What do simulation and aging have to do with each other? This article explores the role of clinical simulation and virtual reality in addressing the challenges of aging, offering innovative solutions to improve the quality of life of the elderly. From early diagnosis with serious games to prevention through virtual experiences, to treatment with cognitive rehabilitation programs, simulation emerges as a crucial tool for transforming healthcare in an era of longevity.
We have doubled life expectancy, but are we really prepared for the inevitable impact of aging on our minds? Although advances in medicine and pharmacology have prolonged life expectancy, the extension of healthy life has not kept pace. Chronic diseases, particularly neurodegenerative diseases, are on the rise, creating a complex challenge for healthcare systems. In an age of advanced simulation and artificial intelligence, how can we use these technologies to address the challenge of aging and cognitive decline? However, it is worth making some theoretical premises before discussing the role that simulation can play in the diagnosis, prevention and treatment of cognitive decline, probably the most worrying of the signs of aging.
The aging process
Aging is a biological process in which cells lose the ability to replicate and function properly, culminating in a decline in physiological functions. Although influenced by genetics, it is strongly modulated by lifestyle, with factors such as a sedentary lifestyle and obesity playing a central role.
Cognitive decline is one of the most evident signs: according to the WHO (2021), Alzheimer’s and dementia affect 8.1% of women and 5.4% of men over the age of 65. Most cases are linked to environmental factors, highlighting the importance of prevention. Even in adulthood, the brain maintains a limited capacity for neurogenesis, particularly in the hippocampus, and for creating new synaptic connections, processes influenced by cognitive stimuli, physical activity and sleep quality. These mechanisms help slow cognitive decline and preserve brain function.
How can simulation change the rules of the game?
Simulation is growing rapidly at all levels of healthcare practice. In fact, it is increasingly considered not only a tool for training and clinical risk reduction, but also a tool for patients themselves. VR-assisted therapy, for example, has become a popular topic that has attracted numerous studies in the field of rehabilitation (Diaz et al, 2018), mental health disorders (Wiederhold and Riva, 2019), psychiatric disorders (Dellazizzo et al, 2020) and drug addiction (Hone-Blanchetet al, 2014). In the case of cognitive decline, simulation can help in three key phases: diagnosis, prevention and treatment.
Diagnosis
Using simulation systems, it is possible to recognize the signs of cognitive decline at an early stage. Earlier recognition of cognitive disorders can offer significant advantages for doctors and patients. First of all, it offers more time to prepare a therapy to support the patient, accompanied by lifestyle measures that could significantly improve the course of the disease. A study conducted in 2021 by Dr. Natalia Sevcenko and a team of high-level researchers on serious games users revealed that it is possible to determine a subject’s cognitive load simply by playing one of these high-fidelity simulation games for a few minutes. These are games that simulate realistic scenarios, in which the participants have to carry out specific tasks. Based on the way the required actions are carried out and the time taken, the software is able to calculate the cognitive load: the effort used by the working memory to recall the necessary information. According to John Sweller, an Australian psychologist who developed the cognitive load theory in 1991, activities that require a greater cognitive load are more difficult for patients to complete. It is important to remember that this parameter is completely individual and that an activity that would require a low cognitive load for a healthy subject could require a very high load for a neurological patient. This should make clear the importance that simulation can have in the context of early diagnosis, as it is capable of perceiving even minimal cognitive deficiencies, which are not always evident to the human eye.
Prevention
In the field of prevention, simulation can be a valid tool for healthy subjects who present specific risk factors for the development of cognitive pathologies. In fact, all activities that stimulate intellectual abilities play a preventive role against cognitive disorders. Experiences such as walks in nature, traveling, mental games and social interactions can be simulated with modern virtual reality tools. In this way, even the most isolated individuals, those least involved in society, could receive the stimuli necessary to maintain a good level of synaptogenesis and neurogenesis. We should remember that these combined processes guarantee protection for neurons, thus playing a preventive role against the pathologies typical of old age, according to the theory of the cognitive reserve. The concept of cognitive reserve is widely used in neuroscience. It states that every experience, every reading, every social interaction leaves a trace in our brain, enriching our cognitive repertoire. It becomes clear that, starting from a vast cognitive reserve, it is less likely to suffer from senile decay. Michela Matteoli, director of the neuroscience program at the Humanitas Institute in Milan, summarizes the concept with an intriguing botanical metaphor, saying: “We should water our memory so it doesn’t wither”. It seems clear that simulation, in its various forms, offers numerous possibilities to enrich the experiences of each of us, helping to increase our cognitive reserves. In the preventive field, the serious games we mentioned, which are intellectually challenging, are an extraordinarily useful method for keeping the mind active and trained. Learning itself, whether through reading, studying new languages, or from any other source, has proven benefits for the human brain. In fact, after periods of learning specific activities, real changes occur in the structure of the brain. This phenomenon is made possible by the virtue of our brain called plasticity, that is, the property that allows our most important organ to change at a macroscopic level, thanks to the microscopic modifications that occur at the synaptic level. This process occurs following a stimulation of cognitive functions, which will tend to improve and preserve themselves. On the contrary, a brain that receives little stimulation is more at risk of incurring the process of decay. From this point of view, simulation, and more specifically virtual reality, could prove to be a game-changing tool in the prevention of diseases belonging to the spectrum of cognitive decline.
Treatment
The topic of treatment is, according to the most up-to-date neuroscientific knowledge, still too similar to prevention. In fact, to date we have no real cure for cognitive decline. However, there are tools that can strengthen certain cognitive functions and create a sufficient reserve of them, in order to prevent a real collapse in old age. In this, the practice of simulation, and once again virtual reality, can play a leading role. VR allows the simulation of particularly engaging mnemonic activities for patients. In this regard, a twelve-week study conducted in Taiwan by Ying-Yi Liao’s research group on the effectiveness of VR in the treatment of cognitive decline may be useful in understanding the possible applications of simulation in the treatment of these pathologies. The aim of the Taiwanese study was to compare the changes in terms of neuronal activation in two groups of patients suffering from Mild Cognitive Impairment. The first group followed a regime of physical exercise and classic cognitive stimulation. The second group maintained the physical exercise, but integrated cognitive stimulation exercises in virtual reality. At the end of the twelve weeks, improvements were seen in both groups; however, the group that included VR in their training program showed significantly greater improvements in verbal memory and general cognitive ability. In addition, hemodynamic analyses also showed an increase in the efficiency of neuronal involvement in the prefrontal cortex area for the VR-integrated training group. Obviously, the conclusion reached by the study is that it is probably useful to introduce virtual simulation in the rehabilitation program for elderly patients suffering from cognitive deficits. Another category of patients particularly prone to developing cognitive pathologies is that of subjects with hearing deficits. In fact, this condition can often become a reason for isolation, precisely because of the difficulties that patients with partial hearing loss encounter in daily life. These difficulties lead to a progressive neuronal readaptation in the prefrontal area, useful for enhancing compromised auditory functions, but determining a loss in cognitive and motor abilities such as balance and coordination. In a study currently in progress, carried out in collaboration with Concordia University and the Toronto Rehabilitation Institute (KITE), it is claimed that home training methods with VR, capable of simulating visual and auditory stimuli, can be useful for progressing in the performance of combined cognitive and motor actions in subjects with hearing impairments. However, researchers from both institutes agree that the use of hearing aids would be able to offer a further improvement in results, allowing the cognitive resources of patients to return to focusing on other actions that are taking place, rather than listening to their surroundings.
Other applications of simulation could involve new experiences and new relationships, which are always very stimulating for our nervous system. For example, it would be possible to simulate travel, which is an excellent way to increase patients’ curiosity about different cultures. The infinite experiences that virtual reality makes accessible directly from home could be one of the most effective methods of treating patients with cognitive disorders, at least until more effective therapies than those available today become available. The relational sphere also plays a leading role in the treatment of these patients. In fact, social engagement has a preventive and therapeutic role in the cognitive field. It is well known that maintaining one’s social relationships and being an integral part of a united community is a powerful protective factor. It would be extremely useful to find methods to involve patients suffering from cognitive decline in a community environment. In this way, it would be possible to make them feel useful and important, offering them the right motivation to keep their minds active. Simulation could be the appropriate vehicle to connect all these people in a virtual community, equally capable of promoting new relationships and affections for subjects who too often find themselves forced to stay at home alone.
How to act?
It might be useful to equip subjects at risk of developing cognitive decline pathologies with devices such as VR viewers, suitable for maintaining adequate involvement of the patients’ mental faculties. In this way, many cases of disease could be prevented and the damage of those that are inevitable could be limited, with simultaneous intervention with an active lifestyle regime that helps maintain good physical and mental performance. A holistic approach, such as the one described, would have several advantages. First, it would reduce the burden of patients with cognitive decline on families and caregivers, promoting their independence. Patients would remain more physically and mentally fit, as well as being more involved in the physical and virtual activities of their communities. The costs incurred for the purchase of therapies, often not very useful, would be drastically reduced. But above all, we could be able to offer much more rewarding living conditions to the generations without whom we would not be here.
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