Facilitators and Barriers to Using Virtual Reality and its Impact on Social Engagement in Aged Care Settings: A Scoping Review

Abstract

Aim: This scoping review aims to identify the facilitators and barriers to the implementation of VR technology in the aged-care setting. Background: Virtual reality (VR) offers the potential to reduce social isolation and loneliness through increased social engagement in aged-care settings. Methods and Analysis: This scoping review followed the Joanna Briggs Institute scoping review methodology and took place between March and August 2022. The review included a three-step search strategy: (1) identifying keywords from CINHAL, Embase, Medline, PsycInfo, Scopus, and Web of Science (2) conducting a second search using all identified keywords and index terms across selected databases; and (3) searching the reference lists of all included articles and reports for additional studies. Results: The final review included 22 articles. The analysis identified factors affecting the VR technology implementation in aged care settings to reduce isolation and loneliness: (a) key facilitators are local champions and staff training. (b) barriers include technological adaptability, video quality, and organizational culture. Conclusion: Existing evidence points to VR as a promising intervention to decrease loneliness and feelings of isolation and improve social engagement in older people living in aged-care settings.

Summary Statement of Implications for Practice

• Staff can play a vital role in facilitating implementation of Virtual Reality in aged care settings to improve social engagement.

• Careful adaptions are required to meet the unique needs of the older individuals living in aged care settings.

• Further research is needed to better understand varied issues and strategies to mitigate harm and maximize technology benefits for better care.

Introduction

Loneliness among older adults, especially those living in institutionalized settings such as long-term care, is a major, long-standing concern (LeVasseur, 2021). The lockdowns, visitation restrictions, and reduced social activities in care settings during COVID-19, further aggravated these concerns (Boamah et al., 2021; Smith et al., 2022; Wong et al., 2022 ). In the United States, between 22% and 42% of older adults feel lonely living in long-term care, while 10% of those living in communities complain of loneliness (Simard & Volicer, 2020 ). The urgency for innovative solutions is realized as social isolation and loneliness could cause adverse mental health outcomes, including depression, suicide (Donovan et al., 2017), anxiety, cognitive decline, and negative physical outcomes, such as frailty and mobility issues (Hugelius et al., 2021).

Virtual Reality (VR, fully immersive) and Augmented Reality (AR, semi-immersive) are present today as possible innovative solutions (Afifi et al., 2021). Thanks to technological advancements (e.g., Microsoft HoloLens; Oculus Quest), immersive equipment is becoming more user-friendly to allow versatile usage among patients or residents in care settings. Both VR and AR display computer-simulated graphics in recorded videos or real-time, for users to experience an immersive digital environment (Carroll et al., 2021) by replacing the view of the real world or augmenting the real-world scene by adding digital elements. Virtual Reality/Augmented Reality may use wearable hardware (e.g., wearable haptic devices, headsets, and/or hand controllers) or the images projected on a screen. Compared with other more conventional technologies such as tablets or televisions, VR/AR users are more likely to feel “being there” that is, the subjective experience of feeling the presence and being part of the virtual world—a sensory response to the immersiveness (Appel et al., 2020).

A recent Canadian feasibility study by Schutte and Stilinović (2017) showed that it is feasible and safe to use VR among older adults with different levels of physical and cognitive impairments who can experience activities, such as virtual travel around the world. In addition, it helps older adults to feel more relaxed after use. Virtual Reality studies in care settings indicate positive outcomes for residents, too, including an increase in pleasure and alertness (Moyle et al., 2018), improvement in balancing (Blomqvist et al., 2021), reduction in depression, loneliness, and social isolation (T.-Y. Lin et al., 2020), an increase in positive feelings and enhancement in the mental health and well-being (Moyle et al., 2018; Seifert & Schlomann, 2021).

However, there are gaps in the literature on the use of VR in care settings. First, research tends to focus on the innovative dimension of VR and AR, rather than on the preferences and needs of older adults using them (Lee et al., 2019) and the utilization of VR to decrease loneliness. Second, there is scant literature on addressing the crucial aspect of VR implementation, including understanding the contextual complexity (e.g., the role of staff and families) and the required structural support and resources (e.g., human resources, funding) (Damschroder et al., 2009). Considering these literature gaps, we propose a scoping review to understand them better for effective implementation and use of VR by older adults in care settings, thereby addressing the challenge of loneliness in this population.

Study Objective

The objectives of this scoping review are (a) to identify the facilitators and barriers to implementing VR/AR in care settings, and (b) the impact of this technology on the social engagement and/or loneliness of the users.

There are complex challenges to adopting VR/AR technology in aged care settings that are not present in-home settings. Dermody et al. (2020) conducted a systematic review of the role and effectiveness of VR among community-dwelling older adults. Carroll et al. (2021) completed a scoping review to explore how VR/AR technology is being used with older adults and to examine whether consistent terminology is being used across VR and AR studies. Informed by the previous work, our review aims to contribute to the literature by synthesizing the evidence of facilitators and barriers related to adopting VR/AR in care settings. Additionally, we map the impact of VR/AR on social engagement and/or loneliness in these settings. In our next study, we will be doing an evaluation of long-term care (LTC) residents’ experiences of using VR/AR technology. For effective implementation of VR/AR, this scoping review provides practical insights to inform strategies for adopting VR/AR in aged care settings.

Review Questions

1. What are the facilitators and barriers to adopting VR for older adults in care settings?

2. What is the current evidence on the impact of VR on social engagement and well-being?

Methods

Our scoping review follows the Joanna Briggs Institute methodology (Aromataris & Munn, 2020). A scoping review is useful for: identifying the conceptual boundaries of a topic, examining emerging evidence, and providing a broad overview of a topic (Arksey & O'Malley, 2005; Levac et al., 2010). Therefore, a scoping review is appropriate for the above review questions. Our review was conducted between March and August 2022.

Participants

This review considers studies that include older adults aged 65 or older living in geriatric care settings, with care home staff, and/or family (Table 1).

Table 1.

Inclusion and Exclusion Criteria.

Inclusion Criteria

Exclusion Criteria

1. Articles that include users who are aged 65 or older 2. Articles with a focus on Virtual Reality (VR) and/or Augmented Reality (AR) 3. Articles addressing residents in a healthcare setting with formal care provided by paid staff 4. Articles that included mentions of any facilitators or barriers to implementation 5. Peer reviewed journal articles, full reports, case studies, user reports; gray literature Publications in English

1. Articles focused on users who are aged younger than 65 2. Articles with no focus on Virtual Reality (VR) and/or Augmented Reality (AR) 3. Research conducted in non-formal care settings (e.g., home care) 4. Non- English publications 5. Only abstracts available 6. Published prior to April 2018

Concepts

We include studies that use VR and/or AR to produce an immersive experience for the users (e.g., creating a life-like environment through a head-mounted device that could be manipulated by the user). Articles must address at least one of the following areas of adopting VR/AR: barriers, facilitators, social engagement, and/or loneliness. Barriers are defined as any factors (e.g., resources, practice culture, policies) that “impede the implementation of, or adherence” to the use of VR/AR in the practice setting (Feyissa et al., 2019, p. 5). Conversely, facilitators are factors that promote “the implementation of, or adherence to” the technology (Feyissa et al., 2019, p. 5). For addressing social engagement and/or loneliness objectives the articles would need to discuss how VR/AR enabled the user to interact and engage with others. The articles that were published more than 5 years ago were not included, as VR/AR technology has evolved significantly in the last 5 years. This also ensured that updated and current information on the facilitators, barriers, and social engagement of this technology is included.

Context

Studies that are included were situated in aged care settings such as (but not limited to) Long-term care (LTC) and assisted living (AL) settings.

Types of Evidence Sources

A wide range of studies (e.g., randomized trials, descriptive studies) are included, including user experience reports.

Search Strategy

We follow JBI’s three-step search strategy. First, initial search in CINAHL included keywords, medical subject headings, index terms, titles, and abstracts appropriate for the purposes of this scoping review. Second, in our full review, we used the terms: (“older adult*” or geriatric* or elder* or aging or aged or senior* or “older people*”) AND (“virtual realit*” or “augmented realit*”) AND (“residential facilit*”“ or “nursing home*” or “long term care” or “long-term care” or “homes of the aged”) in the following databases: CINHAL, Embase, Medline, PsycInfo, Scopus, and Web of Science. Google was searched for gray literature (e.g., student theses and university dissertations, and other articles not otherwise indexed in library databases) using phrases such as “virtual reality in aged care settings” OR “virtual reality in long-term care” OR “augmented reality in aged care settings” OR “augmented reality in long-term care.” We worked with a librarian to refine the search strategy. The third step involved checking reference lists for any additional articles that meet our inclusion criteria.

We used the reference management tool, Mendeley, to organize all references and articles selected for our review and duplicates were removed. The selected articles were mapped in a summary table (see Appendix Table A1) by domains: author and country, setting, participants, intervention, impact, facilitators, barriers, and strategies. In research meetings, the whole team, including patient and family partners, took part in analyzing the extracted data sorted according to potential themes. Different interpretations were critically analyzed to resolve conflicts. The extracted data were collectively evaluated, refined, and collated into categories to develop the final themes. See Figure 1 for the PRISMA flow diagram (Peters et al., 2015) that describes the review process.

Figure 1.

VR Scoping review PRISMA flow chart.

Ethical Considerations

Ethics approval is not required for this scoping review study because the study consists of only data from articles in public domains. As an inclusive team that included patient and family partners, academic scholars, and interdisciplinary students, team reflections were embedded in the research meetings using the guidance of the ethical framework “ASK ME” specifically developed for co-research with people living with dementia (Mann & Hung, 2019 ). The voices of patient and family partners enriched researchers’ understanding of the topic.

Results

In this review, the literature search yielded 22 articles meeting the eligibility criteria. Appendix Table A1describes the characteristics of the studies and relevant data related to the two review questions: 1) facilitators and barriers and 2) the impact. The published studies were conducted in Australia (n = 8), Taiwan (n = 3), Canada (n = 3), Japan (n = 2), the United States (n = 2), UK (n = 1), Austria (n = 1), Portugal (n = 1), and Belgium (n = 1). For impact, VR technology can provide opportunities to engage with others in aged care settings and reduce behavioral symptoms. Key facilitators for using VR in LTC settings are local champions and staff training. Barriers included technology adaptability, video quality, and organizational culture (Figure 2).

Figure 2.

Graphic map of themes utilized for the scoping review.

Interventions

The studies involved various brands of VR headsets, and/or other types of equipment in tandem with the headsets (see Appendix Table A1). All the headsets provided a three-dimensional, 360-degree immersive experience. Helmet-mounted displays equipped with headphones helped isolating the user from the immediate physical environment, and thus provide a total, self-contained experience, comparable to entering another world. In some instances, the participants were able to manipulate and control the electronic environment using hand controllers such as joysticks and handles, and touch controls. In the VR Forest program study, the participant could enjoy a virtual walk with music while the Microsoft Kinect^® motion sensors enabled virtual interactions using kinetic movements (Moyle et al., 2018). The participants could use the equipment from their beds, sitting in chairs, including swivel chairs. The VR sessions varied in length, for example, from 3 min (Appel et al., 2020) to 60 min (Baker et al., 2020), the frequency, for example, once daily (C. X. Lin et al., 2018) to twice per week (Brimelow et al., 2022), and the duration of the programs, for example, 2 weeks (Baker et al., 2020) to 9 weeks (Huang et al., 2021). Not all studies provided sufficient details of the intervention features. The virtual environments included attractive and relaxing scenes such as travel destinations and other natural locations. Google Earth Maps VR software program often provided reminiscence experiences by bringing back familiar neighborhoods, for example.

Facilitators

Champions

Champions have been reported as important facilitators for technology implementation in healthcare settings. Local champions who provided knowledge and positive support were found effective in improving residents’ attitudes and uptake of the VR program. In the study by Moyle et al. (2018), staff champions asked questions and encouraged the residents to actively share their experiences. In another study, staff champions used the mirroring feature on the tablet to enhance social engagement and reduce anxiety by promoting conversations (Yahara et al., 2021). Champions helped to increase the use of VR at their local care home. The neutral attitude of some of the older adults without prior experience with Head Mounted Device (HMD)-VR became more positive after they had support from the champions and opportunities to try the HMD-VR device (Huygelier et al., 2019; T.-Y. Lin et al., 2020) .

Training

It was evident that ongoing staff training was critical to facilitate the VR program as it helped more staff and new hires to participate in the program. For example, the staff reported initial instructions and training of the intervention as helpful (C. X. Lin et al., 2018). The residents also took time to become familiar with the equipment. Some residents felt giddy and dizzy (Brimelow et al., 2022; Chaze et al., 2022) while others felt headache, a heavy head feeling or nervousness while trying VR in the beginning. The staff has to be prepared to help residents remove the headset and provide support for safety, as needed (Chaze et al., 2022). Ferguson et al. (2020) raised a practical and salient point about staff education; staff must be trained about the technology and be familiar with the residents’ preferences to tailor the program accordingly. Instructional and structural support to the staff is important, for example, how to support the residents when they experience side effects, or time required to run the program and stable Wi-Fi connectivity (Thach et al., 2021). Yahara et al. (2021) remarked that the burden of VR implementation for nursing staff can be improved by providing remote access to family caregivers who may help with the implementation from a distance.

Barriers

Technology Adaptability

Technological adaptability has been emphasized as essential to support adoption and sustainability in care settings. Adapting to the preferences and unique age-related needs of older adults such as the use of eyeglasses and hearing aids, are integral for technology use. There is a common theme across studies that not all older adults found the headset acceptable. Head Mounted Device (HMD) was occasionally unfocused and difficult for those with glasses (Appel et al., 2020). A few people complained of discomfort including slipping off the headsets while in use (Brimelow et al., 2020, 2022). Some had esthetic concerns about disturbing their hairstyle with the VR headset. Hearing aids were affected by Radio Frequency interference from the HMD. Brimelow et al. (2020) reported that the concerns and anxiety experienced by older adults at the onset of the VR program were ameliorated through flexible, tailored activities that allowed conversation in group settings. They played relaxing scenes, such as underwater themes and beaches.

Video Quality

The content and quality of the VR videos matter for generating an immersive experience. Some residents remarked on poor video quality such as blurred scenery; other residents found the looping of videos boring (Fiocco et al., 2021). They expressed the need for contextual cues and information in the videos; culturally appropriate music, images of high quality, and the appropriate length of videos to improve program quality. In the study by Huang et al. (2021), resident participants highlighted the need for staff to understand their preferences in video selections. The preparation of tailored VR content can be labor-intensive and time-consuming (Saredakis et al., 2021).

Organizational Culture

Organizational culture is a key factor in the implementation of new technologies. Staff and family hold their values, assumptions, and beliefs about using VR with older people, especially for people living with dementia. For example, both staff and family caregivers in a UK psychiatric ward believed that the level of cognitive impairment could impact technology acceptance (Rose et al., 2021). People living with dementia were included in the study to test the feasibility and acceptance of a VR program. Surprisingly, most people living with dementia in the study used the maximum amount of time offered and showed eagerness to use more of the VR programs. Contrary to expectations, the staff reported people living with dementia were calm when using the VR. People living with dementia self-reported that they were excited, happy, and relaxed. In the same study, some participants reported a preference for the projection (i.e., on large screen television/ walls) in comparison to headsets. The staff remarked that different types of VR systems should also be investigated to compare the impact of VR and the type of immersive system, the convenience of use, and adaptability by both the staff and the patients.

Impact

Overall, the emerging evidence suggests that VR programs in LTC provide promising positive impacts on social engagement and well-being of older adults. For example, the VR program in a large Canadian study encouraged conversation among the participants and the other people involved in the session, including their family members, caregivers, and staff (Appel et al., 2020; Brimelow et al., 2020). In the study by Baker et al. (2020), participants reported feeling more energetic, content, relaxed, and adventurous, and less anxious, worried, or stressed after the intervention. In an LTC home, the VR program significantly reduced depression in participants (Brimelow et al., 2022). Participants were seen responding both verbally and non-verbally to narration, staff questions, and the experiences themselves (Coelho et al., 2020). The virtual tourism program of Ferguson et al. (2020) provided a conversation piece to discuss with family and friends, and a topic to write about for those in a writing group. Hsieh et al. (2022) reported improved positive emotions and more calm behavior in people living with dementia. Webber et al. (2021) suggested that the inclusion of family members could be beneficial to ensure the program content can be tailored to the individual concerning cultural relevance.

Reduce Behavioral Symptoms

Immediately after 6 weeks of VR tourism, the participants reported decreased anxiety and fatigue (Fiocco et al., 2021). In an American AL setting, the results show residents felt less socially isolated, showed fewer signs of depression, experienced positive affect more frequently, with improved overall social and emotional well-being (C. X. Lin et al., 2018). When they repeated the study in Taiwan, the participants perceived improved health and meaning in life, as well as decreased loneliness and depression (T.-Y. Lin et al., 2020). Moyle et al. (2018) demonstrated that the Virtual Forest program helped residents relax when the program was conducted in a peaceful environment. The reminiscence program of Niki et al. (2021) helped reduced anxiety among residents in a Japanese LTC home. Yahara et al. (2021) reported similar findings - reduced anxiety in residents of another Japanese LTC home. People with cognitive impairment in the study by saredakis et al. (2020) observed decreased apathy among residents with cognitive impairment while staff reported positive changes in their mood and behavior.

Discussion and Implications

This scoping review provides a comprehensive overview of 22 peer-reviewed articles on VR/AR adoption in care settings. We identified facilitators and barriers of VR/AR implementation, and its impact on the social engagement and the well-being of older adults and thus offer practical recommendations for future implementation of VR/AR in care settings for the older population.

The Significant Role of Staff and Family in Technology Implementation

Some of the reviewed articles demonstrated the significant role of staff in supporting VR/AR implementation in care settings. For example, improving older adults’ attitudes toward the technology (Huygelier et al., 2019), promoting conversations among participants during the intervention implementation (Yahara et al., 2021a), and facilitating the uptake of the technology (Moyle et al., 2018). To gain staff buy-in, providing training, and access to information can promote their technology use and adoption of technology in the care settings (CFIR, n.d. 2022) and potentially lessen the staff burden due to technological unfamiliarity as suggested by Yahara et al. (2021). There were reviewed articles that mentioned the provision of training for staff in the VR/AR research process (Chaze et al., 2022; C. X. Lin et al., 2018; Thach et al., 2021) though details of training were lacking. For example, C. X. Lin et al. (2018) mentioned that training at the beginning of the intervention was helpful. Future reports should provide sufficient descriptions of the training, for example, the number and mode of training that staff preferred, post-training evaluations, and feedback for improvement.

The professional roles of the trained staff were not described in the reviewed articles. The use of VR fits into current leisure and recreation programing and is less likely to be used by nurses and care aides. However, given the impacts noted in this review, there is potential for VR to be used in other ways beyond recreation. The ability of VR to increase social engagement and reduce anxiety and behavioral symptoms may be helpful to care aides and nursing staff in the course of care. Besides, there is limited research on the feasibility of VR/AR on people with moderate to severe cognitive impairment. As suggested by Appel et al. (2021), further research into the use of VR for residents with moderate to severe cognitive impairment as a possible non-pharmacological approach to care is warranted. There is a need to explore staff’s acceptance of VR/AR and their training needs. The involvement of family members in developing content, accompanying older adults during use, and stimulating connections and conversations with family members are means to enhance VR implementation in LTC (Moyle et al., 2018; Webber et al., 2021). Lujikx et al. (2015) reported positive impact of engaging family members in implementation by improving the willingness of older adults to use and adopt the technology. A study by Lazar et al. (2015) showed how family members could play a role in facilitating and motivating the use of technologies in older people living with dementia.

Organizational Infrastructure and Support

Organizational support is a key factor when considering implementing technology in healthcare settings (Bhattacherjee & Hikmet, 2008). During the pandemic, many technologies emerged in healthcare settings, including LTC however limited infrastructure, lack of leadership support, and staff shortages made implementation difficult (Chu et al., 2021). Organizational support can include the provision of adequate technology infrastructure, financial support for the equipment, and permission for staff to take the time to try something new and different. Ferguson et al. (2020) demonstrated that VR headsets that do not require wireless internet more readily facilitate implementation while other headsets required stable internet for the smooth running of a VR program.

A stable internet connection (Thach et al., 2021), and the acquisition of VR/AR equipment with better video quality are suggested for better user experiences (Fiocco et al., 2021), which needs structural and financial support from leadership teams in healthcare settings (Hung et al., 2022). Moreover, Brimelow et al. (2022) demonstrated the importance of human resource management in the VR implementation to manage staff workload and ensure attendance for VR sessions. In the reviewed articles, the factors on organizational support, for example, policy support of relevant guidelines and protocols and staff management in VR/AR activities were not explicitly explored and need further research. Helping organizations understand the broader impact of VR/AR in creating connections between residents and staff in LTC and seeing the use of VR as more than just another activity will be important in gaining this support.

Address Older Adults’ Needs and Their Adaptation to Technologies

This review has demonstrated that most participants in the reviewed articles were able to engage in VR/AR activities and benefit from the processes, despite barriers related to uncomfortable headsets and aged-related needs. These findings have aligned with emerging evidence that with adequate support, the older population of various capacities can adapt to using different technologies (Peek et al., 2019; Talbot & Briggs, 2022). Some articles highlighted the importance of older adults’ preferences in terms of VR/AR content and forms of technology. For example, Saredakis et al. (2020) provided personalized video, while Rose et al. (2021) shared that some participants preferred a large screen over VR. Fiocco et al. (2021) further suggested a way to improve the VR/AR experiences of older adults by having culturally appropriate music.

A more person-centered approach to understanding the needs and preferences of older adults, for example, the content or the suggested improvement of hardware, would increase the adaptation of this technology. In line with integrative knowledge translation, any evaluation and suggested improvements can be brought to the attention of industrial partners in implementation research. Through iterative cycles of implementing, evaluating, and improving, the technology developed will be more suitable for use by this population. During the process, the important opportunity to co-design with older people living in care settings should be utilized as they will be the main users. Carroll et al. (2021) and Appel et al. (2021) also suggested that these experts with lived experiences can help design and evaluate the intervention. Fisher et al. (2020) highlighted the importance of the feeling of ownership by giving older adults options to choose their preferred form of technology and participate in their designs.

Implications for Future Research and Practice

This review found that there are limited studies discussing implementation strategies of VR/AR programs in long-term care, for example, staff training, possible roles, the involvement of family members in the implementation process, as well as organizational and policy support. Future investigation should focus on how to integrate users’ experiential knowledge in the design with the needs and preferences of older adults and staff in the LTC environment. The positive impact reported among the reviewed articles challenged the existing assumptions related to ageism on older adults’ capacities in using technologies, for example, how residents with moderate to severe dementia accepted the technology (Rose et al., 2021), and demonstrated the potential values of implementing innovative technologies in care settings.

Future research needs to pay more attention to the context—the living and working environment in which the technology will be implemented to ensure a better fit between technology and everyday use. Further, there is limited information on the cultural and gender relevance of the older population on the content needs further exploration. Future research should involve stakeholders to tailor individual needs and develop practical implementation plans, for example, to engage staff, older adults, leadership teams, family members, and industrial partners. Co-designing content and having options to use familiar and existing devices should be explored for example, large screen television and projections to make the immersive experience program low cost, easy to access, and culturally relevant. Moreover, evidence-based frameworks can be used to guide the implementation. Finally, researchers can conduct a longer period of study to examine factors affecting the sustainability of the VR/AR program in long-term care and the long-term impact of adapting this technology on older adults.

Strengths and Limitations

This scoping review offers three contributions: (1) useful evidence on what enables and hinders VR/AR adoption in care settings, (2) scientific rigor by following the Joanna Briggs Institute guideline, (3) credibility by involvement of patient partners as well as interdisciplinary clinicians to ensure the relevance of the research questions and findings. The diverse perspectives in our project team enrich the analysis and added quality to the review. One limitation of the review is the exclusion of non-English written papers. There may be other relevant studies published in other languages.

Conclusion

LTC homes often face limitations when implementing technology to improve care, such as resistance to change and limited creative strategies for technology adoption. Existing evidence supports the potential of VR as a helpful intervention to reduce feelings of isolation and loneliness among older adults in care settings. The scoping review identifies two key facilitators (champion and staff training) and three critical barriers (technological adaptability, video quality, and organizational culture) to the adoption of VR for older adults in care settings. The primary impacts are social engagement and reduction of behavioral symptoms. The study underscores the importance of involving patients and family members to support technology uptake. The potential for VR/AR in aged care is tremendous and warrants further exploration to enhance adaptability and promote successful implementation.

Appendix

Table A1.

Studies of Virtual Reality Intervention in Care Settings.

	Author, year, location	Setting	Participants	Intervention	Facilitators	Barriers	Impact
1.	Appel et al. (2020) (Canada)	Long-term care homes, rehabilitation centers, seniors’ residences	66 older adults with varying cognitive abilities	Played 360° videos of nature scenes using VR headsets for 3–20 min.	Staff members were initially keen and willing to engage with VR intervention. Positive outcomes and lack of side effects allowed staff to become increasingly confident and knowledgeable about VR use.	Complexity and variety of video content were insufficient for an immersive experience. VR also may not be compatible with people who wear eyeglasses or hearing aids.	Participants were engaged with family members, caregivers, and study staff during VR sessions and some participants wanted their family members to try the headset.
2.	Baker et al. (2020) (Australia)	Long-term care Homes	5 residents and 5 staff members	Played tutorials, world tours, and games using a VR headset and touch controllers. Participants took part in up to 4, 1-hr sessions over 2 weeks.	The immersive nature of VR allowed participants to have more stimulating and engaging interactions compared to traditional social activities.	VR may not provide adequate social support if it does not involve enough interactivity. Participants can also become frustrated or confused while using VR.	VR provides an interactive and stimulating experience that can engage residents who self-isolate. Participants reported feeling more energetic and relaxed, and less stressed after the intervention.
3.	Brimelow et al. (2020) (Australia)	Long-term care homes	13 residents with some level of cognitive impairment, 9 of which had dementia.	Played relaxing scenes, (e.g., beaches) using a VR headset and mobile phone preloaded with an aged care library. Residents participated in one VR session lasting 4–5 min, either as a group or individual session.	Flexibility of the VR program allows it to be tailored to those with specific impairments, such as using contrasting black and white scenes for residents with visual impairments.	People with cognitive impairment require care staff who they are familiar with to be included in the VR experience. Headsets were also slightly uncomfortable and one resident with severe cognitive impairment experienced anxiousness at the onset of the experience.	VR gives residents the opportunity to converse in a group setting. Group dynamics can also augment the VR experience.
4.	Brimelow et al. (2022) (Australia)	Long-term care homes	25 residents with varying cognitive abilities	Played natural scenes, wildlife, and well-known international locations using a tablet and VR headsets. Residents participated in 10-min, twice-weekly group sessions over 3 weeks.	Care staff and family member participation is valued as it allows for more accurate identification of residents’ changes in behaviour or emotions. Participant discomfort can be managed by the removal of the headset.	VR sessions were a burden for some staff members resulting in poor attendance. VR caused cybersickness or “giddiness” for some residents, reducing tolerability for aged care residents.	VR provided a safe environment for social engagement and relaxation. Although positive effects were inconsistent across sessions, VR appeared to increase pleasure and reduce apathy. VR also significantly reduced depression.
5.	Chaze et al. (2022) (Canada)	Long-term care homes	32 residents, at least 22% had self-reported cognitive impairments	Played popular locations in western Canada and Ontario using VR headsets. Each participant engaged in 1–6 sessions over a 2-week period, and each session was 8–10 min.	Staff was trained on how to use VR equipment. Residents enjoyed the sessions and for some, it allowed them to enjoy things they are no longer able to do, such as going out to a restaurant.	The program of standing at the edge of a drop made some participants feel dizzy and they expressed wanting to move away from the “edge” to feel safer.	VR can be used to support socialization and reminiscence. More specifically, VR provided opportunities for conversation and engagement between participants and staff that otherwise would not have happened.
6.	Coelho et al. (2020) (Portugal)	Long-term care homes	9 older adults with dementia	Displayed 360° videos of locations relevant to the participant’s stories using a tablet and VR headsets. Conducted four 15-min sessions over 2 weeks.	Personalized videos curated based on meaningful locations (relevant to each individual’s life story) were helpful in promoting reminiscence.	Disruption of routine, recollection of negative events, and difficulty perceiving details may contribute to minor irritability, agitation, or anxiety. These barriers may have been emphasized by caregivers.	Participants were seen re-enacting stories, and responding both verbally and non-verbally to narration, staff questions, and the experiences themselves.
7.	Ferguson et al. (2020) (US)	Hospice care	25 participants, 22 of which had Alzheimer’s disease, vascular dementia, or both.	Played 3.5-min 360° beach scene videos looped up to 12 times using a VR headset.	Headset is easy to clean, hands-free, easily portable, and does not require wireless internet connection or a smartphone.	Work-related barriers, such as shift changes and familiarity between caregivers and participants. Looping of videos also caused confusion for some participants.	The VR tourism program provided a conversation piece to discuss with family and friends, and a topic to write about for those in a writing group.
8.	Fiocco et al. (2021) (Canada)	Residential care homes	18 participants	Played videos based on travel destinations using a VR headset and tablets. travel destinations Each VR session was 6–10 min, conducted 3 times per week over 6 weeks.	Program allows participants to see something new and exciting each week. The program offered a heightened sense of immersion, which allowed participants to feel greater enjoyment.	Improvements can be made by using culturally appropriate music; creating enhanced contextual, auditory, and visual cues; and increased quality of images and length of videos. Looping the videos also bored some participants.	Participants reported decreased anxiety and fatigue immediately following exposure and increased social engagement and quality of life 6 weeks after the intervention.
9.	Hsieh et al. (2022) (Taiwan)	Long-term care homes	14 participants	Played a 6-min video of a city vegetable garden for 6 min using a VR headset.	The garden crops shown in the panoramic video were found to be important in improving the positive responses of the participants. The content also reminded many participants of their childhoods in the country.	Participants were not able to choose the content they viewed; thus, this program may not be as effective in providing tailored experiences.	Residents showed improved positive emotions, allowing them to be calmer and more stable.
10.	Huang et al. (2021) (Taiwan)	Long-term care homes	71 participants	Immersive program with 8 activities related to horticulture therapy using a VR headset and joysticks. Participants could use the VR program continuously over a period of 9 weeks.	The VR program provided a sense of immersion and interactivity, which resulted in a higher frequency of VR use among residents.	Lack of continuous assistance may be a barrier. VR may be perceived by participants as unavailable after the 9-week free trial, therefore their continuous usage may decrease.	The level of interactivity and involvement within the VR program significantly affected participant presence, defined as the sense of being there. In turn, presence significantly affects participant acceptance of the VR program.
11.	Huygelier et al. (2019) (Belgium)	Long-term care homes	76 participants	Participants were exposed to artificially made, but natural and familiar-looking environments (e.g., mountain, lake) using a VR headset and touch controllers. Conducted two 60–90-min sessions, with 1–2 days between sessions.	No major safety concerns were observed. Allowing participants to remain seated reduced the risk of falls.	The type of help needed while using VR and the extent to which older adults can learn to use VR independently remains a question. Mild to moderate cybersickness was reported.	Participants became more willing to use VR and had more positive attitudes after having a positive first experience.
12.	C. X. Lin et al. (2018) (US)	Assisted living communities	63 participants	Viewed images related to relaxation, world travel, cultural events, and more using a tablet and VR headset. Conducted daily 20-min sessions over a period of 2 weeks.	Introduction, instructions, and training at the beginning of the intervention were helpful for staff. One tablet that can control all VR headsets is helpful.	Did not specify	Participants reported feeling less socially isolated, showed fewer signs of depression, experienced positive affect more frequently, and felt better about their overall social and emotional well-being.
13.	T.-Y. Lin et al. (2020) (Taiwan)	Assisted living communities	118 participants	Immersive VR program based on horticulture activities (e.g., plant familiarization) using VR headsets and joysticks. Conducted 18 1-hr sessions, twice a week over a period of 9 weeks.	Participants received training on how to use the VR equipment. Availability of horticultural experts and hands-on activities was a complement to the program.	Extra time and support were needed for participants to familiarize themselves with the equipment.	Increased perceived health and perceived mattering in life. Decreased loneliness and depression.
14.	Moyle et al. (2018) (Australia)	Long-term care homes	10 residents all diagnosed with dementia	Displayed an interactive walk through a forest with sound and music using a large screen, and arm and hand motion sensors. Study was conducted over 4 months.	Family participation could be helpful as one participant preferred attending the session with their spouse than with the facilitator. The program provided some level of control to participants. Quiet spaces also support implementation.	Limitations on human resources: staff and family expressed that most residents needed one-on-one assistance. The session was not active enough and did not encourage participants to stand up or walk in the virtual space.	The program increased alertness and pleasure in participants and the forest video had a calming and relaxing effect; however, some participants felt anxiety, fear, and boredom.
15.	Mühlegger (2018) (Austria)	Long-term care homes	6 participants	Played scenes based on natural landscapes and everyday populated places using VR glasses and a tablet. Sessions lasted no longer than 45 min.	Longer sessions were preferred with some lasting 45 min. Various destinations were preferred and could be accommodated by the program.	Did not specify	The VR program gives residents who self-identify as withdrawn from their social life and communities an opportunity to travel and dream.
16.	Niki et al. (2021) (Japan)	Long-term care homes	10 people using day services at the nursing home	Participants alternately viewed live-action or computer graphics images, for 10 min each, of Japanese scenes familiar to those 75 and older (e.g., arcades) using a VR headset to facilitate reminiscence.	Images have little movement, minimizing the risk of nausea. Nursing staff found it easy to communicate with subjects by mirroring the images to a tablet.	Generic images and themes may not be as effective at providing tailored reminiscence. Creating realistic VR content is costly and time-consuming. Some subjects felt nervous trying VR for the first time.	VR transiently reduced anxiety. Reminiscence can be used as a group social activity, and it is important that subjects view the same photos at the same time.
17.	Rose et al. (2021) (UK)	Inpatient psychiatric care setting	8 people living with dementia and 16 caregivers	Played 360° videos using a VR headset for two 15-min sessions offered 2 weeks apart. Participants could choose from 1 of 5 videos: forest, countryside, sandy beach, rocky beach, or cathedral.	For some participants, the VR program offered a sufficiently immersive experience. Implementation did not rely on extraneous factors, such as caregiver accessibility or weather.	Some individuals prefer other forms of technology, such as TVs, over VR, which may be unfamiliar. One individual also reported dizziness due to the headset.	Caregivers initially believed that VR could trigger negative emotions (i.e., distress, agitation). Contrary to their expectations, they observed that individuals were more calm, relaxed, and happy.
18.	Saredakis et al. (2020) (Australia)	Long-term care homes	17 residents, 7 of which had mild to moderate cognitive impairments.	Played personalized 360° videos for 20-min using YouTube VR, the Wander app (Google Street View), and a VR headset, to facilitate reminiscence.	Working with participants to create personalized content can reduce preparation time and provide a more tailored experience. VR content is free and easily sourced. Videos were pre-downloaded, which increased playback reliability.	Program may not provide sufficient interactivity as one participant reported wanting a controller to better navigate the virtual world. Preparation of tailored VR content is time-consuming. Subjects reported side effects, such as dizziness, discomfort, and nausea.	VR decreased apathy and non-significantly increased enjoyment. Staff and family members reported positive changes in mood and behaviour.
19.	Saredakis et al. (2021) (Australia)	3 long-term care homes	43 residents with up to moderate cognitive impairment.	Played personalized 360° videos over three sessions for 20 min each using YouTube VR, the Wander app, VR headsets, and laptops to facilitate reminiscence. Sessions were completed within 2 weeks but were at least 1 day apart.	Use of a swivel chair allowed for a more immersive 360° experience. Content can be easily sourced through readily available apps (Youtube and Google Street View).	Use of VR can reduce personal interactions and compromise interactions between the participant and therapist or researcher. Two participants reported short-lasting side effects, including headache and a heavy head feeling.	VR provided an engaging experience for both participants and caregivers. Anecdotally, VR participants experienced more positive emotions than laptop users.
20.	Thach et al. (2021) (Australia)	Long-term care homes	10 staff members (lifestyle coordinators)	Played videos for residents based on experiential activities and travel destinations using a VR headset to foster socialization and happiness. Staff members answered 5 survey questions.	Continuous training and sufficient instruction for staff would be helpful for implementation. Co-design of technology and content with residents and families is needed.	Current headsets may not be suitable for residents with various complex conditions; they need to be more simple and adjustable. Poor wifi connectivity can cause technological challenges.	VR may be an enrichment experience that can provide opportunities that support the emotional needs and promote social connectedness of people living in aged care.
21.	Webber et al. (2021) (Australia)	Long-term care homes	7 residents, 4 of which showed signs of cognitive impairment.	Facilitated “virtual visits” over two 45-min sessions based on places of significance using the Wander app to facilitate reminiscence. Participants alternated between using a VR headset or Apple iPad over both sessions.	Family members can play a significant and helpful role in VR implementation by suggesting meaningful locations, events, or items. It could also be helpful to have a facilitator who can manage the controller for the participant.	Headsets caused some discomfort and images were blurry for people with impaired vision. Some participants felt frustrated as they were limited to views from the street.	Participants engaged in social, interpersonal, and cultural reminiscence. Family members felt that VR could provide social support and enrichment while enhancing the emotional and social well-being of residents.
22.	Yahara et al. (2021) (Japan)	Nursing home	2 people using day services at a nursing home.	Facilitated 10-min personalized virtual tours based on places of significance using the Wander app and VR headsets to facilitate reminiscence.	Offering sufficient technical support to caregivers could help to reduce the burden of technological unfamiliarity.	Technological unfamiliarity can be a burden for nursing staff.	VR can improve social engagement and transiently reduce anxiety in elderly people by promoting conversations. This can reduce the burden of caregiving for families.