Virtual reality technology will soon be used to screen for cognitive assessment in older adults in Singapore. Based on a recent study by SingHealth Polyclinics (SHP) and Duke-NUS Medical School, the technology showed to be practicable and receptive by elderly participants.
Cognitive decline is an age-related process characterised by reduced performance in various cognitive tasks such as processing information, decision making, memory, and speed of processing information. Before progressing on to more severe forms of age-related neurodegenerative disorders, older adults will usually experience a stage known as mild cognitive impairment. This could increase the risk of developing dementia due to other neurological conditions such as Alzheimer’s disease.
Across the world, around 50 million people have dementia with almost 10 million new cases each year based on a report by the World Health Organisation. With Alzheimer’s disease being the most common types of dementia, it accounts for 60 to 70 percent of all cases. Dementia in itself is a progressive syndrome leading from the deterioration of cognitive function due to the normal process of ageing. Common symptoms or tell-tale signs of dementia include, forgetfulness, impaired judgement, difficulty performing familiar tasks, confusion, personality changes, and mood swings.
In Singapore, based on a report by the Ministry of Health, Health Promotion Board, Institute of Mental Health, and the Alzheimer’s Disease Association, 5.2 percent of Singaporeans over the age of 60 have dementia. By the year 2020, the number of older adults in Singapore expected to have dementia is 53,000 with a projected increase to 187,000 by 2050 as the ageing population continues to expand.
Due to this increasing number and an effort to help understand the cause of cognitive decline, there has been more interest to screen older adults for mild cognitive impairment to facilitate early diagnosis and intervention before the condition deteriorates further. At present, widely used tests used in screening for dementia include the Mini-Mental State Examination (MMSE) as well as the Montreal Cognitive Assessment (MoCA) to screening for mild cognitive impairment. Both forms of screening tests are traditional written formats which require a healthcare worker to administer to the patient.
To help overcome limitations of these “paper-and-pencil” based screening tests, researchers from SingHealth Polyclinics and Duke-NUS Medical School leveraged on technological advancements and increased accessibility of virtual reality (VR) software to develop a new VR experience in cognitive assessment. In a research study, the results showed the usability as well as acceptability of VR in screening for cognitive impairment in older adults.
“Cognitive impairment will usually evolve gradually into dementia. It does not just cause serious changes in an older person’s behaviour, but also affects his or her family members and friends as well. Being able to detect cognitive impairment before it escalates will allow us to administer early treatment and allow our seniors to age gracefully,” said Dr Sean Chua, House Officer, Singapore General Hospital (SGH). Dr Chua graduated from Duke-NUS as part of the 10th cohort in 2020.
The RE@CH Assessment
In the study, 60 senior patients between the ages of 65 and 85 were recruited to participate. The patients were first screening using the MoCA assessment to determine their cognitive levels. Based on the results of this screening the older patients were divided into two groups: cognitively intact individual, and cognitively impaired individual.
Both groups underwent the screening again, this time using the VR screening tool known as the RE@CH Assessment module. This VR tool comprises of VR and motion sensor technology to recreate regular daily activities into various modular games. This way the games were made to assess several cognitive domains which include, learning and memory, perceptual-motor function, and executive function.
“The RE@CH assessment was a prototype used for rehabilitation and was then adapted for cognitive screening for this study. We collaborated with the Institute of Technical Education (ITE), the Technology team from ITE College West to develop this. It included performing selected VR tasks that we thought would be difficult for the senior patients to carry out, but most of the participants were in favour of using the VR screening tool. The positive feedback and results from this study will be invaluable as we move towards our next step of developing a more sophisticated VR system to assess all six domains of cognition,” said Clinical A/Prof Tan Ngiap Chuan, Director of Research, SHP and Vice-chair, Research, SingHealth-Duke NUS Family Medicine Academic Clinical Programme (FM ACP).
Activities that were incorporated into the games include, opening a door using the correct key, making a phone call by recalling a predefined 8-digit number, identification of things or people, sorting of household objects, choosing an outfit, withdrawing money from an ATM, and shopping for groceries. Each game module is a digital simulation of a real-world activity which the elderly could experience in their daily lives. The participant’s performance is assessed using a scoring algorithm developed by the study team to determine their overall cognitive capability.
From the study, the research team was able to understand how older participants would perceive using VR technology in cognitive screening and whether they would be receptive to the technology. One key finding from the study participants found that 90 percent of them demonstrated positive attitude and were in favour of adopting the VR experience in cognitive assessment.
A second key finding from the study demonstrated that between the two groups; cognitively intact and cognitively impaired, there was statistically significant difference between the two total performance scores. The average score was also found to be higher in the group consisting of cognitively intact participants. This demonstrated the possibility of using the VR tool in cognitive screening.
Lastly, the study also showed how this technology is appropriate for use within a primary care clinic where the screening could be conducted before consultation with a primary care physician.
One challenge of traditional methods of cognitive assessment tools outlined by the researchers was the ability to assess executive functions. These include working memory, thinking, and self-control. The team believes that with the development of the VR tool it could provide a potential solution in address this issue.
“This study truly demonstrates how Duke-NUS graduates are taking on substantial research projects to increase their understanding and innovate towards better care and health in our population. We look forward to the next phase of this project in enhancing cognitive screening in the primary care setting,” said Assistant Professor Rahul Malhotra, Health Services and Systems Research Programme, Duke-NUS. A/Prof Malhotra is also the Head of Research at Centre for Ageing Research and Education at Duke-NUS.
- World Health Organization, Dementia. (September 19, 2019). Retrieved from: https://www.who.int/news-room/fact-sheets/detail/dementia
- SingHealth, Dementia in Singapore. (n.d.). Retrieved from: https://www.healthxchange.sg/seniors/ageing-concerns/dementia-singapore
- Chua, S., Tan, N. C., Wong, W. T., Allen, J. C., Jr, Quah, J., Malhotra, R., & Østbye, T. (2019). Virtual Reality for Screening of Cognitive Function in Older Persons: Comparative Study. Journal of medical Internet research, 21(8), e14821. https://doi.org/10.2196/14821