A research study conducted by SingHealth Polyclinics (SHP) and Duke-NUS Medical School (Duke-NUS), has demonstrated the feasibility and acceptability of using Virtual Reality (VR) to screen for cognitive impairment in older adults. The results from the study showed that majority of the older participants indicated positive perception and attitude toward using the VR experience for their cognitive assessment.

In Singapore, one in ten people aged 60 years and above may have dementia. Patients with dementia demonstrate significant cognitive decline in at least one or more cognitive domains, including complex attention, executive function, learning and memory, language, perceptual-motor function, and social cognition.

There has also been an increasing interest to screen for Mild Cognitive Impairment (MCI) for early diagnosis and intervention, and to prepare caregivers to support patients. Currently, the Mini-Mental State Examination (MMSE) is the most widely applied test for dementia screening, while the Montreal Cognitive Assessment (MoCA) is considered the best alternative for screening of MCI. Both these tests are 'paper-and-pencil' based, and are administered to patients by health workers.

For this study, 60 senior patients aged 65 – 85 years old were selected and assessed at SingHealth Polyclinics - Outram Polyclinic, a public primary care clinic serving a multi-ethnic Asian population. The results showed that 90 per cent of the older participants indicated positive perception and attitude toward using the VR experience for their cognitive assessment.

The VR screening tool – RE@CH assessment module, uses VR and motion sensor technology to replicate activities encountered in our daily lives, for example, opening a door using the correct key and passcode number or making a phone call by recalling a predefined –digit number. The virtual environments would recreate an immersive experience for the users to assess their cognitive domains, including learning and memory, perceptual-motor function, and executive function. A scoring algorithm was designed by the study team to appraise the participants' performance, and they were assessed on their ability to complete seven relevant tasks correctly within the stipulated time, the number of attempts, and the proportion of tasks performed correctly.

All the enrolled senior patients had acceptable mental capacity. They were able to understand the information provided to them and were able to make their own decisions. They were first screened via the MoCA assessment to assess their cognitive levels. Those who scored 26 or more marks, were identified as cognitively intact, while the rest who scored less than 26 were classified as having cognitive impairment. Both groups undertook the VR assessment to determine if there was any difference in their performance on it.

In general, the scores for each VR task performed was higher for the cognitively intact individuals compared to those with cognitive impairment.

"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 favor 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).

There are many available cognitive screening tools in the health care setting. However, one of the challenges is to assess executive functions, which are not adequately evaluated by self-reporting questionnaire-based assessment. VR technology may be one plausible solution to address this challenge, by establishing screening tests in the form of real-world settings.

"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.

"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.

The RE@CH Assessmen

The first author, Dr Sean Chua, was a Duke-NUS medical student who was coached by A/P Tan under the Family Medicine Academic Clinical Programme, and co-mentored by faculty members (Asst. Prof. Rahul Malhotra and Prof. Truls Ostbye) from the Centre for Ageing Research and Education (CARE) at Duke-NUS Medical School.

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