Proof-of-Concept Study on the Use of Virtual Reality with Evocative and Aesthetic Content for Elderly Individuals with Cognitive Decline

Abstract

Recent technological advances have introduced novel therapeutic interventions for Alzheimer’s disease (AD). This study introduces a novel virtual reality (VR) intervention consisting of aesthetically pleasing and relaxing immersive videos paired with evocative music for patients with or without cognitive decline. The goal of this intervention is to improve the mood, evoke autobiographical memories in, and enhance the overall well-being of elderly individuals, across stages of cognitive decline (from absent to severe). Twenty-one elderly participants (5 cognitively healthy, 13 with a mild cognitive decline, 2 with a moderate decline, and 1 with a severe decline) were exposed to immersive 360-degree videos depicting both familiar and unfamiliar, pleasant and calming environments, accompanied by emotionally evocative, pleasant, and soothing music. The results demonstrated high levels of immersion and predominantly positive emotional responses, with several participants reporting autobiographical memory recall triggered by the VR stimulation. Statistical analysis revealed a significant improvement in mood over time, regardless of cognitive status, supporting the effectiveness of the intervention. While there were some side effects of fatigue or transient anxiety, the experience was generally perceived as engaging and meaningful. This feasibility study adds to the acceptability and potential clinical utility of VR interventions and provides a justification for future larger trials aimed at the integration of immersive technologies into cognitive rehabilitation interventions for individuals at different stages of cognitive decline.

1. Introduction

Alzheimer’s disease (AD) is a progressive neurodegenerative condition characterized by a significant cognitive decline, emotional disturbances, and impaired social interactions. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), AD falls under the category of Major Neurocognitive Disorders and is defined by a decline from a previous level of performance in one or more cognitive domains that interferes with independence in everyday activities [1] As one of the leading causes of disability in older adults, it presents substantial challenges for patients, caregivers, and healthcare systems worldwide [2]. Strategies for AD prevention, aimed at risk factor identification and reduction, or early intervention, aimed at addressing behavioral symptoms, could enhance the quality of life of impaired subjects by mitigating its pathological impact.

For the planning of early interventions, it is crucial to identify the prodromal stages of AD. Mild cognitive impairment (MCI), a condition associated with an elevated risk of AD progression, which shows measurable deficits in different cognitive domains but does not significantly impair daily activities [3], could represent a critical therapeutic window for interventions aimed at slowing cognitive decline and enhancing psychosocial well-being. For MCI, an estimated 10–15% per year conversion rate has been reported in clinical settings, while community-based studies report lower rates, ranging from 3.8% to 6.3% annually. Moreover, long-term studies reveal that approximately 80% of patients with MCI convert to AD over a six-year follow-up interval [4]. Recent progress in AD has made evident how this disease could be considered a continuous process of neurodegeneration rather than a series of distinct stages, beginning with asymptomatic phases, progressing through MCI, and culminating in full-blown dementia [5]. This poses challenges in precisely evaluating individuals to assess their condition and their specific risk factors for progression [6,7]. Figure 1 illustrates the escalating severity associated with each stage of the AD continuum.

Accurate staging is critical for implementing early, targeted interventions that can delay or prevent irreversible neuronal damage and cognitive decline. This highlights the need for advanced diagnostic tools capable of identifying the AD pathology in its earliest stages to maximize the potential benefits of therapeutic strategies.

Current treatments for AD and MCI mainly include pharmacological interventions, including acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) and NMDA receptor antagonists (memantine), which manage symptoms rather than halt disease progression [8]. In July 2023, Lecanemab was approved by the FDA; it is a monoclonal antibody targeting amyloid-beta aggregates, which represents a milestone as one of the first medications for the Alzheimer’s pathology [9]. Lecanemab binds to soluble amyloid-beta protofibrils, halting cognitive deterioration in early AD. In the Clarity AD phase-three trial, it significantly delayed clinical decline over 18 months, also showing improvement in cognitive and functional endpoints [10]. However, risks such as amyloid-related imaging abnormalities (ARIAs) highlight the need for careful patient monitoring. While approved in the US, Lecanemab is not yet available in Italy, with EMA approval pending [11].

Therefore, non-pharmacological interventions, such as cognitive stimulation, physical activity, and diet modifications, have been shown to have potential in retarding cognitive impairment while improving overall well-being [12]. In addition, complementary therapies, such as music therapy, art therapy, and mindfulness-based therapies, are gaining recognition for their ability to manage behavioral symptoms, reduce anxiety, and enhance the quality of life in both MCI and AD populations [13]. For instance, a systematic review of 15 studies investigating the impact of music therapy on AD patients showed significant improvements in cognitive abilities and daily living activities [14]. Another systematic review and meta-analysis also implied that non-pharmacological therapies, including music therapy, positively impacted activities of daily living (ADLs), behavioral and psychological symptoms of dementia (BPSDs), cognition, and quality of life in individuals with moderate-to-severe dementia [15]. Furthermore, music therapy alone was shown to significantly enhance both cognitive function and quality of life in subjects with AD [16].

Such evidence highlights the need to include these non-pharmacological interventions in treatment plans; in fact, by integrating both pharmacological and non-pharmacological approaches, patient outcomes can be best optimized on a multimodal basis by addressing both the cognitive as well as emotional deficits of AD.

Emerging technologies like virtual reality (VR) hold much potential in the treatment of both MCI and AD. Offering the presentation of immersive, simulated environments that can engage cognitive and emotional processes, VR can be considered a suitable technological framework to address the challenges associated with MCI and early AD [17,18]. The recent literature provides evidence supporting the efficacy of VR interventions in this context. For example, Kim et al. [19] introduced the positive impact of VR on cognitive function for MCI subjects, also impacting daily living activities and neuropsychiatric symptoms, highlighting its potential as a tool for cognitive rehabilitation. Furthermore, Zhu et al. [20] investigated the effects of dual-task interventions in individuals with MCI, combining motor and VR-based cognitive training, reporting enhanced executive function and gait performance.

Very recently, Yang et al. [21] conducted a meta-analysis of 18 randomized controlled trials conducted with VR interventions on MCI patients (722 participants were included), demonstrating significant improvements in cognitive functions among older adults with MCI compared to control groups. The effect sizes reported included a Standardized Mean Difference (SMD) of 0.20 (95% CI: 0.02–0.38) for memory, 0.25 (95% CI: 0.06–0.45) for attention and information-processing speed, and 0.22 (95% CI: 0.02–0.42) for executive functions, indicating small to moderate improvements in these cognitive domains. Many of these scenarios included soundscapes, such as ambient environmental sounds like birdsong or flowing water, or music tailored to enhance relaxation and engagement. Additionally, VR has been used for dual-task exercises that combine cognitive challenges with motor activities, such as navigating virtual pathways or interacting with objects within the virtual space [17,18,19]. These findings emphasize the potential of VR as a therapeutic tool for mitigating cognitive decline and improving the quality of life in individuals with MCI and early AD. At the same time, the scarcity of applications of VR for early AD compared to MCI, as well as the high costs of devices and the need for multiple sessions, highlight significant challenges to its accessibility and feasibility for long-term AD treatment. This underscores the need for implementing novel methodologies that are both cost- and time-effective, paving the way for more sustainable and widely applicable interventions.

In addition to the outcome-based results, it is important to consider the possible effectiveness of VR interventions on age-related cognitive and motor decline. VR provides optimal stimulation through multisensory access within digital worlds that can also promote the cognitive functions of memory and executive control. In particular, Kim et al. [22] advanced a compelling argument for some of the older adults’ motor issues: internal models and visuomotor predictions are poorly managed within the framework of reactive, feedback-driven strategies. VR has unique advantages in this respect, as it can provide manipulable environments that are safe, yet meaningful, and within which users may practice anticipatory actions in a variety of contexts. VR interventions do not only focus on the acquisition of new motor skills. They also enhance the cognitive components of planning, attention, and decision-making. Moreover, VR is more effective than traditional tasks, since real-world scenarios aid in enhanced emotional engagement and presence, which are vital resources for those with diminished cognitive and emotional reserves. At the same time, it is relevant to consider the accumulating evidence on the impact of beauty in dementia, namely the positive outcomes in terms of improved mood and quality of life thanks to music- and art-based interventions [23,24]. Here, we build on previous studies with VR as well as music- and art-based interventions to evaluate the acceptability of a VR-based intervention with novel aesthetic and mnestic features for individuals with various levels of cognitive decline, from absence to MCI and to AD. More specifically, here we wanted to assess whether personalized, emotionally evocative, and aesthetically engaging 360-degree videos combined with music can improve transient mood, evoke autobiographical memories, and enhance overall well-being in this population. The audio–video VR stimulation is rooted in research demonstrating the significant role of multi-sensory experiences in enhancing cognitive and emotional outcomes in aging populations [25]. Positive aesthetic experiences, such as engaging with visually and aurally pleasing stimuli, have been shown to promote emotional well-being, reduce stress, and foster a sense of tranquility [26,27,28,29]. Music, in particular, has a unique ability to evoke autobiographical memories, even in individuals with significant cognitive impairments, by stimulating neural pathways associated with memory and emotion [30,31,32].

The rationale for this specific VR intervention builds upon previous music–neuroaesthetic findings, leveraging the synergistic effects of immersive environments and evocative music to stimulate cognitive processes and elicit positive emotional responses. By integrating familiar landscapes and culturally relevant music, the intervention seeks to evoke memories, enhance mood, and provide a calming and meaningful experience tailored to the needs of individuals with AD or MCI.

2. Materials and Methods

2.1. Participants

Twenty-one elderly participants (4 males and 17 females) with a mean age of 75.09 ± 9.22 years (range: 65–93) were included in the study. Participants included cognitively healthy elderly individuals and individuals exhibiting cognitive impairments compatible with an AD profile, as assessed by their MoCA scores. Specifically, four participants scored within the normal cognitive range (MoCA scores: 26–30), thirteen participants presented with mild cognitive impairment (MoCA scores: 18–25), three participants exhibited moderate cognitive impairment (MoCA scores: 10–17), and one participant showed severe cognitive impairment (MoCA score below 10). These classifications align with the Alzheimer’s continuum framework, which describes a progression of cognitive decline consistent with an AD-related pathology. The mean MoCA score was 21.33 ± 5.34 (range: 5–27). Individual clinical and neuropsychological profiles are detailed in

Table 1. Demographic, clinical, and neuropsychological characteristics of the study participants. The table includes participant gender, age, and cognitive performance scores measured using the Montreal Cognitive Assessment (MoCA).

Participant	Gender	Age	MoCa
1	Male	68	24
2	Male	75	22
3	Female	70	21
4	Female	71	21
5	Female	71	17
6	Female	70	24
7	Female	68	21
8	Female	90	5
9	Male	71	27
10	Male	79	26
11	Female	65	22
12	Female	71	24
13	Female	69	19
14	Female	69	26
15	Female	70	21
16	Female	87	11
17	Female	89	20
18	Female	92	26
19	Female	93	25
20	Female	65	27
21	Female	74	19

.

Participants were recruited through the Centro Servizi per le Famiglie “Libertà” in Bari and through acquaintances. All the recruited participants were of Italian nationality and were born and currently residing in the region of Puglia, Southern Italy. All participants or their caregivers provided informed consent after being instructed as to the study’s purpose and procedures.

All experimental procedures complied with the Declaration of Helsinki—Ethical Principles for Medical Research and were approved by the Ethics Committee at the Department of Education, Psychology, Communication of the University of Bari (ET-24-18-R1).

2.2. Neuropsychological and Behavioral Examination

Self-assessments of mood were recorded before and after each video presentation through simple questions, and the responses were noted each time. Following each video session, participants completed a custom-made questionnaire designed to assess their experience. The questionnaire included items from the Slater–Usoh–Steed (SUS) presence scale [33], which measures the sense of presence on a scale from 0 (no presence at all) to 7 (a strong feeling of being physically present in the environment), and the Visual Analogue Scale (VAS) [34] for an evaluation of mood before (at arrival), during, and after the VR stimulation. Moreover, additional semi-structured questions developed by the research team were included to explore specific aspects of satisfaction and mood regulation during the VR experience, as well as any memory recollection triggered by the videos.

The eligibility of the participants was determined using MoCA (Montreal Cognitive Assessment), a brief cognitive screening tool with high sensitivity and specificity for detecting MCI [35,36].

Video recordings of each participant’s session were collected during the administration of the experimental procedure to support further qualitative analysis and ensure accurate documentation of individual responses.

Additionally, we measured physiological and autonomic observations, like respiratory rate and heart rate variability, which will be analyzed in a separate paper.

2.3. VR Stimulation and Procedure

This work included the administration of four 360-degree videos, each lasting up to 5 min, delivered through VR. Video administration was performed using the Oculus Quest 2, a standalone virtual reality headset equipped with a high-resolution display (1832 × 1920 pixels per eye), a refresh rate of up to 120 Hz, and a wide field of view to enhance immersion. The device’s lightweight design and built-in tracking system enabled participants to interact with the virtual environment comfortably, without requiring additional external sensors. The videos, which were selected by the team of authors to provide contrasting yet equally immersive and emotionally engaging experiences, included two familiar scenarios and two non-familiar scenarios.

The familiar scenarios consisted of relaxing beach landscapes in Sardinia, created using footage from a YouTube video (https://www.youtube.com/watch?v=6yAHk_0sv0Q; accessed on 8 July 2024).

Given the high presence of coastal environments in this area and the value of their cultural context on local inhabitants, we considered the beach scenarios as “familiar”. Although the selected VR videos specifically depicted Sardinian beaches, this choice is due to the limited availability of high-quality 360-degree footage of locations in Puglia. Sardinian beaches were nevertheless deemed appropriate as a depiction for familiar landscapes, given their strong visual and cultural resemblance to the coastal environments to which the participants are or were regularly exposed. These videos were looped to depict calm, uninterrupted seaside environments without external interferences or people, aiming to evoke memories of Southern Italian beaches where the participants were born and live.

The non-familiar scenarios included a serene park in Japan, sourced from a YouTube video (https://www.youtube.com/watch?v=uaJdWd_n1lg; accessed on 8 July 2024), and a mesmerizing aurora borealis display, sourced from another YouTube video (https://www.youtube.com/watch?v=cg_jfip4pSQ; accessed on 8 July 2024).

These videos were paired with corresponding music: traditional Italian folk or melodic pop songs for the familiar scenarios, and non-familiar folk songs for the non-familiar scenario (Figure 2).

The selection of the songs was guided by an evaluation process conducted by a group of 4 musicians with expertise in musicology. The evaluation was based on a pool of 30 songs categorized into three groups: Italian lyric songs, Italian folk songs, and foreign compositions. The evaluation process considered several key dimensions for each song. Familiarity was assessed using a 5-point scale, where 1 indicated very low familiarity (the participant did not know the song at all) and 5 indicated very high familiarity (the participant knew the song well or found it reminiscent of similar genres or melodies). Arousal was also rated on a 5-point scale, with 1 representing very low arousal (the song elicited calmness and relaxation) and 5 representing very high arousal (the song evoked energy and excitement). Additionally, pleasantness was measured on a 5-point scale, where 1 indicated very low pleasantness (the song was not enjoyable) and 5 indicated very high pleasantness (the song was highly enjoyable and evoked positive feelings). The songs that were rated as the most relaxing and least activating were selected for the study to ensure they aligned with the calming and immersive goals of the VR intervention. The selected songs included “Non ho l’età” sung by G. Cinquetti; “Il cielo in una stanza” sung by G. Paoli; “Sogna fiore mio” performed by Lucilla Galeazzi, Marco Beasley, L’Arpeggiata, and Christina Pluhar and composed by Ambrogio Sparagna; and “Vulesse addeventare nu Brigante” sung by Carlo D’Angiò and produced by Musicanova for the familiar scenarios; and “Finnish Chant” and “Japanese Sonata” for the non-familiar scenarios. A full list of the evaluated songs is provided in Supplementary Table S1.

Each participant was shown the two familiar scenarios and one of the two non-familiar scenarios paired with familiar or unfamiliar music (randomly assigned to the videos from among the selected songs), with the order of presentation randomized as follows: one familiar scenario, followed by the other familiar scenario, and finally a non-familiar scenario.

2.4. Statistical Analysis

To explore the relationship between mood changes and cognitive status, one linear mixed-effects model was performed using Jamovi (version 2.6) [37]. Participants were divided into two groups based on the median MoCA score of the sample (median = 22): a low-MoCA group with moderate to severe cognitive decline (scores 0–21) and a high-MoCA group with absent to mild cognitive decline (scores 22–26).

The model was specified as

VAS_score ~ 1 + Time + MoCA Scores + Time × MoCA Scores + (1 | ID)

The model aimed to evaluate overall differences in mood between the two groups and to investigate mood changes over time (pre-, mid-, and post-exposure) and how these changes interacted with cognitive status.

In this model, VAS mood scores served as the dependent variable, with Time (three repeated measures), MoCA group (low-MoCA scores and high-MoCA scores), and their interaction (Time × MoCA scores) included as fixed effects. Participant ID was modeled as a random intercept to account for within-subject variability across repeated measures.

Model residuals were assumed to follow a Gaussian distribution. Degrees of freedom were estimated using the Satterthwaite method, and Wald confidence intervals were calculated. The model converged successfully using the bobyqa optimizer, with a total of 63 observations from 21 participants.

3. Results

3.1. Behavioral Data

The following section provides a comprehensive overview of the results obtained from the SUS presence scale and the VAS.

Nineteen participants reported a high level of immersion in the VR environment, with most perceiving the surroundings as highly realistic. According to the SUS questionnaire, which measures the sense of presence on a scale from 0 (no presence at all) to 7 (a strong feeling of being physically present in the environment), scores ranged from 0 to 7, with a mean score of 6.05 ± 1.60. Notably, one participant was unable to answer the SUS immersion item due to the severity of their cognitive condition, while another participant responded with a score of 0, indicating no sense of presence in the virtual environment. From a qualitative perspective, about half of the participants described the environment as resembling a documentary or an external visual space, whereas the other half reported the sensation of having personally visited the location.

Regarding mood changes as measured by the VAS, most participants showed stable or improved emotional states following the VR experience. Specifically, 11 out of 21 participants exhibited an improvement in mood (i.e., a lower VAS score after the experience compared to before), 9 participants maintained a stable mood throughout the session, and only 1 participant reported a slight worsening of mood (an increase from 1 to 3 on the VAS). It is important to note that on the VAS scale, lower values indicate a more positive mood (0 = extremely happy, 5 = extremely sad). The participant, who expressed a negative change in mood, attributed this change to the type of landscapes presented, describing them as isolated and reminiscent of once-lived in spaces that now appeared abandoned. This was, however, an exception, because the vast majority of participants had tranquility as the most prominent sensation: apart from this one participant who reported a feeling of desolation, all the others felt a sense of calmness during the VR experience.

Regarding side effects, most participants did not report any adverse reactions. However, two participants experienced mild anxiety, likely triggered by aversive memories or recent news events evoked by the VR scenario, as indicated by their VAS responses. One participant reported mental fatigue, which was attributed to the weight of the VR headset. Additionally, four participants described the headset as physically uncomfortable due to its weight. These observations point to potential limitations related to the physical burden of the Oculus headset, which should be carefully considered in future studies, particularly in terms of comfort and accessibility for older adults.

Regarding memory recall, 13 participants reported recollections of past events from their childhood or adolescence, often related to time spent with family members or visits to places resembling those shown in the VR scenarios. Two participants recalled more recent positive experiences, also connected to similar environments depicted in the virtual scenes. The remaining participants did not report any memory recall during the experience. Notably, one participant with moderate cognitive impairment, despite reporting feelings of anxiety and sadness, recalled a specific episode from the past while viewing the Tokyo park scenario, since it resembled a garden where she and her mother used to play with her children. In terms of feedback, six participants expressed a desire to explore more scenarios, three wished to move around or interact with the environment, and four suggested improvements to make the VR headset lighter and more comfortable. Three participants also expressed a preference for a greater variety of music. The participant diagnosed with Alzheimer’s disease, who obtained a MoCA score of 5, exhibited notable difficulties in responding to the open-ended questions included in the post-experience questionnaires. While this participant was able to provide responses related to mood, a more comprehensive understanding of the engagement with the VR experience was derived from the video recordings. Qualitative analysis of the footage revealed a high level of involvement: the participant appeared emotionally engaged and was observed singing along during the virtual scenarios, pointing at parts of the scene, and commenting about the beauty of what was observed. However, due to discomfort caused by the weight of the headset and a minor engagement (less singing and commenting) during the non-familiar scenario, the session had to be interrupted ahead of time.

3.2. Statistical Results

The linear mixed-effects model revealed a significant overall fit (Likelihood Ratio Test: χ²(6) = 16.13, p = 0.013), with a marginal R² of 0.229, indicating that the fixed effects accounted for 22.9% of the variance in mood scores. Omnibus tests showed a significant main effect of Time (F(2, 63) = 6.44, p = 0.003), as well as a significant main effect of the MoCA group (F(1, 63) = 4.31, p = 0.042). However, the Time × MoCA interaction was not significant (F(2, 63) = 0.55, p = 0.581), suggesting that mood improved over time similarly in both cognitive groups.

Post hoc analyses revealed a significant decrease in mood scores from pre- to mid-exposure (β = –0.56, p = 0.007) and from pre- to post-exposure (β = –0.67, p = 0.001), indicating an overall improvement in mood (Figure 3). Additionally, participants in the high-MoCA group reported significantly more positive mood scores overall (β = 0.34, p = 0.042). No significant interaction effects were observed between Time and MoCA group.

Estimated marginal means showed a consistent decline in mood scores across the three time points (Figure 4), confirming a general trend of mood improvement: pre (M = 1.51, SE = 0.14), mid (M = 0.95, SE = 0.14), and post (M = 0.85, SE = 0.14). All statistical analyses are provided in Supplementary Table S2.

4. Discussion

Here, we present a proof-of-concept study on the potential benefits of immersive VR-based interventions for individuals with different stages of cognitive decline, from absent to severe (including individuals with a clinical profile compatible with MCI or dementia). The results suggest that combining immersive virtual environments with emotionally evocative music can promote positive mood changes, trigger autobiographical memories, and offer a calming and engaging experience for most participants.

Statistically, mood significantly improved over the course of the intervention, with a clear reduction in negative affect from the pre- to mid- and post-video assessments. Specifically, participants reported lower mood disturbance scores after the VR experience, suggesting a progressive improvement in emotional state. Interestingly, this positive effect was observed regardless of cognitive status, although participants with lower MoCA scores (indicating greater impairment) exhibited even lower VAS scores overall—indicating a stronger emotional benefit in this subgroup. Previous studies have highlighted the potential of VR therapies in MCI and early AD for improving cognitive and physical functions [38]. Additionally, the integration of music therapy within virtual environments has shown promise in alleviating the psychological and cognitive symptoms of AD [39,40].

Our findings build upon previous research by integrating VR and music into a multi-sensory therapeutic intervention. This novel, multimodal approach shows promise in enhancing both emotional and cognitive outcomes. Notably, several participants with moderate cognitive impairment, as indicated by lower MoCA scores, were able to engage meaningfully with the experience. Many of them recalled emotionally salient autobiographical memories, often from childhood or adolescence, despite occasional feelings of anxiety or sadness. Even the participant with severe Alzheimer’s disease showed signs of emotional involvement—such as singing along during the VR session—although they experienced challenges in verbal communication and required an early termination of the session due to the weight of the headset. These observations highlight the potential of immersive environments to foster emotional and cognitive engagement, even in individuals at more advanced stages of neurodegeneration [41]. Personalized and culturally relevant stimuli played a central role in eliciting these responses, emphasizing the importance of tailoring interventions to individual needs. Moreover, the aesthetically pleasing design of the VR scenarios contributed significantly to the intervention’s overall appeal and effectiveness, enhancing user satisfaction and emotional resonance [42]. While minor side effects such as mental fatigue or discomfort were noted, they underscore the necessity of optimizing the device design and content customization to improve usability and the participants’ experience.

Overall, our findings underline the importance of further research to advance VR-based interventions. Future studies should investigate how integrating culturally sensitive and individually tailored content can amplify the therapeutic benefits of VR. Additionally, exploring long-term impacts, scalability, and the integration of VR with other therapeutic modalities could pave the way for more robust applications in diverse clinical contexts.

The current study has several limitations. Firstly, the characteristics of the sample (elderly individuals with mild to moderate cognitive decline, with only one diagnosed AD patient) limit the generalizability of the findings to the broader AD population. Secondly, the short-term nature of the intervention precludes conclusions about its long-term effects on mood, cognition, or quality of life. Moreover, the lack of a control group makes it difficult to determine whether the observed effects can be attributed solely to the VR intervention. The variability in participants’ familiarity and comfort with technology, as well as the subjectivity of the questionnaire ratings, may have also influenced the outcomes. Finally, another limitation concerns the practical aspects of the VR system itself. The weight of the Oculus Quest 2 device may have caused discomfort during prolonged sessions, particularly for older participants, potentially impacting their overall experience. Additionally, the relatively high cost of VR equipment may limit its accessibility and scalability in broader clinical applications.

However, it is important to note that this is a first proof-of-concept study, and these limitations are more pertinent to intervention studies, which are beyond the scope of the current research. Instead, the specific methodological limitations associated with proof-of-concept studies should be considered. Additionally, the absence of objective physiological metrics to assess engagement and stress levels during VR exposure is often considered a limitation. However, in this study, we collected physiological data, including respiratory frequency and heart rate variability, alongside subjective assessments, which will be used in a subsequent study to verify the feasibility and applicability of this novel VR approach, now that the protocol has been illustrated and proved tolerable even for individuals with dementia [43].

5. Conclusions

The positive results of this proof-of-concept study provide a solid foundation for the design and implementation of larger-scale randomized controlled trials (RCTs) to validate the preliminary findings. Future RCTs should aim to assess the efficacy of VR interventions in improving cognitive and emotional outcomes in AD populations, with a particular focus on long-term effects. Building on the promising outcomes observed, further research could also explore the integration of VR with other non-pharmacological approaches, such as cognitive training or physical exercise, to potentially enhance its therapeutic impact. These next steps will contribute to establishing VR as an accessible and effective tool for cognitive rehabilitation in neurodegenerative conditions.

An important issue related to VR immersions using the Oculus device is its high cost and relatively bulky design, which may reduce its accessibility for widespread use. This limitation could be addressed in future studies by adopting VR visors compatible with mobile phones. These devices are not only more affordable but also portable and easier to use, making them more accessible for patients and their caregivers. As current VR technology allows the translation of Oculus-programmed scenarios to smartphone-compatible formats, this approach could facilitate the testing of this paradigm and other similar interventions in diverse settings, including home environments, thereby increasing its feasibility and practicality.

In our study, we utilized existing videos and music, adopting them to the cultural background of our participants and enhancing their aesthetic and evocative impact. The findings confirmed the validity of this approach. In future, the VR content could be fully tailored to the cultural and individual differences of the participants to further optimize the intervention’s effectiveness and accessibility. For example, VR scenarios could be adapted to reflect familiar landscapes or cultural landmarks relevant to specific populations, such as local parks, iconic monuments, or traditional environments. Additionally, incorporating language customization and culturally specific auditory cues (e.g., traditional music or ambient sounds) could enhance the user experience. Personalizing content based on individual preferences, such as serene natural scenes for relaxation or interactive tasks for cognitive stimulation, might further improve engagement and therapeutic outcomes [44].

In summary, while this study underscores the promise of VR as a complementary therapeutic tool for improving emotional well-being in AD patients, it is noteworthy that even participants with lower MoCA scores, indicative of moderate dementia, and one participant with diagnosed AD, demonstrated positive outcomes. Despite challenges such as transient anxiety and sadness, all our participants recalled meaningful autobiographical memories, suggesting the potential of VR aesthetic immersions to evoke emotional and cognitive engagement even in the most advanced stages of cognitive decline. Quantitative analyses further support this observation: mood scores showed a significant improvement over time, with reductions in negative affect from pre- to mid-VR exposure and from pre- to post-VR, indicating a progressive enhancement in emotional well-being across the session. Interestingly, participants with lower MoCA scores seemed to have even more pronounced mood improvements, suggesting that those with a greater cognitive impairment may derive a particular benefit from this kind of intervention.

The aesthetic quality of the VR experience, characterized by its immersive and visually engaging content, contributed to its overall effectiveness and user satisfaction, encouraging one to further expand the applications of VR for mood and cognitive rehabilitation in dementia.