Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic

Background Advancements in supporting personalized health care and well-being using virtual reality (VR) have created opportunities to use immersive games to support a healthy lifestyle for persons living with dementia and mild cognitive impairment (MCI). Collaboratively designing exercise video games (exergames) as a multistakeholder team is fundamental to creating games that are attractive, effective, and accessible. Objective This research extensively explores the use of human-centered design methods that involve persons living with dementia in long-term care facilitates, exercise professionals, content developers, game designers, and researchers in the creation of VR exergames targeting physical activity promotion for persons living with dementia/MCI. Methods Conceptualization, collaborative design, and playtesting activities were carried out to design VR exergames to engage persons living with dementia in exercises to promote upper limb flexibility, strength, and aerobic endurance. We involved a total of 7 persons living with dementia/MCI, 5 exercise professionals, 5 community-dwelling older adults, a VR company for content creation, and a multidisciplinary research team with game designers, engineers, and kinesiology experts. Results An immersive VR exergame called Seas the Day was jointly designed and developed and it is freely available to be played in state-of-the-art VR headsets (Oculus Quest 1, 2). A model for the triadic interaction (health care institution, industry partner, academia) is also presented to illustrate how different stakeholders contribute to the design of VR exergames that consider/complement complex needs, preferences, and motivators of an underrepresented group of end users. Conclusions This study provides evidence that a collaborative multistakeholder design results in more tailored and context-aware VR games for persons living with dementia. The insights and lessons learned from this research can be used by others to co-design games, including remote engagement techniques that were used during the COVID-19 pandemic.


Design and Procedure
TMT is a neuropsychological test and can reflect a wide variety of cognitive processes. TMT will be delivered using an online platform. The test is consisted of at least two conditions: condition A, the participant is instructed to draw lines to connect circled numbers on a sheet of paper or computer screen in a numerical sequence (i.e., 1-2-3, etc.) as rapidly as possible while still maintaining accuracy, Condition B, the participant is to draw lines to connect circled numbers and letters in an alternating numeric and alphabetic sequence (i.e., 1-A-2-B, etc.) as rapidly as possible. The goal of the test is for the participant is to finish both parts as quickly as possible, and the time taken to complete the test will be used as the primary performance metric.

Design and Procedure
VF is a widely used test of executive function.VF will be delivered using an online platform and participants will be given 60 seconds to produce a list of animal names. This test will be performed to explore how VR exergames can potentially impact verbal fluency and verbal learning in community-dwelling older adults.

Design and Procedure
Flanker task includes a set of response inhibition tests used to assess the ability to suppress responses that are inappropriate in a particular context. Similar to other cognitive tests, Flanker will be delivered using an online platform. There will be three types of stimuli: Incongruent, congruent, and neutral stimuli represented by arrows/letters.

Design and Procedure
The PAAS is self-administrated and will be used to evaluate affective states among participants. Affective states are thought to be highly influenced by exercise, thus leading to the development of the PAAS as a concise affect measurement tool. The PAAS has twelve items, which can be further broken down into four sub-domains each further broken down into three mood states positive affect (upbeat, energetic, and enthusiastic), negative affect (miserable, discouraged, and crummy), physical exhaustion (tired, worn-out, and fatigued) and tranquility (calm, peaceful, and relaxed).

Design and Procedure
This is a self administrated questionnaire developed based on validated usability and acceptability models (e.g., SUS, TAM, SNs, etc.) in order to explore users' perceived usefulness, perceived ease of use, perceived enjoyment and intention to use after interacting with the VR exergame system. Participants will be asked to rank each question from 1 to 5 based on how much they agree with the statement they are reading. 5 means they agree completely, 1 means they disagree completely.

VR-At-Home: Feasibility of Using Virtual Reality (VR) Exergames to Promote Physical and Mental Well-Being in Community-Dwelling Older Adults
Page 4 of 7 VERSION 1|DECEMBER 17, 2020

Design and Procedure
This scale is self-administrated and will be used as a predictor of the adoption and maintenance of exercise behavior. Also, it will be used to assess the participant's beliefs in their ability to continue exercising in the future. This scale includes 9 statements and participants will rank each statement from 1 to 4 based on how sure they are: 1 means very sure and 4 means not sure at all.

Materials and Stimuli
Participants will be asked to sit in a quiet room while directly facing their personal computing device. Participants will be asked to place their personal computing device at arm's length, equating to an approximate distance of 57 cm, and the visual stim will be presented in the form of white circles, subtending 2⁰ of visual angle. The visual stimulus will appear 8⁰ below the fixation cross (0.5⁰ visual angle, appears at the center of the screen and will remain on display throughout the trial) for 16 ms. The auditory stimulus will be presented in the form of a beep (3500 Hz, 16 ms, 68 dBA) through speakers [AB1] either connected to the participant's device or external speakers placed besides the screen. In order to reduce temporal predictability, each trial began with the stimulus being presented after a delay of 1000-3000 ms. Psychopy will be used to generate the stimuli. A computer keyboard will be utilized by participants to input their responses for each trial. As seen in previous research (Chan et al., 2015), participants have reported having seen or heard three or more stimuli, thus responses will not be limited to '1' or '2', as participants can perceive more than the presented stimuli (audio or visual). The entire experiment will be selfpaced with no emphasis on speed of responses.

Design and Procedure
There will be three conditions (vision-only, auditory-only, and audiovisual). In the vision-only block, one or two flashes will be presented, and the participants' task will be to indicate how many flashes were presented. In the auditory-only block, one or two beeps will be presented, and the participants will be asked to indicate how many beeps they heard. The following SOAs that will be used in these conditions will be as follows: 0 ms (one stimulus event), 50 ms, 90 ms, 162 ms, 292 ms, and 525 ms for both 2 beep and 2 flashes conditions (these SOAs were chosen as they cluster around 0, and were generated to follow a logarithmic growth of 0.8 with 50 ms as the anchor). There will be 110 trials in each of the unimodal conditions, where 60 trials for 1 stimulus presentation (0 ms) and 50 trials for the two-stimulus presentation, with an equal number divided between the SOA conditions (10 trials for each SOA condition).

VR-At-Home: Feasibility of Using Virtual Reality (VR) Exergames to Promote Physical and Mental Well-Being in Community-Dwelling Older Adults
Page 5 of 7 VERSION 1|DECEMBER 17, 2020 The audiovisual trials will consist of two control conditions (1 beep/1 flash and 2 beeps/2 flashes) and the illusion condition (2 beeps/1 flash). In the audiovisual control conditions, the auditory and visual stimuli will be presented simultaneously. In the 2 beeps/1 flash (illusory condition) auditorylead trials, the auditory stimulus will be presented first, after which the auditory and visual stimuli will be presented simultaneously following a variable SOA. In the 2 beeps/1 flash vision-lead trials, the first auditory stimulus will be accompanied by a visual stimulus and the second auditory beep will be presented following a variable SOA. The following SOAs will be utilized for this study: ±50 ms, ±90 ms, ±162 ms, ±292 ms, and ±525 ms; here '+' indicate vision-lead trials while '-' indicates auditory lead trials. In the 2 beeps/2 flashes trials, the same SOAs will be used. These conditions will be randomly presented within the testing block to avoid response bias. Participants will be asked to fixate on fixation cross for the duration of the task and report the number of flashes seen. Participants will be asked to ignore the auditory stimuli and to respond as accurately as possible. All conditions will be repeated 10 times for a total of 150 trials. Practice trials will also be presented in order to help familiarize the participants with the task.

Materials and Stimuli
Participants will be asked to sit in a quiet room while directly facing their personal computing device. Participants will be asked to place their personal computing device at arm's length, equating to an approximate distance of 57 cm, and the visual stim will be presented in the form of white circles, subtending 2⁰ of visual angle. The visual stimulus will appear 8⁰ below the fixation cross (0.5⁰ visual angle, appears at the center of the screen and will remain on display throughout the trial) for 16 ms. The auditory stimulus will be presented in the form of a beep (3500 Hz, 16 ms, 68 dBA) through speakers either connected to the participant's device or external speakers placed besides the screen. In order to reduce temporal predictability, each trial began with the stimulus being presented after a delay of 1000-3000 ms. Psychopy will be used to generate the stimuli. A computer keyboard will be utilized by participants to input their responses for each trial where participants will press '1' if they perceive the auditory and visual stimuli to be simultaneous and '2' if they perceive the auditory and visual stimuli to be non-simultaneous. The entire experiment will be self-paced with no emphasis on speed of responses.

Design and Procedure
Participants will be presented with auditory beeps and visual flashes of light on a personal computing device. The visual stimuli will be presented below a fixation cross while the auditory stimuli will be presented through speakers, either connected to the participant's device or external speakers placed beside the screen. Over the course of the task, participants will be asked to indicate whether they perceived the auditory and visual stimuli to be occurring 'simultaneously' or 'nonsimultaneously' by pressing '1' (simultaneous) or '2' (nonsimultaneous) or in their keyboard to indicate their responses. The following SOAs will be used for this task: 0 ms , ±50 ms, ±90 ms,

VR-At-Home: Feasibility of Using Virtual Reality (VR) Exergames to Promote Physical and Mental
Well-Being in Community-Dwelling Older Adults Page 6 of 7 VERSION 1|DECEMBER 17, 2020 ±162 ms, ±292 ms, and ±525 ms. During this task they will be presented with 130 trials, as well as practice trials in order to help familiarize the participants with the task.

Materials and Stimuli
Participants will be asked to sit in a quiet room while directly facing their personal computing device. Participants will be asked to place their personal computing device at arm's length, equating to an approximate distance of 57 cm, and the visual stim will be presented in the form of white circles, subtending 2⁰ of visual angle. The visual stimulus will appear 8⁰ below the fixation cross (0.5⁰ visual angle, appears at the center of the screen and will remain on display throughout the trial) for 16 ms. The auditory stimulus will be presented in the form of a beep (3500 Hz, 16 ms, 71.7 dB) through speakers either connected to the participant's device or external speakers placed besides the screen. In order to reduce temporal predictability, each trial began with the stimulus being presented after a delay of 1000-3000 ms Psychpo will be used to generate the stimuli. A computer keyboard will be utilized by participants to input their responses for each trial where participants will press '1' if they perceive the light first and '2' if they perceive the sound first. The entire experiment will be self-paced with no emphasis on speed of responses.

Design and Procedure
Participants will be presented with auditory beeps and visual flashes of light on a personal computing device. The visual stimuli will be presented below a fixation cross while the auditory stimuli will be presented through speakers, either connected to the participant's device or external speakers placed beside the screen. Over the course of the task, participants will be asked to indicate whether the "light came first" or "sound came first" by pressing '1' (light first) or '2' (sound first) on their keyboard to indicate their responses. The following SOAs will be used for this task: 0 ms, ±50 ms, ±90 ms, ±162 ms, ±292 ms, and ±525 ms. During this task they will be presented with 130 trials, as well as practice trials in order to help familiarize the participants with the task.
Note that the stimuli are exactly the same for the SJ and TOJ task and the only difference is the question that the participants are being asked.

Materials and Stimuli
Participants will be asked to sit in a quiet room while directly facing their personal computing device. Participants will be asked to place their personal computing device at arm's length, equating to an approximate distance of 57 cm, and the visual stim will be presented in the form of