| Background:In the aging society,solving health problems of older adults and promoting healthy aging have become issues of global concern.Activities of daily living(ADL)is an important indicator of independent living ability and overall health of older adults.In China,the incidence of ADL dysfunction is high among older adults living in nursing homes.Due to the limitations of living environment and health service capacity of nursing homes,ADL rehabilitation has been neglected,which is a prominent problem affecting the health of older adults.The application of virtual reality(VR)technology in the field of geriatric rehabilitation has made certain progress.VR technology can provide a training environment like the real world,meaningful task settings and realtime training effect feedback.VR has the characteristics of fun,interactive and immersive.VR technology can provide a new idea for ADL rehabilitation of older adults in nursing homes.Objectives:The main purpose of this study was to find an effective rehabilitation approach to improve the ADL function of older adults in nursing homes.Specific researchobjectives included:(1)Based on evidence-based methods,this study aimed to explore the application status and existing problems of VR technology used in nursing homes.In order to provide evidence for ADL rehabilitation of older adults in nursing homes.(2)Based on multidisciplinary approaches,this study aimed to develop a VRbased ADL rehabilitation training and evaluation system for older adults in nursing homes,to build a human-computer interactive VR technology platform,to design a VRbased rehabilitation training and evaluation methods,to create a new functional VR rehabilitation training and evaluation model which suitable for older adults in nursing homes in China.(3)This study aimed to verify the intervention effects of rehabilitation which based on the self-developed VR-based ADL rehabilitation training and evaluation system for older adults in nursing homes,and to test the accuracy of the system for ADL evaluation.(4)This study aimed to understand and analyze the cognition,emotion,and the final behavioral tendency of the older adults who participated in the intervention,to further improve the VR-based ADL rehabilitation training and evaluation system and provide evidence for the application and promotion of VR technology in the field of geriatric nursing.Methods:(1)The effects of VR-based technology for older adults in nursing homes:a systematic review.Eight Chinese and English databases were searched for controlled trials which demonstrated the effects of VR-based technology used in nursing homes.The publication date was limited to May 31,2022.Descriptive methods were used to analyze the results to explore the effects of VR-based interventions on the physical and psychological of older adults in nursing homes,and to provide evidence for the subsequent construction of the VR system and the intervention plan.(2)The construction of the VR-based ADL rehabilitation training and evaluation system for older adults in nursing homes.The system was designed for older adults with mild ADL dysfunction in nursing homes.The system was constructed based on the person-environment-occupation model(PEO),using daily life activities training as the content framework.Four steps were taken to construct the system which included demand analysis,system design,programming development and system testing.(3)The effects of the VR-based ADL rehabilitation training and evaluation system for older adults in nursing homes.Participants were recruited from a large nursing home in Changchun by convenient sampling.A non-randomized controlled study design was adopted to include 60 older adults with mild ADL dysfunction in the nursing home.According to the living floor,participants were assigned to two groups,intervention group(n=30)or control group(n=30).The intervention group used the VR-based ADL rehabilitation training and evaluation system to carry out rehabilitation training.The intervention duration was 45 minutes per session,including 5 minutes of warm-up,30 minutes of rehabilitation training including 5-minute intervals of rest,and 5 minutes of relaxation.During the training,5 minutes of rest could be taken.The intervention was conducted twice per week for 12 weeks.The control group did not intervene and kept original life.Participants’ADL function,cognitive function,frailty,depression,fatigue,and quality of life were assessed at baseline,6th week,and 12th week.Assessment tools included self-orientated general information questionnaire,functional independence measure(FIM),Barthel index(BI),Lawton instrumental activities of daily living scale(Lawton IADL),mini mental state examination(MMSE),Fried frailty phenotype Assessment(FP),15-item geriatric depression scale(GDS-15),Piper fatigue scale,12item short-form health survey(SF-12).The differences in outcome changes between two groups were analyzed by generalized estimating equations,to verify the effects of rehabilitation on older adults with mild ADL dysfunction living in nursing homes.The mediating effect analysis was used to explore the influence path of rehabilitation training on ADL level in older adults with mild ADL dysfunction.At the same time,during the intervention process,the system automatically gave the ADL evaluation results according to the subjects’ completion of the tasks,and compared the consistency with the results of ADL scales to verify the accuracy of the system’s evaluation of ADL.(4)A qualitative study on the involvement process of the older adults participating in the rehabilitation training using VR-based ADL rehabilitation training and evaluation system.Participants were selected from older adults in nursing homes who completed the VR-based ADL rehabilitation training by purposive sampling.Face-toface semi-structured interviews was conducted.Sample size was based on information saturation.The interview contents included the cognition,emotion,and the resulting behavioral tendency of the older adults during the participation of the rehabilitation training.Qualitative content analysis was used for data analysis.Result:(1)The effects of VR-based technology for older adults in nursing homes:a systematic review.A total of 30 studies were included.The intervention included VRbased exercise intervention,VR-based cognitive stimulation intervention,VR-based aromatherapy,VR-based horticultural therapy,and VR-based recall therapy.VR-based interventions could improve the physical function of older adults in nursing homes,but the evidence needs to be strengthened.Among outcome measures,the included studies showed inconsistent results for dynamic stability,balance function,fall risks,functional ability,mobility,gait,muscle strength,physical activity,and pain.Interventions based on VR technology could improve the psychological function of older adults in nursing homes,but the evidence was not strong.Among outcome measures,the included studies showed inconsistent results for cognitive function and depressive symptoms.(2)The construction of the VR-based ADL rehabilitation training and evaluation system for older adults in nursing homes.The development process had four steps including demand analysis,system design,programming development and system testing.First,the demand analysis showed that older adults in nursing homes had rehabilitation needs,and paid more attention to the effect and convenience of intelligent products;the application of intelligent products in older population should be retrofitted for aging to improve the use experience of older adults.Second,the system design combined VR technology with the training of daily living activities.According to the characteristics of the daily living environment of older adults,virtual scenes of daily life were established.The main scenes include virtual home scene and virtual supermarket scene.Seven tasks were designed in these two scenes,including telephone use,supermarket shopping,food making,housework,transportation,drug responsibility and financial handling.According to the scoring rule of each item in Lawton IADL scale,the corresponding system scoring principle was designed to achieve automatic evaluation by computer and give real-time score feedback.Third,based on VR technology,human-computer interaction technology,gesture tracking and recognition technology,combined with sensors,data gloves and virtual reality glasses and other equipment,the virtual scenes and construct training tasks were established.The virtual environment was designed through CATIA and MAYA,and the assembly engine was built by UNITY 3D.Fourthly,after the completion of the design,10 older adults were recruited and tested respectively according to the process.According to the test results,the system was adjusted,and finally,the VR-based ADL rehabilitation training and evaluation system for older adults in nursing homes was constructed.(3)The effects of the VR-based ADL rehabilitation training and evaluation system for older adults in nursing homes.After the intervention,① compared with the control group,FIM scores in the intervention group showed a significant increasing trend over time,and the difference between the two groups was statistically significant(p<0.001).② compared with the intervention group,the change of BI scores in the control group from baseline to 6 weeks,6 weeks to 12 weeks showed a significant downward trend over time,and the difference was statistically significant(p<0.001).③ compared with the control group,the scores of Lawton IADL in the intervention group showed a significant increasing trend over time,and the difference between the two groups was statistically significant(p<0.001).④compared with the control group,the MMSE scores of the intervention group showed a significant increasing trend with time,and the difference between the two groups was statistically significant(p<0.05).⑤compared with the control group,FP scores in the intervention group showed a significant decrease trend with time,and the difference between the two groups was statistically significant(p<0.05).⑥ compared with the control group,GDS-15 scores in the intervention group showed a significantly decreased trend with time,and the difference between the two groups was statistically significant(p<0.05).⑦ there was no statistically significant difference in Piper fatigue scale scores between the two groups(p=0.104).⑧compared with the control group,the SF-12 scores of the intervention group showed a significant increasing trend with time,and the difference between the two groups was statistically significant(p<0.05).The results of mediation effect analysis showed that the 95%confidence intervals of path 1(rehabilitation training→frailty→ADL)and path 2(rehabilitation training→cognitive function→ADL)were(0.143,0.772)and(0.187,0.741),respectively,excluding 0.The indirect effect was significant,accounting for 36.03%and 35.27%,respectively.Path 3(rehabilitation training→depression→ADL)has a 95%confidence interval of(-0.220,0.293),including 0,and the indirect effect is not significant.The results of ADL accuracy evaluation showed that the total score of the system was correlated with FIM,BI and Lawton IADL scores at baseline and week 6.In week 12,the total system score was correlated with FIM and Lawton IADL scores,but not with BI scores.(4)A qualitative study on the involvement process of the older adults participating in the rehabilitation training using VR-based ADL rehabilitation training and evaluation system.Six main categories were eventually generated,including benefits of rehabilitation training,facilitators of adherence,barriers to adherence,good feelings,willingness to participate in the future,and suggestions for future improvement.The benefits related to rehabilitation training involved physical function,cognitive function,activity ability of daily living,and mental state.The advantages of the rehabilitation training system itself,the appeal of new things to older adults,and the support of peers,families,and staff all encouraged participants to continue to participate in the rehabilitation training.The dysfunction of participants due to diseases,aging,etc.,and the limitations of VR equipment were the main facilitators of adherence.During the rehabilitation training,the participants had good feelings.And based on the benefits of rehabilitation training and good feelings,most of the participants expressed their willingness to continue to participate in the future and to recommend others to participate as well.At the same time,the participants also expected that the system could be improved in the task and difficulty settings in the future to further meet their rehabilitation needs.Conclusions:(1)Interventions based on VR technology were safe and effective for improving physical and psychological health of older adults in nursing homes,but the evidence needed to be strengthened,and the intervention needed to be more targeted for older adults.(2)Based on the life characteristics of older adults in nursing homes,using UNITY 3D engine virtual scene development platform,the VR-based ADL rehabilitation training and evaluation system was constructed for older adults in nursing homes.The system was based on Lawton IADL scale,and combined tasks with daily life activities.The system had seven tasks,including telephone use,supermarket shopping,food preparation,housework,transportation,medicine responsibility,and financial handling.At the same time,the system scoring principle was constructed to achieve automatic computer evaluation and give real-time score feedback.(3)The rehabilitation training using the VR-based ADL rehabilitation training and evaluation system was safe and effective for older adults with mild ADL dysfunction in nursing homes:12-week intervention could effectively improve ADL,cognitive function,frailty,depression,and quality of life of the participants.The intervention could improve the ADL function by improving the cognitive function and frailty of the older adults with mild ADL dysfunction.The system could accurately evaluate ADL and reflect individual’s ADL level and IADL level.Therefore,the VR-based ADL rehabilitation training was an appropriate rehabilitation training method for older adults with mild ADL dysfunction in nursing homes.(4)Participants subjectively felt the benefits of physical function,cognitive function,daily living activities and mental state,generated positive feelings after rehabilitation training,and were willing to continue to participate and recommend others to participate.In the future,the system could be upgraded by multi-task and multi-difficulty level mode,to better meet the rehabilitation needs of older adults in nursing homes. |
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