Neurocognitive disorders (dementia) are a major public health problem and a major cause of disability in aging societies. They affect some 55 million people worldwide and each year nearly 10 million new cases [1]. During the clinical course of the disease, are observed impairments in the patients' ability to understand and express themselves verbally as well as memory, judgment, and reasoning impairments [2].
The pathology also impacts the patient's behaviour and mood, and the appearance of behavioural and psychological symptoms of dementia (BPSD) [3], severely worsen the suffering of the patient and the burden of the disease for caregivers [4,5].
The disruptive BPSD such as agitation, disinhibition, aggressiveness, opposition, and often care refusal, are almost always subtended by environmental factors, sleep deprivation [6], or by a confusional syndrome and favoured or maintained by anxiety, depression, delusions and/or hallucinations.
The use of psychotropic drugs to treat such disorders is often source of iatrogenic effects (drowsiness, falls, faecal impaction, acute urine retention, vascular accidents, extrapyramidal symptoms, etc.) in this particularly frail population [7], or sometimes ineffective [8,9]. Therefore, the use of a first line non-pharmacologic approach is highly recommended by health authorities and guidelines.
Insufficient skills of professionals to manage difficult situations (such as opposition to care, aggressiveness, agitation, severe anxiety, and wandering), increase the risk of negative interactions, exhaustion, absenteeism, inappropriate practices (i.e. physical restraint) [10], and even abuse [11,12]. This is also a cause of the exhaustion of family caregivers, the use of emergency services [13], of increase in the length of hospital stays and consequently in the costs associated with care [14,15].
Despite their cognitive impairment, nonverbal communication skills are often preserved among individuals suffering from major neurocognitive impairments, allowing the patient to communicate through gestures, facial expressions, postures, etc [16] …
These are signs that caregivers must know how to interpret correctly in order to best respond to the patient's needs.
Know-how to do and know-how to be (prosody, body language, facial expression) with such patients, calling on techniques such as validation therapy, empathy, active listening, relational touch, very often make it possible to resolve complex situations while ensuring a better quality of life for the patient as well as a feeling of competence and a lower risk of caregiver burnout [17].
However, institutional contingencies, in particular the rising trends toward decrease in financial resources (especially the financing of continuing education, but also the lack of didactic material) and scarce human resources (limited number of trainers, time-consuming requirements of student supervision) in medico-social structures or geriatric hospitals, make it difficult for caregivers to have general access to this training [18].
The COVID-19 pandemic context has increased these difficulties by the obligation to maintain barrier gestures, including the safety distance between learners, limiting the clinical exposure and expert supervision necessary for the acquisition of these skills, which are essential for an adequate care. Furthermore, theoretical training can be a source of weariness for learners and is generally less favoured by caregivers in their practice over time than training in real situations. Interactive training, such as role-playing, can improve these aspects but is subject to the constraints indicated in the previous paragraph.
Recent advances in educational technologies offer a growing number of innovative learning opportunities thanks to new tools. Among these, virtual reality represents a promising area with great potential for improving the training of health professionals [19, 20]. VR training provides a rich, interactive and engaging educational context, thus promoting experiential learning; it contributes to the interest and motivation of learners and effectively supports the acquisition and transfer of skills, since the learning process can be regulated in an experiential setting [20].
Current applications of virtual training in healthcare are diverse depending on their technological/multimedia sophistication, types of skills being trained (telesurgical applications, interactive simulations of the human body or brain, virtual worlds for emergency training) [21,22]. Other interesting applications include the development of immersive 3D environments for training psychiatrists and psychologists in the treatment of mental disorders [23].
The scientific literature on the contribution of VR to learning techniques (clinical reasoning and self-assessment) is increasingly rich [24]. As Bonk points out, recent technological developments have converged to radically alter the conception of teaching and the learning process [25].
Learning in VR requires interaction, which encourages active participation rather than passivity. The learner assimilates knowledge more effectively when given the freedom to circulate within their learning context.
Therefore, it seems useful to design educational programs based on virtual reality in this field because they would allow repeated practice of clinical gestures through interactions with a virtual agent, with several advantages: (a) Providing the learner with a safe environment for learning a clinical practice. (b) Representing a wide range of symptoms and diseases. (c) Providing the learner with immediate feedback on performance.
The virtual patient (virtual agent) would also allow exposure to a variety of clinical scenarios, compensating for lack of training and facilitating the acquisition of operational skills in the patient-caregiver relations.
A few studies exist assessing simulation as a learning method for training clinicians to communicate with elderly people and those on communication with demented elderly are still scarce [26].
Orton et al. from the University of Iowa's showed that a web-based platform called GeriaSims virtual patient program offered clinicians the opportunity of interacting with a virtual patient embodied as an elderly person and was effective for geriatric education. Indeed, more than 85% of the responses to an evaluation survey of GeriaSims users indicated favourable perceptions of instructional effectiveness, efficiency, and ease of use [27].
In another study, Robinson et al. focused on training communication skills of 82 speech pathology students with a virtual elderly resident of a nursing home with behavioural symptoms of dementia [28]. The two successive 15-minute interactions were based on predetermined scenarios of verbal (e.g., comprehension difficulties, word search, confusion) and non-verbal (e.g., crying, shrugging, chuckling) responses of the virtual elderly that were representative of dementia. The analysis of the trainee’s verbal and non-verbal (V/NV) behaviour coupled with a self-rating by the trainees of their communication skills revealed an improvement in students’ communication skills in the second interaction. However, it was not possible to distinguish the benefit of the simulation on the verbal versus non-verbal level.
Despite these results and as mentioned above the development of virtual reality for training professional caregivers to communicate adequately with people with cognitive impairment and suffering from psychological or behavioural symptoms of dementia is still limited.
In addition, most experiments have used avatars as virtual patients. Although these avatars mimic the body language of real subjects, they still lack realism. Using real actors in an immersive environment would provide the professional caregiver trainee a greater sense of reality and facilitate meaningful interactions.
Aims
The aim of our research is to develop and evaluate a virtual reality educational tool that allows the realisation of care scenarios in a 3D virtual environment. The caregiver learner, immersed in a virtual care environment, will witness V/NV interactions between a virtual colleague and a virtual patient (played by an actor) during two different scenarios. The goal for the trainee is to identify and criticize inappropriate interactions and differentiate them from more appropriate attitudes and words in each clinical situation. At the end of each module, an assessment will provide learners with personalized and detailed feedback on the answers given. An evaluation of their satisfaction with the training tool and their feeling of competence will also be carried out.
Our hypothesis is that the learner caregiver will eventually acquire skills in the non-pharmacological management of psycho-behavioural symptoms of patients suffering from Alzheimer's disease or related disorders, autonomously, without spatial or temporal constraints, in a secure manner, without feeling judged, and at a lower cost. This training will also ensure quality training, adaptable for caregivers in different care settings (nursing home, hospital, home).