watching scientific documentaries on a treadmill, and the fourth group will not be receiving any training and will be the control group. The results of the study indicates that after 3 months of cognitive training, there are emerging evidences that cognitive functions significantly improved. Moreover, it will be more effective when a more ecologically valid cognitive motor VR-based environment and setting that mimics daily activities may effectively increase the transfer of trained skills.

Based on the study of White and Moussavi [24], virtual reality navigation treatment improves spacial cognition of people with Alzheimer’s disease. Their study employs a cognitive treatment program based on spatial navigation using a VR environment that involves an elderly in the early stages of Alzheimer’s disease. The elderly has to perform navigation tasks in a symmetric, landmark-less virtual building. The results has shown that the participant navigated the desired locations perfectly in the VR navigation environment throughout the treatment program.

In the case of VR-based cognitive training games, several popular VR games were identified and classified based on their target cognition training and the results were analyzed. The summary of cognition training methods and expected results of these games were summarized in Table 2.

Table 2.

Summary of VR-based brain training games for cognitive impairment diagnosis and training

The “Brain Age games” which also refers to Dr. Kawashima’s Brain Training are presented and designed as a set of mini-games aiming to help improve the individual’s mental processes [25]. The training activities on Brain Age games are designed to stimulate multiple parts of the brain to help improve an individual’s abilities and prevent normal aging effects on the brain. The user’s performance can be tracked throughout the training activities to show the effects of daily interactions with the game.

The “Enhance VR” is a brain training game provided by the company Virtuleap that are all designed in 3D virtual reality [26]. It includes brain training games aiming to test and train cognitive skills such as memory, problem solving, motor skills, spatial orientation, and spatial-audio awareness. The users performance can be tracked with a scoring system to evaluate their training progress.

Lumosity was introduced which consists of games claiming to improve the player’s memory, attention, flexibility, speed of processing, and problem solving [27]. It was claimed that playing simple Lumosity’s brain training games can improve the individual’s memory, attention, and problem solving skills in all aspects of their life. It can also help prevent the occurrence of age-related memory declination that includes dementia and Alzheimer’s diseases. Lumosity brain training games include mini games that allows players to practice their skills in memory, attention, flexibility, problem solving, speed, math, and language. However, there’s a lot of studies that have not found solid science evidences to show that the Lumosity’s brain training games work the way they say they would.

Currently, one of the most popular VR-based brain training game is Cerevrum [28], which claims that it will definitely improve an individual’s intelligence as it targets the entire range of cognitive functions such as attention, memory, perception, executive functions, etc. Cerevrum consists of 2 mini games and each were incorporated with gamified tasks that targets the individual’s general intelligence and cognitive skills such as multiple object tracking, working memory, 2D and 3D mental rotation, and spatial visualization. It provides a higher level of immersion, thus, the learning motivation or attention on the target material was also increased.

The cognitive training with Cerevrum makes use of the gamified tasks that requires specific cognitive skills. Then, to evaluate the individual’s performance, cognitive assessments during and after the cognitive training were designed. The cognitive assessments may include a multiple‐object tracking task which is used to measure the individual’s perceptual attention, a mental‐rotation task which is used to measure spatial processing, the n‐back task which is used to measure the individual’s working memory, a paper folding task which is used to measure visualization, a racing task which is used to measure visual processing speed, and a useful field of view task which is used to measure spatial visualization.

Ⅴ. Discussions

Based on the analysis of various studies, the utilization of VR technology on cognitive impairment diagnosis, programs, training, and treatment can be considered as an effective method of treating cognitive impairments based on the following advantages [29]:

• 1. VR technology provides an ecologically efficient environment for cognitive programs and training.
• 2. The implementation of VR technology in cognitive programs and training can be done prior to the occurrence of impairment symptoms such as movement inabilities, memory loss, or communication deficiencies.
• 3. The utilization of VR environments provides a safer treatment environment since patients does not require undergoing surgical operations.

However, in the case of VR-based brain training games, there is no concrete results that shows the effectiveness of the utilization of immersive VR-based brain training games to treat cognitive impairments of the elderly. The transfer of skills from the training requires repeated and focused practice and must be provided both on specific cognitive and executive function skills in varied contexts with increasing levels of challenge and embedded feedback.

Through proper gamification of contents, the use of VR-based brain training games would still be viable that cognitive skills and functions will be improved.

Ⅴ. Conclusion

This paper has analyzed the utilization of VR technology and VR-based brain training games in cognitive programs and training for the elderly specifically with cognitive impairments. With plenty of room for improvement, VR technology represents a promising tool for an effective cognitive assessment, diagnosis, and training. On the other hand, VR-based brain training games may not have a concrete science evidence that it can provide significant improvement or recovery for patient’s with cognitive impairments, however, the gamified tasks that were incorporated can still be enhanced and developed in order to provide a more effective transfer of cognitive skills from the virtual environment to real scenarios.

Acknowledgments

This Paper was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MSIT) (No. NRF-2019R1G1A1100341).

References

• E. Y. Jung, S. J. Eun, and D. K. Park, “Effect analysis by application and Development of customized health care service for the elderly in Korea”, Journal of Next-generation Convergence Information Services Technology, Vol. 7, No.. 1, June 2018, pp. 97-110. [https://doi.org/10.29056/jncist.2018.06.07]
• H. M. Lee and Y. Pan, “The Social Interface for Elderly's Quality of Life based on the Daily Living Factor”, Journal of Next-generation Convergence Information Services Technology, Vol. 8, No. 2, June 2019, pp. 125-140. [https://doi.org/10.29056/jncist.2019.06.03]
• Trading Economics, “South Korea – Population Ages 65 And Above (% Of Total)”, tradingeconomics.com, , www.tradingeconomics.com/south-korea/population-ages-65-and-above-percent-of-total-wb-data.html#:~:text=Population%20ages%2065%20and%20above%20(%25%20of%20total)%20in%20South,compiled%20from%20officially%20recognized%20sources, [accessed: March 25, 2020].
• C. Lee, “Korea braces for aged society”, koreanherald.com, , www.koreaherald.com/view.php?ud=20140724001141, [accessed: March 25, 2020].
• J. Y. Kim, “Investigative Analysis of Virtual Reality Technology through Case Study”, Journal of Next-generation Convergence Information Services Technology, Vol. 3, No. 2, pp. 101-108, Dec. 2014.
• H. Kim and Y. S. Kim, “A Study of Dementia Preventions trough Brain Training by Serious Games”, Journal of Next-generation Convergence Information Services Technology, Vol. 5, No. 1, pp. 35-44, Jun. 2016. [https://doi.org/10.29056/jncist.2016.06.05]
• R. E. Mayer, “Computer games for learning: An evidence‐based approach. Cambridge, MA: MIT Press”, ISBN-13: 978-0262027571.
• E. Y. Jung, S. J. Eun, and D. K. Park, “Development of Evaluation Program for Cognitive for Elderly Personalized Services”, Journal of Digital Art Engineering & Multimedia, Vol. 4, No. 1, pp. 85-93, Jun. 2017. [https://doi.org/10.29056/idaem.2017.06.08]
• Lexico, “Cognition”, exico.com, , www.lexico.com/definition/cognition, [accessed: March 25, 2020].
• J. A. Anguera, J. Boccanfuso, J. L. Rintoul, O. Al-Hashimi, and A. Gazzaley, “Video game training enhances cognitive control in older adults”, Nature, Vol. 501, pp. 97–101, Sep. 2013. [https://doi.org/10.1038/nature12486]
• I. Tarnanas, N. Laskaris, M. Tsolaki, R. Muri, T. Nef, and U. P. Mosimann, “On the comparison of a novel serious game and electroencephalography biomarkers for early dementia screening”, Advances in Experimental Medicine and Biology, Vol. 821, pp. 63–77, Oct. 2015. [https://doi.org/10.1007/978-3-319-08939-3_11]
• B. Klimova, “Computer-based cognitive training in aging”, Frontiers in Aging Neuroscience, Vol. 8, pp. 313, Dec. 2016. [https://doi.org/10.3389/fnagi.2016.00313]
• V. Gatica-Rojas and G. Méndez-Rebolledo, “Virtual reality interface devices in the reorganization of neural networks in the brain of patients with neurological diseases”, Neural Regeneration Research, Vol. 9, pp. 888–896, Apr. 2014. [https://doi.org/10.4103/1673-5374.131612]
• G. Burdea and P. Coiffet, “Virtual Reality Technology”, John Wiley & Sons, Inc., New York, 1994.
• Y. Kwon, H. S. Kang, and J. Y. Kim, “A Case Study on the Human Resources Development of Converged Virtual Reality Content in the Software”, Journal of Next-generation Convergence Information Services Technology, Vol. 8, No. 1, pp. 71-82, Mar. 2019. [https://doi.org/10.29056/jncist.2019.03.07]
• I. Tarnanas, M. Tsolaki, T. Nef, R. M. Müri, and U. P. Mosimann, “Can a novel computerized cognitive screening test provide additional information for early detection of Alzheimer disease?”, Alzheimers Dement, Vol. 10, 2014, pp. 790–798.
• I. Tarnanas, A. Tsolakis, and M. Tsolaki, “Assessing virtual reality environments as cognitive stimulation method for patients with MCI,” in Technologies of Inclusive Well-Being. Studies in Computational Intelligence, eds A. Brooks, S. Brahnam, and L. Jain (Berlin, Heidelberg: Springer), pp. 39–74, 2014. [https://doi.org/10.1007/978-3-642-45432-5_4]
• J. W. Park and S. H. Oh, “A study on the Development of VR Contents for Improvement of MCI (Mild Cognitive Impairment)”, Journal of Next-generation Convergence Information Services Technology, Vol. 7, No. 2, pp. 149-162, Dec. 2018. [https://doi.org/10.29056/jncist.2018.12.03]
• S. H. Shin, W. J. Jeong, S. J. Cho, and S. H. Oh, “Design and Implementation of VR Webtoon-Based Contents for Panic Disorder”, Journal of Digital Art Engineering & Multimedia, Vol. 7, No. 1, pp. 83-93, Mar. 2020. [https://doi.org/10.29056/jdaem.2020.03.08]
• G. Weniger, M. Ruhleder, C. Lange, S. Wolf, and E. Irle, “Egocentric and allocentric memory as assessed by virtual reality in individuals with amnesic mild cognitive impairment”, Neuropsychologia, Vol. 49, pp. 518–527, 2011. [https://doi.org/10.1016/j.neuropsychologia.2010.12.031]
• M. Mathews, A. Mitrovic, S. Ohlsson, J. Holland, and A. McKinley, “A virtual reality environment for rehabilitation of prospective memory in stroke patients”, Procedia Comput. Sci., Vol. 96, pp. 7–15, 2016. [https://doi.org/10.1016/j.procs.2016.08.081]
• S. Serino, E. Pedroli, C. Tuena, G. De Leo, M. Stramba-Badiale, K. Goulene, N. G. Mariotti, and G. Riva, “A novel virtual reality-based training protocol for the enhancement of the ‘mental frame syncing’ in individuals with Alzheimer’s disease: a development-of-concept trial”, Frontiers in Aging Neuroscience, Vol. 9, pp. 240, Jul. 2017. [https://doi.org/10.3389/fnagi.2017.00240]
• G. M. Doniger, M. S. Beeri, A. Bahar-Fuchs, A. Gottlieb, A. Tkachov, H. Kenan, A. Livny, Y. Bahat, H. Sharon, O. Ben-Gal, M. Cohen, G. Zeilig, and M. Plotnik, “Virtual reality-based cognitive-motor training for middle-aged adults at high Alzheimer disease risk: a randomized controlled trial”, Alzheimers & Dementia: Translational Research & Clinical Interventions, Vol. 4, pp. 118–129, Mar. 2018. [https://doi.org/10.1016/j.trci.2018.02.005]
• P. J. White, and Z. Moussavi, “Neurocognitive treatment for a patient with Alzheimer’s disease using a virtual reality navigational environment”, J. Exp. Neurosci., Vol. 10, pp. 129–135, Nov. 2016. [https://doi.org/10.4137/JEN.S40827]
• “Brain Age”, wikipedia.org, , www.en.wikipedia.org/wiki/Brain_Age, [Accessed: Mar. 25, 2020].
• “Take Your Brain To The Gym With Enhance VR”, vrscout.com, , www.vrscout.com/news/take-brain-togym-enhance-vr-brain-training/#, [accessed: March 25, 2020].
• A. Jhaveri, “‘Brain training’ with Lumosity – does it really work?”, consumer.ftc.gov, , www.consumer.ftc.gov/blog/2016/01/brain-training-lumosity-does-it-really-work, [accessed: Mar. 25, 2020].
• Cerevrum Inc., “Cerevrum Game Research”, cerevrum.com/research, , www.cerevrum.com/research, [accessed: March 25, 2020].
• A. A. Rizzo, M. T. Schultheis, K. Kerns, and C. Mateer, “Analysis of assets for virtual reality applications in neuropsychology”, Neuropsychological Rehabilitation, Vol. 14, No. 1 pp. 207–239, Mar. 2004. [https://doi.org/10.1080/09602010343000183]