The Efficacy of an IADL-based Non-immersive Virtual Reality Training Program to Enhance ADL Performance and Cognitive Function for Persons at Risk of Dementia

Participants practice multi-step, realistic daily scenarios on a touchscreen computer, including shopping and cooking for a holiday meal, hospital registration and medication management, and travel planning.

Delivered on a 16-inch touchscreen computer incorporating touch, handwriting recognition, and voice interaction. The software features three core daily living themes with 3 to 4 sequential sub-tasks each, graded across 5 to 8 difficulty levels:

1. Holiday Reunion Dinner Preparation: Checking home inventory to create a shopping list, supermarket shopping while filtering out audio promotional distractions, price comparison and checkout calculation, and following cooking sequences.
2. Health Management: Operating a hospital registration kiosk under time and step constraints, remembering physician and pharmacist instructions during a clinic visit, and organizing a medication pillbox.
3. Travel Planning: Packing luggage spatially, navigating bus and train schedules/platforms, reacting to unexpected events (e.g., retrieving blown-away luggage), and problem-solving during travel emergencies (e.g., lost items or suspended train services).

Participants play short, decontextualized digital brain-training mini-games targeting attention, memory, math, and language.

Uses commercial digital cognitive games consisting of 22 short mini-games (under 2 minutes each) across five domains: attention, memory, mathematics, general cognition, and language, without real-life situational integration.

Participants engage in therapist-guided tabletop board games targeting various cognitive skills.

Uses structured commercial board games and tabletop activities facilitated by an occupational therapist, focusing on a specific cognitive domain each week (attention, working memory, visuospatial skills, executive function, cognitive flexibility, and language).

Assessed via a semi-structured interview based on the 24 items of the Subjective Cognitive Decline Questionnaire (SCD-Q). Participants identify up to 5 of their most concerning daily life cognitive difficulties and rate each item on two dimensions: (1) Frequency of occurrence, rated from 1 to 10 (where 10 indicates very frequent occurrence), and (2) Perceived distress/bother level, rated from 1 to 10 (where higher scores indicate lower distress, with 10 representing no distress at all).

An objective, performance-based measure that evaluates instrumental activities of daily living (IADL) in simulated real-world scenarios across two domains: financial skills and communication skills (telephone use). Total scores range from 0 to 100, with higher scores indicating better everyday functional performance.

A performance-based assessment evaluating cognitive flexibility within daily life contexts across 5 IADL-related scenarios (e.g., public transportation use, financial management, and daily life problem-solving). Each scenario consists of two parts assessing (1) spontaneous cognitive flexibility and (2) reactive cognitive flexibility (including intra-dimensional and extra-dimensional shifting). Higher scores indicate better real-life cognitive flexibility.

Assesses global cognitive function across 8 cognitive domains: visuospatial/executive function, naming, memory, attention, language, abstraction, delayed recall, and orientation. Total scores range from 0 to 30, with higher scores indicating better global cognitive function.

Evaluates sustained attention, alternating attention, and executive function. Consists of two parts: CTT-1 requires connecting numbered circles from 1 to 25 in sequence as quickly as possible; CTT-2 requires connecting numbered circles from 1 to 25 while alternating between pink and yellow colors. Measured by completion time (in seconds), where shorter completion times indicate better attention and executive functioning.

Evaluates immediate and delayed visual memory. Participants view 4 pictures of family scenes and are asked to recall the characters, their spatial locations, and their activities immediately and after a 25-to-35-minute delay. Scores for both immediate recall and delayed recall range from 0 to 64, with higher scores indicating better visual memory.

Assesses visuospatial working memory. Participants tap blocks on a board in the same order (Spatial Span Forward) or reverse order (Spatial Span Backward) as demonstrated by the examiner. Scores for the forward and backward subscales each range from 0 to 16 (total score range: 0 to 32), with higher scores indicating better visuospatial working memory.

Evaluates changes in resting-state functional connectivity using a 3.0-Tesla MRI scanner (Magnetom Prisma, Siemens). Includes T1-weighted structural MRI (MPRAGE sequence) and blood-oxygen-level-dependent (BOLD) resting-state functional EPI sequences to assess neural network changes before and after the cognitive intervention.

Assesses short-term and delayed verbal memory across learning and 10-minute delayed recall phases. Scoring includes position score (range: 0 to 60), accuracy score (range: 0 to 60), total learning score (range: 0 to 20), and 10-minute delayed recall score (range: 0 to 30). Higher scores in each component indicate better verbal learning and memory performance.

A performance-based task evaluating executive planning and problem-solving skills. Participants move perforated disks of varying sizes across three pegs from an initial state to a goal state while adhering to specific rules. This outcome assesses task execution efficiency, measured as the total completion time in seconds across all test trials. Shorter completion times indicate better planning and problem-solving ability.

A performance-based task evaluating executive planning and problem-solving skills. Participants move perforated disks of varying sizes across three pegs from an initial state to a goal state while adhering to specific rules. This outcome assesses movement efficiency, measured as the total number of moves made to complete the task. Fewer moves indicate more efficient planning and problem-solving ability.

A performance-based task evaluating executive planning and problem-solving skills. Participants move perforated disks of varying sizes across three pegs from an initial state to a goal state while adhering to specific rules (e.g., only one disk may be moved at a time, and a larger disk may never be placed on top of a smaller disk). This outcome assesses rule-following and inhibitory control during problem-solving, measured as the total number of rule violations committed across the test trials. Fewer rule violations indicate better executive control and planning ability.

A 15-item self-report questionnaire assessing the severity of depressive symptoms in older adults. Total scores range from 0 to 15, with higher scores indicating more severe depressive symptoms (a score of 8 or higher suggests clinically significant depressive symptoms).

A 21-item self-report inventory measuring the severity of emotional and somatic symptoms of anxiety. Each item is rated from 0 to 3, yielding a total score ranging from 0 to 63. Higher scores indicate more severe anxiety (8-15: mild to moderate anxiety; 16-25: moderate to severe anxiety; 26-63: severe anxiety).