The Asian American population in the United States nearly doubled between 2000 and 2019. Asians now make up about 7% of the nation’s overall population, and their numbers are projected to surpass 46 million by 2060, nearly four times their current total [1]. Older Asian immigrants often immigrate to the United States at a late age [2] and experience many challenges related to migration, such as low acculturation, limited English language proficiency, ineligibility for entitlement and welfare programs, family or generational conflicts, and social isolation [3,4]. Older Asian American adults also face numerous challenges and physical, psychological, and mental health problems [5], as well as racial discrimination on a regular basis, especially after COVID-19 [6,7]. As the US population becomes older and more diverse, programs and interventions on how to improve mental health of older immigrants are sorely needed.

In addition, if older immigrants are diagnosed with dementia, they face triple adversity: immigration, aging, and dementia. Immigration is a life-changing event that is often accompanied by elevated stress and adversity; aging adds an additional layer of adversity to immigration, and dementia can lead to experiencing further adverse events. This triple jeopardy poses a trauma risk to older Asian American adults, creating a pressing need to understand how to best restore and preserve their resilience. After a dementia diagnosis, people often experience anxiety, negative impacts on self-esteem, preoccupation with the diagnosis, and hyper-vigilance, which can precipitate a crisis [8]. Asian Americans also report feelings of shame and weakness after a dementia diagnosis; however, they seek fewer formal services for support compared to Whites [9-11], leading to negative emotional and mental health outcomes [12]. Despite vulnerabilities among this population, Asian Americans often attract less research attention, in part due to the “model minority” myth [13].

Despite their overall better physical health, older Asian immigrants have worse mental health outcomes than their White counterparts [14-16]. People who are emotionally well (ie, are satisfied with life, have a positive affect, and find purpose or meaning in life) have a quality of resilience and are able to bounce back faster from difficulties [17]. While there are some studies that have specifically looked at emotional well-being among adults and adolescents [18], few studies have examined emotional well-being among older adults. Prevention and interventions to improve emotional well-being among aging populations have attracted special attention because of its strong correlation with health [19]. Reminiscence and life review have been identified as potentially effective intervention strategies for helping depression and increasing emotional well-being among older adults [20-23]. The literature also asserts the positive impact of an intergenerational approach in achieving positive mental health and emotional well-being among older adults [24-26]. Intergenerational solidarity between grandparents and grandchildren has been emphasized in Asian families [27] and is beneficial for the health of persons with dementia [28,29]. When reminiscence and life review strategies are combined with the intergenerational approach, the mental health benefits for older adults are even clearer and more significant [30]. This approach may also help grandchildren gain more historical and cultural understanding of their grandparents’ lived experiences, positively change their views of aging, and increase their bonding with grandparents.

Using technology to help enhance the well-being of older adults is a growing research and practice trend. One recent technological advancement is audiovisual virtual reality (VR), which creates a 3D computer-generated environment to provide an immersive and interactive personal experience [31]. Emerging technologies that allow older adults to socialize across geographic boundaries using a head-mounted display paired with a smartphone have been well accepted by older adults [32]. Studies have also shown the potential of social VR as a powerful reminiscence tool to challenge stereotypes of aging and promote the well-being of older adults [33].

This proposed study aims to develop and evaluate the potential feasibility and effectiveness of an intergenerational reminiscence approach in improving the emotional well-being of older Asian American adults who have a recent dementia diagnosis. This pilot study is the first to develop and test how social VR can help older Asian Americans improve their emotional well-being and cope with the stress and adversity of having been diagnosed with dementia. It is hypothesized that the resiliencies of family through grandchildren, reminiscence, and technology together will help older adults develop better emotional well-being, which will help them withstand difficulties in the journey of dementia and have better mental health outcomes. The study addresses three specific aims: (1) develop 6 intervention sessions based on the reminiscence and life review theory using VR technology; (2) quantitatively test the effectiveness of this intervention in improving emotional well-being; and (3) qualitatively evaluate the usefulness of this intervention.

An explanatory sequential mixed methods design [34] will be used, involving first collecting quantitative data and then analyzing this data to identify subsamples of participants who report the greatest and least change in emotional well-being. Next, we will conduct qualitative interviews among these subsamples. For the intervention, a single-arm trial will be used in which all the recruited participants are given the intervention and then followed over time to observe their response. This design is used when the objective of the trial is to obtain preliminary evidence of the efficacy of the intervention, but it is not generally used for confirmation of efficacy [35]. Such a design may be desirable when the available participant pool is limited; thus, it is not optimal to randomize many participants to a control arm [35].

Participants in this study will be recruited from immigrant Chinese, Korean, Vietnamese, and Indian families since they are the top 4 minority Asian groups in the greater urban area of Dallas, Texas [36]. The eligibility criteria of the older adult participants include (1) self-identification as Chinese, Korean, Vietnamese, or Indian American and living in the greater Dallas area; (2) age 65 years or older; (3) a dementia diagnosis in the past 12 months (self-reported); and (4) at least one grandchild aged 18 years or older. When both an eligible older adult and his or her grandchild agree to participate in the study, the grandparent-grandchild dyad will be included in the study. The dyads will be recruited through multiple ways, including referrals from facilities or community agencies, flyers posted in Asian grocery markets, announcements posted on Facebook and Twitter, and local churches that service these Asian American groups. Eight dyads from each of the 4 Asian groups are proposed to be recruited (64 total participants).

After participants sign the informed consent form, both the older adults and their grandchildren will be offered a VR headset. Training on how to use the VR headset will be offered to grandparents and grandchildren by the research team before the intervention starts. If the grandchildren do not reside locally, Microsoft Teams–based training will be offered. Then, older adults will receive 6 sessions of life review with their grandchildren in VR (1-1.5 hours each week for 6 weeks). The themes will include (1) major turning points in life, (2) family history, (3) life and career accomplishments, (4) history of loves and hates, (5) experiences of suffering or stressful experiences, and (6) meaning and purpose of life. A manual of interaction guidelines will be prepared for the grandchildren to lead the interactions with their grandparents based on the intervention manual proposed by Watt and Cappeliez [37,38] and others, which will outline the implementation of integrative and instrumental reminiscence interventions that promote acceptance of self, conflict resolution and reconciliation, a sense of meaning and self-worth, recalling how one coped with past problems, and drawing from past experience to solve present problems.

The process is a series of discussions using the above themes of major moments in the participants’ lives, aided by pictures and virtually traveling to important places in their lives with Google Earth to look around these places and remember important times. Information on important pictures and places will be collected by the grandchildren before the session by asking the grandparents’ spouses, their own parents, or the grandparents’ caregivers or legally authorized representatives (LARs). Both the grandparents and their grandchildren will participate in the intervention remotely. The VR intervention process is linked to YouTube 360 slideshows, an application that enables 2 or more people to communicate verbally while seemingly in the same shared space despite being physically apart. Participants open the YouTube app and select the video we have created. The videos are slideshows using 360-degree scenery that fits with their personal history and the images provided by their family members. The subjects speak over a speakerphone, talking about their memories, while viewing the same video. The intervention through VR linked to YouTube is not recorded, and the private family account set up for this study does not publicly list any scenery video and is thus private to the participants (grandparents and grandchildren), the older participants’ caregivers or LARs, and the research team. Mobile Oculus Quest headsets will be mailed to each participant in the dyads. These headsets do not require a computer and enable an immersive video chat–like experience where participants can do activities together in a virtual world. Some older adults with dementia may need some help from their caregivers or LARs if needed. An eyeglass spacer (a rubber border) comes with every headset provided to the subjects. The interaction process via VR will offer older adults audio as well as visual perceptions and thus increase interactions and engagements while overcoming the limitations of geographical distance between the 2 generations. Pretest, posttest, and 3-month follow-up tests will be performed. Qualitative interviews with selected participants will also be integrated into the study design.

The primary outcomes of the study will be the social and emotional well-being of grandparents, and the secondary outcomes are the benefits to the grandchildren.

The quantitative data from surveys will be entered into SPSS (IBM Corp) and analyzed using descriptive analyses, Pearson chi-square tests, Friedman tests, or nonparametric Wilcox signed-rank tests (2-tailed). The qualitative data will be transcribed by research assistants, coded by the investigators independently, and then analyzed with the guidance of content analysis software (Atlas.ti; Atlas.ti Scientific Software Development GmbH).

Prior to commencing the study, all members of the research team successfully completed the Human Subject Protection training and acquired the necessary certification. The study adheres strictly to the guidelines outlined in the Declaration of Helsinki and received approval on July 14, 2020, from the University of Texas at Arlington (UTA) institutional review board (2020-0210). Before conducting the interviews, the participants were provided with clear and comprehensive information regarding the purpose of the study, the procedures involved, the potential risks and benefits associated with participation, the use and anonymization of research data, and the maintenance of confidentiality. Furthermore, the participants were explicitly informed, both initially and through reminders, that their involvement was completely voluntary and that they could withdraw from the project at any point without facing any penalties. The study officially commenced only after participants signed the consent form. The consent form included the contact details of the principal investigator and the institutional review board office, and each participant received a signed copy for their records. Each participant who successfully completes the study is provided compensation in the form of a $110 Walmart gift card.

Each participant is given an ID number. The data obtained for this study has been carefully collected to exclude any personal identifiers. All data files are securely stored in password-protected and encrypted formats on laptops provided by the UTA. These UTA-issued laptops also adhere to encryption protocols mandated by the UTA Office of Information Technology. The encrypted data files will be stored using an approved UTA storage tool, such as OneDrive, to ensure their secure preservation. The utmost priority is given to safeguarding the privacy of the participants involved. A list containing participant names will be maintained securely using author LX’s authorized and protected OneDrive account. In the final report, only deidentified data will be included, ensuring anonymity. The data will be retained for a period of 3 years following the conclusion of the study’s protocol.

The objective of this study is to create and implement a 6-session intervention using VR technology and the reminiscence approach targeting grandparents and grandchildren in Asian American families. By gathering both qualitative and quantitative data, this study aims to assess the effectiveness of the intervention in enhancing the emotional well-being of grandparents and strengthening intergenerational bonds. The research will contribute valuable and up-to-date data to address existing research gaps, particularly by focusing on reminiscence and life review content, incorporating VR technology, and including Asian grandparents who experience cognitive impairment.

Given the various physical, psychological, and mental health issues and instances of discrimination faced by Asian American families [5-7], this study holds significant importance. By focusing on the emotional well-being of older Asian adults, it aims to enhance their life satisfaction, positive emotions, and sense of purpose, all of which contribute to resilience and faster recovery from adversities [17], including the challenges associated with dementia diagnosis. Consequently, this study makes a valuable contribution to the limited existing literature on emotional well-being among older adults, particularly within the context of Asian American families.

Moreover, this research incorporates an innovative approach that combines the positive practice of reminiscence and life review [20-23] with an intergenerational perspective [24-26]. While intergenerational approaches involving younger and older generations have been documented in the literature [24-26], it is worth noting that no previous studies, to the best of the authors’ knowledge, have applied this approach specifically to grandparents and grandchildren. This grandparent-grandchild approach holds special significance for Asian Americans, as it aligns with the emphasis placed on intergenerational solidarity between grandparents and grandchildren within their culture. By engaging in this approach, grandchildren can gain a deeper understanding of their immigrant grandparents’ lived experiences, from both a historical and cultural perspective. This, in turn, has the potential to positively reshape their perceptions of aging and strengthen their bonds with their grandparents.

This mixed methods study is the first to develop and examine an intergenerational reminiscence-based intervention to improve the well-being of older adults in Asian American families with the aid of VR technology. Intergenerational reminiscence provided by grandchildren is a promising approach to improving the emotional well-being of grandparents, as VR technology is likely to be accepted by older adults. This study will help increase intergenerational closeness between grandparents and grandchildren. Findings from this study will also help health or human service providers develop programs to help Asian American families in general.

Limitations of this study include its small sample size and the absence of a control group. Future research may consider scaling up this pilot into a trackable, replicable model that includes more participants and has a more rigorous study design with a control group to test the effectiveness of this intervention for older adults with dementia. In addition, because there are wide differences between different Asian-American groups, it would be better to focus on only one Asian ethnic minority for one research project and compare the differences within that ethnic Asian group. Lastly, this protocol is proposed for in-person interactions between grandparents and grandchildren. Due to the risks and feasibility of conducting an in-person intervention during COVID-19, this project had to be tailored to a telephone-based approach. Future studies may consider comparing the effectiveness of interventions delivered as in-person meetings versus those that use a telephone-based approach.

Intergenerational reminiscence programs have the potential to foster social connection and engagement between grandparents and grandchildren within Asian American families. These programs also serve as a means for grandchildren to gain a deeper understanding of the life experiences of older adults both before and after immigration. By specifically focusing on intergenerational reminiscence between grandparents and grandchildren, a valuable avenue is opened for strengthening generational bonding and relationships. This, in turn, has the potential to enhance the psychological well-being, particularly the emotional well-being, of older Asian immigrant adults residing in the United States. Furthermore, this study will contribute valuable evidence to support future research exploring the feasibility and effectiveness of using VR in interventions or programs designed for older adults with cognitive impairments.