Feasibility and safety of virtual-reality-based early neurocognitive stimulation in critically ill patients

Abstract

Background: Growing evidence suggests that critical illness often results in significant long-term neurocognitive impairments in one-third of survivors. Although these neurocognitive impairments are long-lasting and devastating for survivors, rehabilitation rarely occurs during or after critical illness. Our aim is to describe an early neurocognitive stimulation intervention based on virtual reality for patients who are critically ill and to present the results of a proof-of-concept study testing the feasibility, safety, and suitability of this intervention.

Methods: Twenty critically ill adult patients undergoing or having undergone mechanical ventilation for ≥24 h received daily 20-min neurocognitive stimulation sessions when awake and alert during their ICU stay. The difficulty of the exercises included in the sessions progressively increased over successive sessions. Physiological data were recorded before, during, and after each session. Safety was assessed through heart rate, peripheral oxygen saturation, and respiratory rate. Heart rate variability analysis, an indirect measure of autonomic activity sensitive to cognitive demands, was used to assess the efficacy of the exercises in stimulating attention and working memory.

Results: Patients successfully completed the sessions on most days. No sessions were stopped early for safety concerns, and no adverse events occurred. Heart rate variability analysis showed that the exercises stimulated attention and working memory. Critically ill patients considered the sessions enjoyable and relaxing without being overly fatiguing.

Conclusions: The results in this proof-of-concept study suggest that a virtual-reality-based neurocognitive intervention is feasible, safe, and tolerable, stimulating cognitive functions and satisfying critically ill patients. Future studies will evaluate the impact of interventions on neurocognitive outcomes. Trial registration Clinical trials.gov identifier: NCT02078206.

Keywords: Critically ill patients; Early intervention; ICU; Neurocognitive impairments; Neurocognitive stimulation; Virtual reality.

Figures

Fig. 1

Schematic diagram of the smart middleware connecting ENRIC platform, bedside monitor and ventilator (screenshots of bedside monitor and ventilator courtesy of BetterCare®, Barcelona, Spain). The platform uses smart middleware to connect the cognitive stimulation software with input from a motion sensor (Kinect®, Microsoft, Redmond, Washington, USA) that captures and interprets patient movements. The platform also incorporates a system to collect and store physiological data (BetterCare®, Barcelona, Spain) from bedside monitors and ventilators that could be used to adapt the level of cognitive stimulation to patients’ clinical condition

Fig. 2

Flow diagram of sample. During a period comprising ~9 months, 193 patients were admitted to the ICU; 148 met at least one exclusion criterion. Of the 45 eligible patients, 25 were finally excluded. Thus, 20 patients received the early neurocognitive intervention

Fig. 3

Time distribution (%) of neurocognitive exercises for each session during the first five sessions. In the first session, passive exercises requiring simple attention and gross motor functions were the most performed exercises. In subsequent sessions, the time spent on passive exercises gradually decreased, while the time spent on exercises focusing on selective attention and working memory increased. Guided-observation exercises were well tolerated for patients from the first session. The most complex exercises, focusing on working memory, were only performed from the third session, and the time assigned for these exercises was increased progressively with each session. Note that in the fifth session, equal time was assigned to each type of exercises