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Abstract

Objectives

Virtual reality (VR) holds significant potential to address the psychosocial needs of residents living with dementia in long-term care (LTC) settings. This study employed a qualitative research approach, guided by Kitwood's person-centred care approach – personhood theory, to explore how VR can support the well-being of residents living with dementia.

Methods

Conducted at three LTC homes in Vancouver, Canada, our team collected and analysed qualitative data through conversational interviews, observations, and feedback from 33 residents, 21 staff and three family members.

Results

We identified six themes that illustrate how VR supports residents’ well-being and psychosocial needs: (1) VR offers meaningful experiences; (2) VR promotes the sense of continuity of self and identity in the past; (3) VR fosters social connections in long-term care; (4) VR involves family in care; (5) VR provides comfort and a pleasant virtual environment; and (6) VR engages residents in later stages of dementia and diverse needs. VR enables residents to engage in activities beyond physical boundaries, evokes reminiscence, fosters social connections, and provides a sense of comfort.

Conclusion

This study emphasizes the interactive components of VR content and the involvement of family members in VR sessions, leading to meaningful experiences that enhance the residents’ comfort and attachment. Overall, VR shows promise as a tool for enhancing the psychosocial well-being of residents living with dementia in LTC, advocating for continued research and advancements in this field.

Keywords

Virtual reality dementia person-centred care long-term care psychosocial needs

Introduction

According to the World Health Organization, there are approximately 55 million people who have dementia worldwide, with 10 million new cases emerging yearly.¹ With no existing cure available, current treatment options focus on symptom management and enhancing the individual's quality of life. Beyond clinical care, other dementia support is needed to address the diverse psychosocial needs of people living with dementia. Minyo and Judge identified several domains of unmet needs frequently reported by people living with dementia, including the importance of early diagnosis, being heard and validated, and receiving emotional and cognitive support.² These needs reflect broader aspects of their needs, such as emotional well-being, social interaction, and the maintenance of a sense of identity and purpose. Neglecting these needs could contribute to increased feelings of isolation, frustration, and depression, all of which can significantly impact their overall health and well-being.³ Given that a significant proportion of residents in long-term care (LTC) settings are living with dementia,⁴ it is imperative that these environments should utilize effective and innovative strategies and tools to address residents’ needs to support their psychosocial well-being.

In recent years, technological interventions have become increasingly populator tools used for enhancing the quality of life for people living with dementia, especially those in LTC settings. Examples include therapeutic media such as dementia television videos and social robots such as PARO, which have been associated with positive emotional responses and increased engagement from residents living with dementia in LTC.^5,6 Among these technological advancements, virtual reality (VR) technology is becoming more prevalent in LTC homes, gaining attention as a promising tool that can deliver immersive and personally meaningful experiences.⁷

VR headsets can offer immersive and interactive environments that can enhance users’ sense of presence and transport them to alternate settings without requiring physical mobility.⁷ A recent scoping review by Appel et al. highlighted VR as an effective means of promoting well-being and engagement among residents living with dementia.⁸ In particular, VR is able to stimulate multisensory experiences, elicit emotional responses, and support person-centred care. The review found that VR experiences often led to improved mood, reduced apathy, and increased verbal and non-verbal communication. Similarly, Flynn et al. found that VR was generally well-tolerated and provided a pleasant and meaningful experience for older individuals living with dementia.⁹ These older adult participants frequently expressed relaxation, joy, amusement, and calmness during and after VR exposure. Additionally, they reported reductions in agitation, boredom, and other behavioural symptoms commonly associated with dementia. These studies reflect the therapeutic potential of VR, offering enriching experiences, especially for those who face physical or social barriers to participating in real-world activities such as travel or outdoor exploration.^8,9

Existing literature noted that the success of VR interventions may be impacted by the relevance of the content to the user's personal history.⁸ The importance of personalization was further discussed in the literature, which stated that personalized and natural VR environments were typically better received than generic content.¹⁰ Other practical considerations identified were around the importance of adapting session timing and environmental context to optimize user experience, and staff and caregivers’ concerns regarding using VR in dementia care, such as inducing discomfort, disorientation, or triggering negative feelings.^10-13

Despite the growing research in the field of VR usage, the social dimension of VR interventions has received limited attention with most studies focusing on individuals’ experiences. A recent study suggested future research to explore how VR can support multi-user experiences and enhance social interaction.¹⁴ While family involvement and interventions promoting these involvements were found to enhance quality of life, support emotional connection, reinforce shared memories, and reduced sense of isolation for residents living with dementia in LTC,^15,16 very few VR studies have actively considered and incorporated family members, caregivers, or staff in VR session planning, execution or facilitation.^8,17 Besides, many studies only recruited individuals with mild cognitive impairment or moderate dementia.¹⁸ There is currently limited evidence detailing how individuals in the later stages of dementia responded to VR.^19,20 Additionally, very few studies have examined the long-term adoption of VR,¹⁷ with most interventions lasting an average of 7.6 weeks.⁸ Notably, existing research rarely draws on guiding theories to understand how VR usage may address the psychosocial needs of residents living with dementia in LTC.

To address these gaps, this study provides insights into the residents’ experiences using VR over an extended period, following a guiding theory that addresses factors regarding residents’ psychosocial needs. We aim to answer the research question: How can VR support the psychosocial needs of people living with dementia in LTC settings?

Methods

Theoretical framework

We used the person-centred care approach – personhood theory, a philosophy and approach to dementia care by Kitwood, as our theoretical framework to guide all aspects of research, including data collection and analysis.²¹ Kitwood argued that the biomedical model focuses solely on the dementia of the person, neglecting their personhood. He emphasized that individuals living with dementia retain their personhood and that healthcare providers should consider other aspects such as their backgrounds, interests, and life histories. Kitwood proposed that person-centred care addresses five psychosocial needs: attachment, inclusion, identity, occupation, and comfort, all of which are interconnected with the fundamental need for love. Comfort – the sense of trust that comes from others. Attachment – finding security and familiarity in unexpected settings. Inclusion – being involved in the lives of others. Occupation – engaging in the routines of everyday life. Identity – the traits that set individuals apart and define their uniqueness.²²

Study sites

Our study took place in three LTC homes in Vancouver, Canada. They will be named with pseudonyms: Fleetwood Manor (FM), Rose Garden Home (RGH) and Tulip Care Home (TCH). These homes provide 24-hour nursing care, with various interdisciplinary services, including rehabilitation and recreational therapy. FM, RGH and TCH have 132, 116 and 83 beds, respectively.

Virtual reality

We implemented a VR program in three LTC homes for 4–8 months, using a wireless head-mounted VR device to provide participants with a fully immersive experience. The VR program is a commercial product by the company Rendever,²³ which allows up to six headsets to connect to a VR tablet simultaneously with internet connection, facilitating both individual and group VR sessions. The VR program includes a video library, encompassing categories like animals, travel, and concerts, which are updated by the company regularly. The VR tablet allowed the facilitator and residents to select videos from any category to be shown on the headsets. There will be one video shown on all headsets at the same time. Additionally, the tablet displays the video being viewed in the headsets for the facilitators to follow. The VR program also enables families to upload videos and photos to share with residents. Residents were invited to join regular weekly individual and group VR sessions facilitated by staff or research team members. Residents could choose to join the sessions or not based on their preferences.

Participant recruitment

We used convenience sampling to recruit residents, family members and staff members. Our staff champions (i.e. a designated staff member at each site who actively supported the project) at the sites facilitated recruitment of residents and family members with the criteria of who were willing to try the VR headsets and had no medical contraindications (e.g. sensitive to lights, motion sickness and seizures). Our research team recruited staff members who facilitated individual or group VR sessions, and staff who observed the VR sessions. The research team approached all potential participants in person to explain the project. Our research team determined the recruitment strategy and dataset size by reflecting on the data depth and richness with the research question.²⁴

Data collection

We utilized qualitative research methods, drawing insights from a variety of qualitative sources and engaging participants from diverse backgrounds to inform our data collection. Qualitative research is well-suited to explore the complex, subjective, and often non-verbal experiences of individuals living with dementia.²⁵ As dementia progresses and cognitive and language abilities decline, individuals, especially those with moderate-to-severe dementia – may find it challenging to verbally express their thoughts and emotions.²⁶ However, even as verbal expression diminishes, non-verbal communication, through facial expressions, body language, gestures, and emotional responses – often remains intact.^26,27 Non-verbal cues can convey feelings, preferences, and levels of engagement, and people living with dementia frequently retain both the desire and the ability to communicate in these ways.²⁶ Qualitative research is particularly well-equipped to capture these subtle, meaningful forms of expression.

By integrating prolonged engagement, participant observation, and thick description, this study moves beyond reliance on spoken-word data to include rich, multi-dimensional observations of participants’ experiences.²⁷ These core elements of qualitative inquiry allowed us to carefully document verbal and non-verbal expressions, emotional responses, and interactions with other residents and staff during and after the VR sessions. Prolonged engagement also helps build trust and provides the necessary time to observe patterns and nuanced reactions that might otherwise be overlooked. Ultimately, a qualitative approach provides the flexibility and depth needed to meaningfully interpret the experiences of people living with dementia,^25-27 so that their voices, whether spoken or unspoken, are authentically represented in the study's findings. The following section describes the interviews conducted with residents, staff, and family members.

Videotaped conversational individual interviews with residents

Two research trainees conducted individual interviews with residents while using VR either in their rooms or in the common areas of the LTC home. Before the interview was conducted, residents had participated in at least four VR sessions, depending on how long the VR program had been implemented in the LTC home. The interviews were conversational interviews, designed to be natural and jargon-free,²⁸ which could help residents feel more relaxed and expressive. One trainee asked residents questions like ‘What do you see now?’ ‘How are you feeling now?’ ‘Which video do you like to watch?’ ‘Can you tell me more about […]?’ and ‘How do you feel wearing this headset?’ while the other trainee video recorded the session to capture verbal and non-verbal responses. One interview was audio recorded based on the resident's preference. Each conversational interview/VR session lasted 5–45 minutes, depending on the residents’ attention span and their comfort level with the VR headsets. In total, we conducted 37 individual interviews with 33 residents during group and individual VR sessions. Four residents were interviewed twice. See Table 1 for residents’ characteristics.

Table 1.

Descriptive characteristics of residents (N = 33).

Category	Subcategory	Number (percentage)
Mean of age (range)		78.12 years old[67–92 years old]
Sex	Female	23 (70%)
Sex	Male	10 (30%)
Ethnicity	White/Caucasian/Caucasian European/Caucasian Canadian	15 (46%)
	Canadian (Indigenous)	1 (3%)
	Hungarian	1 (3%)
	Finnish	1 (3%)
	Italian	1 (3%)
	Chinese	7 (21%)
	Korean	1 (3%)
	Vietnamese	1 (3%)
	Filipino	1 (3%)
	Indian	1 (3%)
	Iranian	1 (3%)
Language	English	28 (85%)
	Cantonese	3 (9%)
	Hungarian	1 (3%)
	American Sign Language (ASL)	1 (3%)
	More than one language	4 (12%)
Forms of expressions	Participants who were verbal (including expressions through ASL)	29 (88%)
Forms of expressions	Participants who were non-verbal (expressions through facial expressions/sounds)	4 (12%)
Diagnosis	Without a dementia diagnosis	10 (30%)
	Dementia	15 (45%)
	Cognitive impairment	8 (24%)
Mobility	Independent	13 (39%)
Mobility	With mobility aides, e.g. wheelchair	20 (61%)
Care homes	Fleetwood Manor	5 (15%)
	Rose Garden Home	17 (52%)
	Tulip Care Home	11(33%)

Individual and group interviews with staff

The interviews with staff involved two trainees with questions such as: ‘How do you feel when you experience the VR program with the resident?’ ‘Do you see any change in the behaviour of the resident regarding their psychosocial needs (mental well-being, mood…)?’ and ‘Has the program helped/affected your interactions with the resident?’ All interviews were audio recorded. Depending on the participants’ preferences, the interviews were either conducted individually or in groups at the LTC home. Each interview and focus group lasted 15–30 minutes, based on the participants’ availability. In total, we conducted five group interviews and four individual interviews with 21 staff from three LTC homes. 10 staff were from Fleetwood Manor, one was from Tulip Care Home, and 10 were from Rose Garden Home. See Table 2 for the disciplines of the staff.

Table 2.

Descriptive characteristics of staff (N = 21).

Disciplines	Number (percentage)	Facilitated (F) or observed (O) VR sessions	Participated in group or individual interview
Care aides	5 (24%)	O	Group interview
Director of care	1 (5%)	O	Individual interview
Music therapist	1 (5%)	F	Group interview
Nurse	1 (5%)	O	Individual interview
Recreation staff	7 (33%)	F	Group interview and individual interview
Screeners (mainly worked at the reception of LTC)	2 (10%)	F	Group interview
Volunteers	4 (19%)	F	Group interview

Individual interviews with family members

Three individual interviews were conducted with family members by a research trainee: one was face-to-face at the LTC home, one was over the phone, and the last was through email. The initial two interviews were audio recorded and lasted 15 minutes each. The interview questions were the same as those asked of the staff (see above). Among family members who frequently visited the care homes, the staff champion approached them and introduced the VR project. Three family members were recruited from the Rose Garden Home and were female. One of them was identified as Canadian Indigenous, and two as Chinese. Two of the family members spoke English, and one spoke Chinese. Their relationships to the residents were sibling, spouse, and child.

Staff check-ins

Two research trainees visited study sites weekly to check in with staff facilitators who facilitated individual and group VR sessions and supported family involvement in VR use, gathering updates on residents’ VR use. Staff were asked questions like, ‘What are your feedback and experiences on implementing the VR program?’ and ‘What are your insights on the psychosocial needs of residents living with dementia?’ These sessions lasted 10–30 minutes, with field notes taken during and after.

Research team meeting

Our research team included members with diverse expertise: patient and family partners with lived experience of dementia, interdisciplinary LTC staff facilitators with experience in resident care, and researchers and trainees with expertise in qualitative research methods. We met weekly for an hour via Zoom to discuss insights from interviews, check-ins, and huddles. In team meetings, researchers, patient and family partners, and LTC frontline staff shared insights with trainees on how to better engage residents with dementia during conversations and interviews. Meetings were video-recorded, and notes summarizing the main points were taken.

Field notes and reflection

After each interview, check-in, and huddle, we documented field notes on aspects not captured by videos or audios, such as the LTC home environment, key learnings, and reflections from data collection.

Observation notes written by staff facilitators

Each study site had one to two staff facilitators who facilitated residents’ VR use. The facilitators took observation notes on residents’ verbal and non-verbal expressions, interactions with other residents and staff, and emotions during and after sessions.

Data transcriptions

Interviews and video recordings were transcribed verbatim, with non-verbal actions (e.g. reaching out, pointing, and smiling) noted in the transcripts. Our trainee interviewed the residents who spoke Cantonese, transcribed and translated the interviews into Chinese. For residents who were Hungarian or communicated in ASL, we mainly observed and documented non-verbal expressions noted from the video recordings.

Data analysis

We conducted reflexive thematic analysis.²⁴ Guided by the researchers in the team, three research trainees, including the first author, one graduate and one undergraduate student, each reviewed 12–13 video/audio recordings of resident interviews independently to immerse themselves in the data and write detailed descriptions independently. They developed preliminary codes based on Kitwood's framework of personhood. The trainees met to discuss their findings, ask questions, and adjust their descriptions and preliminary codes accordingly. They also coded staff interview transcripts, field notes, and observation notes written by staff facilitators using Kitwood's framework collectively. The codes were then grouped into categories and further into preliminary themes. JW presented the preliminary themes to the research team, which provided feedback. Based on this feedback, the themes were refined and finalized.

Rigour

To enhance the credibility of our study, we implemented several measures. First, we employed multiple research methods for data collection, ensuring data triangulation. Second, we engaged patient and family partners with lived experiences at every research stage, including developing interview questions, participating in data collection team debriefing and data analysis meetings, to enhance the practical significance of our study. Third, as a research team, we practised reflexivity by recognizing our individual assumptions stemming from our diverse social backgrounds and challenging these assumptions during team meetings. Lastly, we improved the transferability of our study by providing rich details of the research process, study sites, and participants. This enables readers to consider the relevance of our findings in their own contexts. To enhance the rigour and clarity of our qualitative reporting, we used the COREQ checklist to guide the reporting of our study procedures and findings. See Appendix I for COREQ checklist.

Ethical considerations

Our study received ethics approval from the University of British Columbia's Behavioural Research Ethics Board (ethics ID: H22-02470). Consent was obtained from the residents. If they were unable to consent, consent would be obtained from their families or substitute decision-makers, while residents provided verbal assent for the interview and audio/video recordings. If a resident showed disinterest or declined participation, their decision was honoured without any attempt to persuade or coerce them into the VR session or conversational interviews. Consent was obtained from family members and staff participants for participating in interviews or focus groups and recordings. Fieldnotes were taken if the interview was consented to, but videotaping or audiotaping was declined. Verbal consent was obtained for the pictures used in the article. Pseudonyms are used in this paper to protect the anonymity of the participants and the care homes.

Results

Our team analysed data collected during seven group VR sessions and 24 individual VR sessions. Each VR session lasted five to 45 minutes, depending on the residents’ attention span and their comfort level with the VR headsets. Overall, the residents preferred the videos of animals and travelling, while some enjoyed musical performances and documentary videos with narrative information. Six themes resulted from the data analysis guided by the theory of personhood: (1) VR offers meaningful experiences, (2) VR promotes the sense of continuity of self and identity in the past, (3) VR fosters social connections in long-term care, (4) VR involves family in care, (5) VR provides comfort and a pleasant virtual environment, and (6) VR engages residents in later stages of dementia and diverse needs.

Theme 1: VR offers meaningful experiences (occupation)

This theme aligns with the psychosocial need of occupation. Residents in LTC homes often experience constraints and limitations on participating in meaningful activities such as outdoor or adventurous pursuits. Typically confined to indoor spaces within the care home, VR activities offer residents the opportunity to explore beyond spatial boundaries and engage in activities that may be challenging due to physical limitations.

Cheryl, a resident, shared how VR allowed her to experience something new outside the care home: ‘It [VR] really looks like bringing me outside [the care home]. I look at the sky in the video’. Another resident, Diane, also highlighted the benefits of the VR program, mentioning how it provided a break from the usual routine: ‘I am stuck in here [the care home]. I wish I could travel. It [VR] is a good way to pass the time and make me happy’.

During a group VR session where residents went on an adventure to ‘ski together’, a resident, Lucy, said, ‘Listen to the sound. You hear the move of what's going on in the air. I can feel the cold’. During another group viewing of a hot air balloon video, one resident, David, was captivated by the experience and stated, ‘Wow, look at the hot air going up (Pointing to the top and looking at the top)’ Another resident, Sam, looked up and said, ‘Look at it. It is absolutely amazing’.

Residents interacted with people in the VR videos, such as exercising alongside them. For instance, one resident imitated Tai Chi moves from a video of a person practising on a forest trail, while another followed a chair exercise routine with about 20 older adults. If videos paused due to Internet disconnections, residents would pause and resume watching the videos.

Some residents interacted directly with the video narrators and participants. For example, Cheryl, the resident with limited right-hand movement due to a stroke, imitated a pianist's gestures with both hands. She shared, ‘I played the piano with the guy [in the video], and I said hello to the narrator’. When a narrator introduced historical sites or gardens, some residents would nod and respond, sometimes expressing a preference for a narrator who provided descriptions and shared information. One resident, Albin, suggested having a family member or staff facilitator as the narrator in the VR videos. In one video, when a person offered a strawberry to the camera and stated, ‘Would you like one?’, a resident, Rosie, responded, ‘Yeah, thank you.’

Theme 2: VR promotes the sense of continuity of self and identity in the past (identity)

This theme echoes the psychosocial needs of identity. Upon entering care homes, residents are often identified by their current state or medical conditions. VR sessions stimulate residents to reminisce about their past, enabling them to maintain their sense of self by sharing memories with others. The VR programs also offer residents the opportunity to revisit their past hobbies and activities from their younger years. A recreation staff shared an experience with a resident who was once a competitive cross-country skier. By showing skiing videos, the resident was then prompted to recall specific locations, reminisce about past skiing experiences, and share stories with the staff.

In another example, a facilitator asked a resident, Diane, about a song sung to kittens in a video and an Italian phrase mentioned. Diane responded, ‘I taught high school students. I was teaching Spanish, French, and Italian’. Another resident, Lisa, who was proud of being a teacher, shared this after the VR session:

Lisa: I think this [VR] is very good, it is really important, especially for today's young people, they look at something like this, and they want to figure out how it works. And basically, this is how a teacher will say, ‘Okay, how does this work? (Pointing at the two lenses) What are these eyes? What are they doing in there?’

Facilitator: How long have you been a teacher? 30 years?

Lisa: Yes.

Facilitator: Are you proud of being a teacher?

Lisa: (Firmly) Yes. I wanted to be a doctor. But I ended up working with children who needed a lot of help as a teacher. I even taught the teachers how to help these kids. Yeah, I think I did quite well.

Many residents discussed their favourite travel destinations and selected appropriate videos to watch using VR headsets. One resident was grateful that the VR headset transported her back to her hometown, sparking conversations about her memories, family, and the local cuisine she missed. A family member from an indigenous background mentioned that their relative would appreciate videos featuring indigenous festivals and dances: ‘If there are indigenous-related videos that would be great, but we cannot find them. There can be celebrations … like dancing … with First Nations dancers and singers’.

The VR videos depicting residents’ past experiences evoked various emotions. A resident, Michelle, was moved to tears after watching a video about her hometown:

Michelle: (with tears, calmly) I watched a video about Ireland, and I came from Ireland… (started to have tears) I don’t know why, tears just kept coming down…

Facilitator: Do you miss Ireland?

Michelle: Yes.

Facilitator: Are you still comfortable with the conversation?

Michelle: Yes.

Facilitator: It feels a bit emotional, right?

Michelle: Yes…. I don’t know why.

Facilitator: Would you still want to use the VR next time?

Michelle: Yes. It's interesting.

(Michelle then chose to watch another video about Rome.)

(Field notes, Trainee)

Theme 3: VR fosters social connections in long-term care (attachment)

This theme reflects the psychosocial needs of attachment. People living with dementia often face a sense of insecurity and detachment. It is crucial for residents to feel connected and safe in an unfamiliar environment. The VR program fostered connections among residents and between residents and staff.

During group VR sessions, the staff facilitating the sessions observed and shared instances of residents interacting and having fun with each other. One notable example of how peer influence in a group session motivated a resident to try the VR headset was shared by a staff:

The resident is very interactive with her surroundings. She likes the penguins. She and the other resident interact with each other and ask questions. They both share thoughts. One resident actively tells the other resident what she's seeing and is happy to see the penguins. (Staff observation notes)

Some residents might not be comfortable trying the VR headset upon introduction, as this technology was new to them. There was an example of how peer influence in a group VR session encouraged a resident to try the VR headset. A staff shared,

The resident was willing to put on the VR headset once he saw his wife [who was also a resident in the care home] was wearing it too. He looked around, explained his surroundings with his daughter, making animal sounds with animals […] He was very happy to see his wife looking around with the headset and was also happy to be looking at the same things with her. (Director of Care)

Staff also observed residents encouraging each other to use the VR headsets. In a conversational interview, a resident, Diane, expressed her wish to share the VR equipment: ‘It [The VR headset] makes me happy. I am happy to see it. I hope they [the staff] get this equipment to [be] used by other people’.

Consistent VR sessions not only strengthen connections between residents but also with VR facilitators, including staff members and volunteers (see Figure 1). A staff documented the anticipation of a resident when seeing him with the VR equipment, ‘A resident immediately approached me, sat down and put on the headset I was setting up for himself’. A volunteer shared similar observations: ‘Residents anticipated our arrival [with the VR session] every week; one resident said, “I was waiting for you here at 3 pm last Friday”’. The interactions during the VR sessions were not just directed by staff; residents also actively participated. A recreation staff shared a session during which the resident took the lead to teach something new to the staff. A recreation staff shared,

A resident, who grew up in Budapest, was able to go all around his hometown and introduce spots to me and tell me about his memories, history, and stories. The session was very reciprocal, with the resident taking the lead on where to go and being able to teach something new to myself. (Recreation staff)

Figure 1.

A resident with a staff facilitator in a VR session.

Theme 4: VR involves family in care (attachment and comfort)

This theme covers both the psychosocial needs of attachment and comfort. The VR sessions had a positive impact on strengthening the bonds between residents and their families. During a family-facilitated one-to-one VR session, engaging interactions, joy, and care were evident in the conversations. In the resident's room, both the family member and a resident, Albin, wore a VR headset and watched the same video together:

Family: What colour is this guy [penguin]?

Albin: (reaching out) Which one?

Family: The one in front of us.

Albin: Brown.

Albin: (watching a video with cows) They are licking my face.

Family: (family member laughed) ‘They are licking my face!’

Albin: There are bigger ones.

Family: Yeah? Those are cows. Wow.

Albin: Why [did you say ‘wow’]? Would you be afraid?

Family: Yeah. Coz look at how big they are.

This family member also discovered her brother's past experiences of horseback riding after a VR session together:

It [VR experience] is something new and it's like a reminder for him. He recognizes certain animals … landscape … lakes, rivers…. I didn't know that my brother knew how to ride a horse. He told me when we were watching an animal video with the horses going by. I asked him, “Have you ridden a horse before?” And he said, “Oh yeah.” He used to ride them all the time.

The research team encouraged family members to upload personalized pictures and videos to the VR online platform for residents to enjoy. Witnessing pictures of her daughters and grandchildren, Carol, a resident living with dementia, smiled and conveyed her pride and affection towards her family:

This is my daughter, she is so smart, she is a dentist […] I have five grandchildren […] They [Carol's grandsons] are big boys, so handsome […] She [Carol's granddaughter] is so tall now […] (When seeing her grandson took a picture with a crutch) Oh, what happened to him? Fell or what?

A family member mentioned the significance of a shared VR experience for the resident:

I feel like he enjoys people watching that [VR video] with him […] It's almost like he believes that we’re all in that scenery. He believes we’re both in that [virtual world], at the farm […] he sometimes will ask, ‘Are you there?’

Theme 5: VR provides comfort and a pleasant virtual environment (comfort)

This theme is related to the psychosocial need of comfort. Residents living with dementia may experience boredom, loneliness, and insecurity in LTC homes. The VR sessions bring them joy, excitement, and distraction. Most residents enjoyed videos of animals and babies, expressing their delight through words, gestures, and facial expressions. A resident, Julie, expressed,

(Watching babies’ videos) Oh, they are beautiful, they are so funny […] He is eating […] (the baby is sitting in front of a large wooden table). He looks like an executive, sitting at his desk, looking after his office (giggled) […] They are so innocent (giggled). Sleepy baby.

Another resident, Diane, showed love during a kitten video through verbal and physical expressions: ‘Hello baby. Baby, baby […] Yes, baby. Hello, where are you going? […] Bump into my face! Very nice pet. (She then started blowing kisses to the kitties in the videos)’. The positive emotions from the VR sessions sometimes lingered afterward. A staff observed:

A resident really enjoys this [VR session]. She is always moving her head and body around, reaching out to try and touch things, and smiling all the time […] She is in a happy mood after watching the VR video for 20 minutes and said she would do it again. (Staff observation notes)

A resident showed excitement by clapping hands during the VR session. A staff shared, ‘One resident was looking around, interacting with lots of head movement […] The resident was clapping his hands while viewing dogs. He was engaged for at least 15 minutes and wanted to watch more’. (Care aide) A staff commented that the use of VR was a meaningful activity and a relief from the sense of boredom for residents:

In a special (locked) care unit, they [the residents] want to go home. With virtual reality, they are occupied, not bored, and they’re doing something, right? It makes them a little bit tired during the day too. When they are sitting and doing nothing, then they’ll be like, ‘I want to go out.’ (Director of Care).

VR headsets provided pleasant virtual environments, helping residents feel relaxed. For example, one resident felt relaxed watching scenery videos, choosing to virtually sit by the Eiffel Tower in Paris and enjoy an ocean view at a Maldives resort.

Although most residents enjoyed the VR experiences, a few residents expressed that the VR headsets were heavy and caused discomfort. These residents would prefer taking off the headsets within five minutes after the start of the VR session.

Theme 6: VR engages residents in later stages of dementia and diverse needs (inclusion)

This theme articulates residents’ psychosocial needs of inclusion. Residents living with advanced or later stages of dementia often face challenges in verbal communication and participating in group recreational activities. Some participants in our study are in this stage and, while they might not express their feelings verbally about the VR experiences, families and staff observed changes in their body movements, gestures, and facial expressions. A paid companion regularly used the VR headset with a resident living with advanced dementia. The family member shared with us the companion's observation: ‘She [The resident] needs to be prompted to respond appropriately, such as when the companion asks if the baby is cute, or if the dog is witty, so that she will laugh’.

A director of care shared that she noticed a typically immobile resident in a wheelchair showed increased awareness and movement while using the VR headset, moving her head to follow the virtual scene. A family member also expressed the differences she saw in her husband compared to not wearing the VR headset: ‘I found that he is concentrated and focused with the VR [headset]. His head is not moving, different from when he was not using the VR headset’. She further stated, ‘He did not push away the headset, which he would usually do when he didn’t enjoy something. He is enjoying the VR headset’.

The VR sessions also benefited residents with other capacity challenges. One resident, Venus, often isolated due to hearing impairment, found joy in using the VR headset. According to a recreation staff member, ‘introducing the VR headset in her room brought her joy’. Venus communicated her happiness through sign language and even created a special sign for VR to communicate with the staff.

Traditional activities in Canadian LTC homes may not cater to residents from diverse cultural backgrounds, but VR activities, including travel videos, helped bridge this gap. One resident, Mei, who was an immigrant from Hong Kong, expressed, ‘I felt happy using this [VR headset]. I cannot go back to Hong Kong now. But I can watch videos about Hong Kong. I ‘took the tram’ just now. I will be happy if I can use it with my family members’. Some VR videos engaged residents beyond languages. An observation of an interaction was documented:

A resident spoke Hungarian. She watched the videos of dogs and babies. She enjoyed both, especially the baby video, laughing, talking, making gestures, and trying to touch the baby. She would remove the headset in between [the videos] to talk to the facilitator [in her languages and gestures], then put it [VR headset] back on herself. (Staff Observation Notes)

Discussion

This study explores how fully immersive VR supports the psychosocial needs of residents living with dementia in three LTC homes in Vancouver, Canada, guided by Kitwood's person-centred care approach.²¹ We implemented VR in LTC over a period of 4–8 months to deepen our understanding of the use of VR among residents living with dementia. The six identified themes illustrate how VR supports the five psychosocial needs of residents.

Occupation

Being occupied is described as ‘involved in the process of life in a way that is personally significant’.²¹^(p83) VR engages residents in activities that are meaningful to them. Many residents expressed that VR allowed them to explore places they had never been and engage in activities they could not do in the care home. VR breaks the physical boundaries of care homes, providing meaningful experiences for residents. This aligns with the articles by Suchomelová et al. and Rose et al. that VR brought the outside into the indoor space for people living with dementia.^29,30 Our findings underscore the potential of interactivity with people in the virtual world. Residents suggested having family members and facilitators as narrators in the VR videos. These interactions often did not require verbal communication; residents would follow exercises or nod to questions and invitations in the video. This interactivity gives residents a sense of agency and offers meaningful engagement during VR sessions, especially for those living with dementia. Interestingly, interactions between residents living with dementia and people in the virtual world are rarely mentioned in current literature. This may be due to the limited involvement of narrators and interactive components in the videos used in other studies. Our findings suggest that future research should explore adding interactive elements to VR videos for residents living with dementia.

Identity

This psychosocial need refers to having ‘an identity to know who one is … a sense of continuity with the past … creating some kind of consistency across the different roles and contexts of present life’.²¹^(p83−84) VR prompts residents to tell their past stories and reminisce. This finding mirrors previous VR studies conducted in LTC settings and with people living with dementia, indicating that videos could evoke memories.³¹ Residents’ identity and sense of self can be built from the stories they shared. Existing literature predominantly highlights the positive impact of VR reminiscence on people living with dementia. Brimelow et al. documented one instance of negative emotion where a resident with severe cognitive impairment felt anxious when a water scene appeared in the VR headset.³² Our findings also indicate that residents may experience various emotions during reminiscence. For example, one resident experienced an emotion she could not explain after watching a video about her hometown. Despite limited evidence in the literature reporting similar emotional responses, this finding underscores the importance of preparing and supporting VR facilitators to manage residents’ diverse emotions or potential trauma triggered by VR experiences. Providing guidelines for VR facilitators to assist residents living with dementia in coping with triggered emotions could be beneficial. The trauma-informed practice guideline prepared by our team will be reported in another paper.

Attachment

Attachment is ‘shown in the forming of specific bonds … creates a kind of safety net…’²¹^(p82) This study distinguishes two types of connections – the connection between residents and staff in the care homes, and the connection between residents and family members. Residents in our study engaged in conversations with facilitators who were staff, student volunteers, trainees, and family members. The findings of this study are consistent with other literature, showing that residents, when accompanied by friends and family, are more likely to initiate conversations during VR sessions.³¹ Furthermore, our study elaborates on how residents with dementia shared their enjoyment of VR sessions with fellow residents and encouraged others to try the VR headsets. We also observed a unique bond developing between residents and VR facilitators during VR sessions over 8 months. Residents showed anticipation for both the VR sessions and the facilitators, a phenomenon not often noted in studies with shorter VR implementation times. Future research could compare the short-term and long-term impacts of VR use on the relationships between residents living with dementia and LTC staff. Furthermore, VR sessions facilitated by family members and featuring individualized pictures and videos uploaded by them helped include families in the care of residents living with dementia. Often, family members feel excluded and invisible in the care process in LTC homes.³³ The involvement of family members in VR activities provides meaningful interactions and brings joy and comfort to residents. Our findings suggest that family members may discover new aspects of residents’ past experiences and stories through VR interactions.

Comfort and inclusion

Comfort is described as ‘tenderness, closeness, the soothing of pain and sorrow, the calming of anxiety, the feeling of security … to provide a kind of warmth and strength…’,²¹^(p81) while inclusion is ‘to be part of the group’ and ‘having a distinct place in a shared life of a group’.²¹^(p83) Similar to other VR studies, the sense of presence in the virtual world, despite the lack of physical touch, allows residents to experience pleasure.^14,18,34 Residents in our study expressed love and felt relaxed during VR sessions, echoing Flynn et al.'s review regarding the benefit of increased relaxation.⁹ Our study shows the inclusiveness of VR in engaging residents with diverse needs, e.g. those who are deaf and from diverse cultural backgrounds. Our findings also highlight how residents living with later stages of dementia and challenges in verbal expressions were included in VR sessions. The reactions and responses of these residents were rarely documented in existing literature. A recent study in acute care reported that VR use significantly reduced the physical aggressive behaviours of patients living with moderate to severe dementia.¹⁹ Another study, which involved residents with moderate and severe cognitive impairment in using VR, did not detail the residents’ responses.³¹ Despite the challenges for residents living with later stages of dementia or other capacity challenges to express themselves verbally, family members, staff, and paid companions who knew the residents well observed subtle changes and movements indicating engagement in the VR sessions. Our findings suggest the potential of VR to offer meaningful activities for these residents and emphasize the importance of involving family members in facilitating VR sessions.

Implications for healthcare practice and future research

Our study shows that people living with dementia can engage in conversations, express love, tell their life stories and reconstruct their identity through VR in LTC homes. The VR sessions are not unidirectional; residents are not always the passive recipients. Residents can share and take the lead in the VR sessions. Staff and family members can thus learn more about the residents to provide quality person-centred care. Our study challenges the assumption that residents living with dementia cannot engage in meaningful activities and with technologies. Healthcare professionals and researchers need to acknowledge that persons living with dementia are heterogeneous and, in particular, those with later stages of dementia can still enjoy the sense of comfort and benefits brought by technologies such as VR. Furthermore, our study shows the significance of qualitative observations when exploring technology use with residents living with dementia. Many nuances and subtle non-verbal reactions, particularly from non-verbal residents, are difficult to capture through quantitative tools such as surveys.

Future research on VR with residents living with later stages of dementia or challenges to express themselves verbally should involve staff and family members who know the residents well and can notice subtle behavioural changes. This will ensure a more robust data collection process. Researchers can use video ethnographic observations and conversational interviews to capture changes in behaviour and facial expressions, as well as in-the-moment experiences. Further exploration is needed on how to better engage family members in VR experiences in LTC, such as by uploading personal videos and pictures and training more family members in VR facilitation. The longitudinal impact of VR use on broader dimensions of well-being of residents with dementia also needs further examination, such as social connectedness, emotional regulation, and the quality of relationships between residents and staff. The design of VR should be further explored and enhanced to address the discomfort brought by the weight of the VR. Interdisciplinary collaborations (e.g. with technologists, designers, and gerontologists) in VR research can further support the co-development of scalable and ethically grounded VR interventions in LTC based on the results of relevant scientific literature.

Strengths and limitations

The study demonstrates strength with a 4–8-month VR implementation in LTC homes, providing a comprehensive exploration of VR's impact on residents’ psychosocial needs. The research team includes patient and family partners with lived experiences and members from diverse disciplines, enriching team discussions. Another strength is the use of the person-centred theory to guide a rigorous data analysis process.

This study has limitations. We did not distinguish between the different types of dementia among the resident participants. We also acknowledge the limitation of not translating videos for participants who spoke languages other than English and Cantonese, such as Hungarian and ASL, which limited our inclusion of these perspectives and the richness of our analysis. The varied VR facilitation skills among staff, trainees, and family members may have influenced residents’ VR experiences. Due to recruitment challenges such as conflict in work schedules, there was a limited number of family members engaged in the study, which may restrict the perspectives included in the findings. Furthermore, the study focused on LTC homes in urban areas, where findings may differ from areas with more frequent VR use and limited outdoor experiences due to weather conditions.

Conclusion

Our study demonstrates how VR can support the psychosocial needs of residents living with dementia in LTC homes, providing meaningful activities, enhancing identity continuity, promoting social connections, and engaging family members in care. The findings underscore the potential of VR for residents living with later stages of dementia and those with challenges to express themselves verbally, the significance of involving family members as an active part of the VR session delivery and the importance of qualitative observations in VR research in LTC. Future research can explore strategies to engage family members in technology initiatives in LTC and examine the long-term impact of VR on residents living with dementia.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076251374160 - Supplemental material for A qualitative study on virtual reality and psychosocial needs of residents living with dementia in long-term care

Supplemental material, sj-docx-1-dhj-10.1177_20552076251374160 for A qualitative study on virtual reality and psychosocial needs of residents living with dementia in long-term care by Joey Oi Yee Wong, Karen Lok Yi Wong, Kayla Wen, Adebusola Adekoya, Christine Wallsworth, Jim Mann, Lily Wong, Mario Gregorio and Lillian Hung in DIGITAL HEALTH

Footnotes

Acknowledgments

We would like to acknowledge all residents, family members, and staff who participated in the study and three trainees – Mary Van, Mona Upreti and Winnie Kan – who helped collect data in multiple VR sessions.

ORCID iDs

Joey Oi Yee Wong

Karen Lok Yi Wong

Adebusola Adekoya

Ethical approval

Our study received ethics approval from the UBC Behavioural Research Ethics Board (H22-02470). Consent or assent to participate and for publication were obtained from the residents, or if they were unable to consent, from their families or substitute decision-makers. Consent to participate and for publication was obtained from family members and staff participants. Fieldnotes were taken if the interview was consented to, but videotaping or audiotaping was declined.

Contributorship

The conceptualization and methodology of the study: LH; data analysis and interpretation: led by JW and involved all authors; drafting article: JW, KLYW, KW, AA guided by LH; review, editing and approval of the final manuscript: all authors.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the MITACS Inc., Canada Research Chairs, Vancouver Coastal Health Research Institute (VCHRI),

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplementary material

Supplemental material for this article is available online.

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Supplementary Material

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